UROLOGY
Reconstructive Buccal Mucosa Graft Urethroplasty: Perineal Urethrocutaneostoma in a Patient with Multiple Urethral Strictures
Pasichnyk Serhii, Burylo Khrystyna
WJMI 2025; 5(1):53-56
Published online: 2025.12.29
DOI: https://doi.org/10.5281/zenodo.18089742
Citation: Pasichnyk, S., & Burylo, K. (2025). Reconstructive Buccal Mucosa Graft Urethroplasty: Perineal Urethrocutaneostoma in a Patient with Multiple Urethral Strictures. World Journal of Medical Innovations, 5(1), 53-56.
Affilations
Department of Urology, Lviv National Medical University, Lviv Ukraine
Communal Noncommercial Enterprise of Lviv Regional Council “Lviv Regional Clinical Hospital”, Lviv, Ukraine
Corresponding author. Pasichnyk Serhii, Department of urology, Danylo Halytsky Lviv National Medical University, Lviv, Ukraine, e-mail: pasichnykdoctua@gmail.com
Abstract
Urethral strictures and meatal stenosis in patients with congenital anomalies of the urinary tract significantly complicate surgical management, particularly after multiple prior operative interventions. We describe a clinical case of a 36-year-old male with congenital abnormalities of the genitourinary system, complicated by hypospadias, total postoperative obliteration of the penile urethra, and lichen sclerosis. The patient had a long-standing history of obstructed voiding since childhood and had undergone numerous urological procedures, including cystoscopies, urethrotomies, cystostomies, two-stage Reich procedures, circumcision, orchidopexy for cryptorchidism, urethral dilations, meatotomy, optical urethrotomy, urethrotomy with mitomycin C instillation, penile curvature correction, Brock procedure, urethroplasty using a skin–fascial flap, trocar suprapubic cystostomy under ultrasound guidance, and an attempted cystoscopy. The last intervention resulted in the diagnosis of total postoperative obliteration of the penile urethra. Based on this diagnosis, the patient underwent buccal mucosal graft urethroplasty with the creation of a perineal urethrocutaneostoma. An 18 Fr Foley catheter was inserted into the newly formed urethrostoma. The postoperative period proceeded without complications. The patient reported satisfaction with the outcome and the ability to void independently. This clinical case demonstrates a practical approach to managing urethral obliteration in patients with extensive surgical histories and congenital genitourinary anomalies. Urethroplasty using buccal mucosa, combined with the creation of a perineal urethrocutaneostoma, can provide effective urinary diversion and improve quality of life. This case underscores the importance of individualized surgical planning in complex urethral reconstruction.
Introduction.
Urethral strictures, particularly those involving the entire penile urethra, remain a significant challenge in urology. Surgical management is quite diverse, ranging from endoscopic procedures to multi-stage reconstructive urethroplasties. Modern urethroplasty techniques generally demonstrate high success rates; however, certain factors may reduce the likelihood of a favorable outcome. These include long-segment urethral strictures, lichen sclerosis, multiple previous unsuccessful urological interventions, a history of hypospadias repair, and prior pelvic radiotherapy.
Objectives.
To improve understanding and management of complex congenital and acquired urethral pathologies, including total postoperative obliteration of the penile urethra, and to demonstrate the surgical strategies used to restore urinary function in patients with multiple comorbidities.
Material and methods.
Due to the rarity of total postoperative penile urethra obliteration combined with congenital malformations and concomitant renal anomalies, we present this detailed clinical case. The case illustrates the diagnostic challenges, surgical interventions, and stepwise reconstructive approaches to restore urethral patency and urinary function.
Case presentation.
Patient, 36-years old, has a long history of recurrent urethral strictures and presented with difficulty urinating. The full diagnosis includes congenital malformation of the urinary system, trunk hypospadias, meatostenosis, acquired urethral stricture, and lichen sclerosis of the glans penis and neourethra. Concomitant conditions are dystopia of the right kidney and partial duplication of the left kidney. The patient has undergone multiple surgical interventions over the years: appendectomy in 1993, circumcision in 1995, testicular descent due to cryptorchidism in 1999, meatotomy on 05/01/2005, urethrotomy on 04/11/2013, urethral dilatation on 06/14/2013 and 10/25/2013, optical urethrotomy on 05/26/2017, 11/21/2017, 05/21/2019, and 12/22/2022, optical urethrotomy with Metamycin C on 06/17/2021 and 07/21/2021, urethroscopy, cystoscopy, and trocar cystostomy under ultrasound guidance on 07/03/2023, correction of penile curvature with a 2-stage Broca operation (removal of buccal flap and implantation into the urethra) on 07/11/2023, urethroplasty with a skin-fascial flap on a vascular pedicle (Reich operation stage 1) on 07/23/2024, trocar cystostomy under ultrasound guidance on 07/31/2024, urethroscopy on 10/07/2024, Reich operation stage 2 (oleogranuloma, penile plastic) on 10/14/2024, urethroscopy on 11/14/2024, trocar cystostomy under ultrasound on 01/02/2025 due to inability to urinate independently, and an attempted cystoscopy on 02/06/2025.
