Augmented Perineal Urethrostomy
Augmented perineal urethrostomy combines a standard perineal urethrostomy (PU) with a dorsal onlay buccal-mucosal graft (BMG) to widen the proximal urethral opening and support perineal-stoma construction in patients with complex anterior urethral stricture disease.[1] It is a modification of the standard PU designed specifically to counter the dominant failure mode — stomal stenosis — by lining part of the neomeatus with hairless oral mucosa. Superiority over an otherwise suitable non-augmented PU has not been established; LS-associated recurrence can occur despite buccal grafting.
Crucially, augmented PU is approach-agnostic: the dorsal BMG can be incorporated through either a midline incision (preserving the algorithmic loop / 7-flap framework) or an inverted-U incision (Blandy). It is therefore a graft-augmentation option layered onto a PU rather than a distinct incision/flap technique — which is why it warrants its own page rather than living under any single approach. It is best understood as a PU-shaped first stage of urethroplasty: the patient leaves the operating room with a definitive perineal stoma whose lumen has been augmented with buccal mucosa, with no obligatory second-stage tubularization unless later elected.[1]
For the non-augmented techniques, see Midline Perineal Urethrostomy (loop / 7-flap) and Blandy Perineal Urethrostomy (inverted-U).
Indications
Augmented PU is reserved for situations where standard skin-only PU is at elevated risk of stenosis or where standard urethroplasty is not feasible or has failed:[1][2]
- Pananterior (long-segment) anterior urethral strictures — the dominant indication.
- Lichen sclerosus with extensive urethral involvement (~23% of the DeLong cohort).
- Failed prior hypospadias repairs ("hypospadias cripples") — depleted local tissue and a hairless requirement.
- Multiple failed urethroplasties.
- Fournier's gangrene with urethral destruction; extensive urethral excision for urethral/penile cancer.
- Older or comorbid patients who are poor candidates for prolonged or staged reconstruction and accept sitting to void.
The AUA 2023 urethral stricture guideline amendment endorses PU as a long-term option — either as an alternative to urethroplasty (Conditional Recommendation) or for patients at high risk for reconstruction failure (Expert Opinion); graft augmentation is a refinement within that framework.[10]
Surgical Technique
The technique described by DeLong, Jordan, McCammon, and Virasoro layers a dorsal BMG onlay onto a PU.[1]
- Positioning and incision — dorsal lithotomy. A midline or inverted-U perineal incision is made and the bulbospongiosus divided to expose the bulbar urethra.
- Urethral exposure and urethrotomy — the bulbar urethra is mobilized and opened; the urethrotomy is extended proximally until healthy, non-strictured urethra is reached. Only the segment needed to establish a patent proximal outlet is opened: a PU bypasses distal disease and does not require opening the entire penile stricture.
- Dorsal preparation — expose the dorsal urethral surface and corporal graft bed with the mobilization required for the chosen reconstruction; preserve remaining spongiosal and lateral vascular attachments where possible. A free graft subsequently relies on a viable recipient bed, not an intact pedicle of its own.[1][8]
- BMG harvest — a buccal-mucosal graft is harvested from the inner cheek (one or both cheeks for long strictures), defatted, and tailored. Buccal mucosa was the preferred graft in approximately 99% of the 134 respondents to a GURS survey; that is a survey response, not a population-wide estimate.[9]
- Dorsal onlay graft placement — the BMG is quilted onto the dorsal corporal bed and sutured to the edges of the dorsal urethrotomy with fine absorbable suture (5-0/6-0 polyglactin or polydioxanone). Dorsal placement provides a well-vascularized, mechanically supported bed for graft take.[1][9]
- Urethrostomy maturation — the ventral urethral edges are matured to the perineal skin, creating a composite stoma of skin and buccal mucosa in which the graft forms the widened dorsal wall of the neomeatus.
- Catheter and closure — a 16–18 Fr catheter is placed through the urethrostomy; the perineal wound is closed in layers and the catheter typically removed at ~2–3 weeks.
A related minimal-access dorsal BMG approach via a ventral sagittal urethrotomy (Gupta) shares the same dorsal-onlay, vascularized-bed principle.[8]
Rationale for Dorsal Graft Augmentation
The key innovation is the dorsal BMG, which addresses skin-only PU's primary failure mode — stomal stenosis (reported 5–22% across PU series). Buccal mucosa offers several advantages over perineal or scrotal skin:[1][9]
- Preferred to genital skin in LS, but not immune to disease-associated recurrence; recurrent LS or stricture in a first-stage BMG was reported in 9/37 patients in one LS series.[7]
- Thick, resilient epithelium with a thin, highly vascular lamina propria that promotes reliable graft take.
- Hairless — avoids intra-stomal hair growth and its sequelae.
- Can widen an otherwise inadequate proximal urethral segment; comparative durability versus skin-only PU remains uncertain.
