Palminteri Double-Face (Two-Sided) BMG Urethroplasty
The Palminteri double-face urethroplasty is a single-stage urethral-reconstruction technique that uses two buccal mucosal grafts (BMGs) placed on both the dorsal and ventral surfaces of the urethra to augment tight or near-obliterative bulbar strictures while preserving the native urethral plate.[1][2]
For the single-sided alternatives, see Dorsal Onlay BMG (Barbagli) and Ventral Onlay BMG. For the dorsal-inlay variant on which the dorsal half of the double-face technique is built, see Asopa Dorsal Inlay BMG. For the obliterative-bulbar transecting alternative, see Augmented Anastomotic Urethroplasty. For the canonical graft material, see Buccal Mucosa Graft.
Concept and Rationale
The technique addresses a key limitation of single-sided graft urethroplasties: in very narrow (tight) urethral strictures, a single dorsal or ventral graft alone may not provide an adequate urethral lumen.[1][2] Anastomotic techniques (EPA / AAU) achieve wide lumens but carry sexual-complication risk from urethral transection and mobilization.[1] The double-face technique avoids transection, preserves the urethral plate, and augments the urethra from both sides simultaneously.[1][2][3]
Indications
- Tight or near-obliterative bulbar urethral strictures where a single-sided graft would be insufficient to create an adequate lumen.[1][2]
- Strictures typically ≥ 2 cm in length (mean stricture length 3.3–3.65 cm, range 2–10 cm in the Palminteri series).[1][2]
- An alternative to augmented anastomotic urethroplasty for tight segments with a salvageable plate; complete circumferential obliteration may require a different repair.[3]
- Adapted for post-phalloplasty anastomotic strictures in transgender patients, where excisional techniques have high failure rates due to poor neourethral vascularization.[4]
Surgical Technique
| Step | Detail |
|---|---|
| 1. Positioning | Lithotomy; perineal incision to expose the bulbar urethra[2] |
| 2. Ventral urethrotomy | Open the stenotic urethral segment along its ventral surface through the spongiosum, exposing the lumen and the dorsal urethral wall[1][2] |
| 3. Dorsal Asopa-type incision | Incise the exposed dorsal urethra in the midline from the luminal side, creating an elliptical raw area directly over the tunica albuginea of the corpora cavernosa[1][2] |
| 4. Dorsal inlay BMG | Place the first BMG into the dorsal incision as a dorsal inlay; quilt to the underlying tunica albuginea / corpora cavernosa to augment the dorsal urethral plate[1][2] |
| 5. Ventral onlay BMG | Suture a second BMG to the lateral urethral margins as a ventral onlay, completing circumferential augmentation[1][2] |
| 6. Spongiosal closure | Close the corpus spongiosum over the ventral graft for vascular support and mechanical protection[1][2] |
| 7. Catheter | Urethral catheter for ~ 3 weeks[2] |
Graft Material
- Buccal mucosa is the standard graft material — consistent with AUA 2023 first-choice oral-mucosa recommendation. Dorsal and ventral graft segments are needed; donor-site extent depends on the dimensions and may not require both cheeks.[5][6]
- Chen / Santucci combined ventral BMG with dorsal full-thickness skin graft in 15 patients, compared retrospectively with 115 ventral BMG repairs. Overall failure was 21% versus 17%; a subgroup of strictures ≥6 cm favored double grafting (0% versus 24%). This small subgroup does not establish a general benefit.[7]
Outcomes
| Series | n | Population | Mean follow-up | Mean stricture | Success | Re-stricture |
|---|---|---|---|---|---|---|
| Palminteri 2008[2] | 48 | Bulbar | 22 mo | 3.65 cm | 89.6% | 10.4% |
| Palminteri 2011[1] | 73 analyzed of 105 operated | Bulbar | 48.9 mo | 3.3 cm | 88% | 12% |
| Schardein 2020[4] | 8 followed of 9 operated | Post-phalloplasty | 31 mo | — | 75% | 25% |
A systematic review reported a pooled success of 90.1% for the Palminteri technique across 53 patients at mean follow-up 21.9 mo.[8]
In the long-term series, 49 sexually active men reported no postoperative erectile impairment. This selected, uncontrolled denominator does not establish superiority over transecting repair. The early and later Palminteri cohorts overlap and should not be summed as independent patients.[1]
Key Advantages
- Additional augmentation — two grafts can provide adequate caliber when one graft would not, while retaining usable native plate.[1][2]