Due to persistent total obliteration of the penile urethra, the patient underwent augmentation urethroplasty using a buccal mucosal graft with perineal urethrocutaneous stoma. The operative field was disinfected three times with Cutasept-G and draped. Complete meatostenosis prevented insertion of a urinary catheter. A longitudinal perineal incision was made to access the bulbar urethra. The urethra was incised along the anterior wall, and intraoperative cystoscopy revealed a 1.5 cm membranous urethral stricture. The striture site was incised dorsally, and an elastic guidewire was introduced. Buccal mucosa (3 × 1.5 cm) was harvested from the right cheek, cleaned of submucosal fat, and sutured to the incised urethral edges with two continuous 4-0 Monocryl sutures over a urethral catheter. Attempted passage of a guidewire through the bulbar urethral incision revealed complete obliteration, so a perineal urethrocutaneostoma was created. Hemostasis was satisfactory, and an 18 Fr Foley catheter was placed through the stoma. The wound was dressed aseptically.
Figure 1. Intraoperative demonstrations: A: ventral urethrotomy; B: formation of urethrocutaneostoma; C: final result
Discussion.
Complex anterior urethral strictures, particularly those involving both congenital narrowing and iatrogenic obliteration, present significant reconstructive challenges. In the present case, the patient demonstrated meatal stenosis with severe urethral strictures,, which precluded urethral catheterization and required surgical intervention. Access to the bulbar urethra was achieved via a midline perineal incision, and the urethra was opened along the ventral wall. Intraoperative cystoscopy revealed a membranous urethral stricture approximately 1.5 cm in length. The dorsal urethral plate at the site of stricture was incised, and an elastic guidewire was introduced to establish urethral continuity.
Given the extent of obliteration and poor tissue quality, augmentation with a buccal mucosa graft was performed. The graft, harvested from the right cheek (3 × 1.5 cm) and carefully defatted, was sutured to the edges of the urethrotomy over a Foley catheter using continuous 4-0 monofilament sutures. When passage of the guidewire through the bulbar urethra proved impossible due to complete obliteration, a perineal urethrocutaneostoma was created to ensure urinary diversion and maintain urethral patency. Hemostasis was satisfactory, and an 18 Fr Foley catheter was placed through the urethrocutaneostoma.
Several technical considerations contributed to the success of this procedure. The midline perineal approach allowed optimal exposure of the bulbar urethra, while careful harvesting and placement of the buccal mucosa graft ensured a viable, well-vascularized neourethral surface. The length of the graft and precise suturing minimized tension, reducing the risk of graft contraction or stricture recurrence. Meticulous intraoperative hemostasis and aseptic technique further supported favorable outcomes.
Postoperative management included antibiotic therapy, and structured follow-up with clinical assessment . Regular monitoring is crucial to detect early signs of restenosis, infection, or impaired healing, particularly in patients with prior urethral surgery or extensive fibrosis.
Overall, this case illustrates that staged reconstruction, beginning with perineal urethrocutaneostomy and buccal mucosa augmentation, can successfully restore urethral patency in complex anterior strictures. Careful patient selection, meticulous surgical technique, and structured postoperative follow-up are essential components for achieving durable functional outcomes, while preserving the option for further reconstructive interventions in the future.
Conclusions.
Perineal urethroplasty with the formation of a urethrocutaneostomy in men with anterior urethral strictures of various etiologies is currently an extremely effective technique. Even in patients with strictures caused by lichen sclerosus or previous unsuccessful surgeries, this method demonstrates high success rates. Key factors for achieving favorable outcomes include preservation of the dorsal urethral plate and adequate blood supply to the corpus spongiosum. Staged surgical planning, careful handling of grafts, precise suturing, and structured postoperative follow-up ensure stable functional results and reduce the risk of stricture recurrence. This approach not only improves current urethral function but also preserves the option for further reconstructive interventions if needed, highlighting the importance of individualized and stepwise management in patients with complex urethral pathologies.
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