Outcomes
| Series | n | Cohort | FU | Success |
|---|---|---|---|---|
| DeLong 2017 (augmented PU)[1] | 44 | Pananterior; 23% LS; mean age 60 | 45 mo | 35/44 (80%) primary; four successful revisions among nine recurrences |
| Joshi 2024 (standard midline PU)[3] | 103 | Mixed midline algorithmic | 61 mo at survey in 49 respondents | 98/103 (95.1%) |
| Fuchs 2018 (standard PU)[4] | 77 | Mixed | 50.7 mo | 94.8% |
These are separate retrospective cohorts with different case mix, definitions and follow-up; they cannot rank augmented versus non-augmented PU. In Joshi, only 49/103 men completed the telephone survey: 42/49 were satisfied and 12/49 reported de novo ED; 31/41 answering the sitting-to-void question were unbothered. These responder outcomes are not augmented-PU-specific risks.[1][3][4]
Selection and Lichen Sclerosus
Consider augmentation when a healthy, adequately wide proximal opening cannot be fashioned with local tissue alone, particularly with proximal bulbar extension or a stenosed prior PU. EAU guidance supports augmented Blandy or 7-flap PU as options for selected proximal bulbar/membranous disease, with technique chosen for anatomy and expertise; augmentation is not mandatory for every LS case.[11]
Prior radiation was associated with PU stenosis in the small Myers cohort (OR 11.2; 95% CI 1.4–87.2), an imprecise risk signal rather than evidence that a graft overcomes radiation injury.[5] In Patel's LS series, 13/14 PU patients and 15/20 single-stage BMG patients met the study success definition; selection and small numbers prevent a comparative superiority claim. LS-related recurrence can occur in BMG and at a PU, so continuing follow-up is necessary.[7][11]
PU can be discussed as a primary long-term choice, alongside reconstruction, when the patient accepts a perineal outlet. A healthy, tension-free non-augmented stoma avoids oral donor morbidity. For graft biology and donor counseling, see Buccal Mucosa Graft.
Augmented PU in the Family of PU Techniques
| Technique | Incision | Key feature | Best suited for |
|---|---|---|---|
| Blandy | Inverted-U | Posteriorly based inverted-U flap; apex parachuted to opened urethra | Standard PU with adequate perineal skin |
| Johanson | Midline or inverted-U | Simple marsupialization of opened urethra to skin (no formal flap) | Historical / staged-urethroplasty first stage |
| 7-flap | Midline | Laterally based "7" skin flap advanced into the depth of the wound | Long urethra-to-skin distance; obesity; proximal transection |
| Loop | Midline | Dorsal plate preserved; urethra matured directly to skin, no flap | Distal strictures; low BMI |
| Augmented (this page) | Midline or inverted-U | Dorsal onlay BMG + skin maturation → composite stoma | LS; failed hypospadias; high stomal-stenosis risk |
| Propeller flap | Revision | Posterior-thigh perforator flap rotated into a scarred perineum | Complex PU revision when local tissue is depleted |
Revision Setting
The same dorsal-BMG principle salvages an already-stenotic perineal urethrostomy. Kamat described BMG widening of a stenotic stoma to create a composite skin-and-mucosa neomeatus — particularly useful when lichen sclerosus / BXO threatens the skin component of the stoma.[6] When local perineal tissue is wholly depleted (radiated, multiply operated), salvage escalates to a posterior-thigh propeller flap.
See Also
- Midline Perineal Urethrostomy — loop and 7-flap (non-augmented midline)
- Blandy Perineal Urethrostomy — inverted-U flap PU
- Dorsal Onlay BMG Urethroplasty — the graft-placement principle augmented PU borrows
- Buccal Mucosa Graft · Lichen Sclerosus
References
1. DeLong J, McCammon K, Capiel L, et al. Augmented perineal urethrostomy using a dorsal buccal mucosal graft, bi-institutional study. World J Urol. 2017;35(8):1285-1290. doi:10.1007/s00345-017-2002-z.
2. Verla W, Oosterlinck W, Waterloos M, Spinoit AF, Lumen N. Perineal urethrostomy for complicated anterior urethral strictures: indications and patient's choice. An analysis at a single institution. Urology. 2020;138:160-165. doi:10.1016/j.urology.2019.11.064.
3. Joshi EG, VanDyke ME, Langford BT, Franzen BP, Morey AF. Algorithmic midline approach to perineal urethrostomy is associated with long-term success and high patient satisfaction. Urology. 2024;190:133-139. doi:10.1016/j.urology.2024.03.016.
4. Fuchs JS, Shakir N, McKibben MJ, et al. Changing trends in reconstruction of complex anterior urethral strictures: from skin flap to perineal urethrostomy. Urology. 2018;122:169-173. doi:10.1016/j.urology.2018.08.009.
5. Myers JB, Porten SP, McAninch JW. The outcomes of perineal urethrostomy with preservation of the dorsal urethral plate and urethral blood supply. Urology. 2011;77(5):1223-1227. doi:10.1016/j.urology.2010.10.041.
6. Kamat N. Perineal urethrostomy stenosis repair with buccal mucosa: description of technique and report of four cases. Urology. 2008;72(5):1153-1155. doi:10.1016/j.urology.2008.06.072.
7. Patel CK, Buckley JC, Zinman LN, Vanni AJ. Outcomes for management of lichen sclerosus urethral strictures by 3 different techniques. Urology. 2016;91:215-221. doi:10.1016/j.urology.2015.11.057.
8. Gupta NP, Ansari MS, Dogra PN, Tandon S. Dorsal buccal mucosal graft urethroplasty by a ventral sagittal urethrotomy and minimal-access perineal approach for anterior urethral stricture. BJU Int. 2004;93(9):1287-1290. doi:10.1111/j.1464-410X.2004.04822.x.
9. Berg C, Singh A, Hu P, et al. Current trends in the use of buccal grafts during urethroplasty among Society of Genitourinary Reconstructive Surgeons. Urology. 2024;191:139-143. doi:10.1016/j.urology.2024.06.019.
10. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482.
11. EAU Guidelines on Urethral Strictures: perineal urethrostomy. https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males. Accessed September 12, 2026.