- Preservation of the urethral plate — supports graft take and preserves urethral blood supply.[1][3]
- Non-transecting — preserves urethral continuity; a comparative reduction in sexual dysfunction has not been established for this specific technique.[1]
- Single-stage — completes reconstruction in one operation in suitable patients; comparative morbidity has not been established.[1][2]
Complications
- Re-stricture — primary failure mode, ~ 10–12% in the bulbar urethra; up to 25% in the post-phalloplasty setting.[1][2][4]
- Urethrocutaneous fistula — 3 / 48 (6.3%) in the initial series, all resolved with prolonged catheterization.[2]
- Bilateral BMG donor-site morbidity — transient oral pain peaking at 1 wk and resolving by 3 mo in most; temporary difficulty with eating / speaking; occasional long-term oral numbness or restricted mouth opening (~ 7.5%).[9]
- Erectile dysfunction — none reported by the 49 sexually active respondents in Palminteri 2011; the small uncontrolled sample cannot exclude risk.[1]
Where It Fits
Single-sided dorsal and ventral BMG urethroplasties have broadly similar reported success, without clear superiority in the available comparisons for typical bulbar strictures.[10][11][12] The double-face technique is reserved for cases where a single graft would be insufficient — namely tight, near-obliterative, or longer strictures.[3]
A single-center retrospective Redmond / Rourke cohort associated augmented anastomotic repair with more recurrence than pure dorsal onlay (adjusted HR 4.8, p = 0.002). It did not evaluate double-face repair and cannot establish this technique’s superiority.[13]
Post-Phalloplasty Application
The technique has been adapted for neophallus anastomotic strictures following gender-affirming phalloplasty. The pars fixa is exposed through a perineal dissection, and surrounding tissue analogous to a Martius flap is rotated to support the ventral graft. Schardein 2020 reported 6/8 evaluable patients without recurrence at mean 31 mo with a mean postoperative IPSS of 3.1; IPSS measures urinary symptoms, not satisfaction.[4]
Videos
References
1. Palminteri E, Berdondini E, Shokeir AA, et al. Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. J Urol. 2011;185(5):1766-1771. doi:10.1016/j.juro.2010.12.103.
2. Palminteri E, Manzoni G, Berdondini E, et al. Combined dorsal plus ventral double buccal mucosa graft in bulbar urethral reconstruction. Eur Urol. 2008;53(1):81-89. doi:10.1016/j.eururo.2007.05.033.
3. Horiguchi A. Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: current topics and reviews. Int J Urol. 2017;24(7):493-503. doi:10.1111/iju.13356.
4. Schardein J, Beamer M, Hughes M, Nikolavsky D. Single-stage double-face buccal mucosal graft urethroplasty for neophallus anastomotic strictures. Urology. 2020;143:257. doi:10.1016/j.urology.2020.06.010.
5. 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.
6. 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.
7. Chen ML, Odom BD, Johnson LJ, Santucci RA. Combining ventral buccal mucosal graft onlay and dorsal full-thickness skin graft inlay decreases failure rates in long bulbar strictures (≥ 6 cm). Urology. 2013;81(4):899-902. doi:10.1016/j.urology.2012.11.055.
8. Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol. 2011;59(5):797-814. doi:10.1016/j.eururo.2011.02.010.
9. Desai D, Joshi S, Ravichandran K, et al. Donor-site morbidity and impact on oral health following buccal mucosal graft harvesting for urethroplasty: a prospective study. World J Urol. 2025;43(1):531. doi:10.1007/s00345-025-05898-6.
10. Hassan AA, Soliman AM, Shouman HA, et al. Dorsal- vs ventral-onlay buccal mucosal graft urethroplasty for urethral strictures: a meta-analysis. BJU Int. 2025. doi:10.1111/bju.16811.
11. Barratt R, Chan G, La Rocca R, et al. Free graft augmentation urethroplasty for bulbar urethral strictures: which technique is best? A systematic review. Eur Urol. 2021;80(1):57-68. doi:10.1016/j.eururo.2021.03.026.
12. Shalkamy O, Elatreisy A, Salih E, et al. Erectile and voiding function outcomes after buccal mucosa graft urethroplasty for long-segment bulbar urethral stricture: ventral versus dorsal onlay technique. World J Urol. 2023;41(1):205-210. doi:10.1007/s00345-022-04220-y.
13. Redmond EJ, Hoare DT, Rourke KF. Augmented anastomotic urethroplasty is independently associated with failure after reconstruction for long bulbar urethral strictures. J Urol. 2020;204(5):989-995. doi:10.1097/JU.0000000000001177.