Dorsal Onlay Buccal Mucosa Versus Penile Skin Flap Urethroplasty for Anterior Urethral Strictures: Results From a Randomized Prospective Trial Deepak Dubey,* Vivek Vijjan, Rakesh Kapoor, Aneesh Srivastava, Anil Mandhani, Anant Kumar and M. S. Ansari From the Department of Urology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India Purpose: Reconstructive techniques for anterior urethral strictures have not been subjected to a randomized comparison. In a randomized controlled study we compared outcomes of buccal mucosa dorsal onlay vs skin flap dorsal onlay urethroplasty in patients with complex anterior urethral strictures. Materials and Methods: In this prospective study 55 patients with anterior urethral strictures were randomized to undergo buccal mucosa dorsal onlay (27) or penile skin flap (28) urethroplasty. Operative time, hospital stay, short and long-term complications, recurrence rates, and patient satisfaction were compared between the 2 groups. Results: The number of patients with pendulous, bulbar and bulbopendulous strictures as well as mean stricture length and median followup were comparable between the 2 groups. Mean operative time was significantly higher in the penile flap (224 minutes) vs the buccal mucosa group (162 minutes, p 0.001). In the penile flap group 6 patients had superficial penile skin necrosis, 1 had extensive skin loss and required skin grafting, and 2 had penile torsion. In the buccal mucosa group 25.6% of patients had minor morbidity which settled by 4 weeks after surgery. There were 9 (34.1%) patients in the penile flap group and 4 (14.8%) in the buccal mucosa group (p 0.001) who had troublesome post-void dribbling. In the buccal mucosa group 89% and in the penile flap group 65% said they would recommend this procedure to another patient (p 0.001). The success rate in the buccal mucosa (89.9%) and penile flap (85.6%) groups was similar (p 0.05). Conclusions: On intermediate followup dorsal onlay penile skin flap and buccal mucosa urethroplasty provide similar success rates. Compared to buccal mucosa, penile flap procedures are technically complex, associated with higher morbidity and less preferred by patients. Key Words: mouth mucosa; surgical flaps; urethral stricture; penis; surgery, plastic I n recent years resurgence of the use of free grafts for anterior urethral stricture reconstruction has renewed the search for the ideal urethral substitute. Tradition- ally penile skin flaps, which have the advantage of a robust vascular pedicle, were considered the most reliable material for reconstruction of complex strictures. 1,2 Results from nu- merous centers dedicated to urethral reconstruction have highlighted the emerging role of buccal mucosa graft as the most versatile method of reconstructing the bulbar ure- thra. 3–5 Controversy still exists regarding the use of buccal mucosa on the less vascular pendulous urethra 6,7 despite good results being reported. 3 In our experience 4,8 and that of others, 9 dorsal placement of penile skin flaps and free grafts has yielded superior outcomes compared to ventral placement. To our knowledge no prospective randomized comparison between the use of flaps and grafts for substitution urethroplasty has been per- formed. We present the results of a randomized prospective trial comparing dorsal onlay buccal mucosa grafting and penile skin flap urethroplasty. MATERIALS AND METHODS Between February 2003 and February 2006 a total of 55 patients with anterior urethral strictures requiring substi- tution urethroplasty were randomized to receive either dor- sal onlay buccal mucosa urethroplasty (27) or penile skin flap urethroplasty (28). Only patients in whom the stricture etiology was considered to be inflammatory or idiopathic were included in the study. Patients with balanitis xerotica obliterans, unhealthy penile skin, oral mucosal pathology or those who had undergone more than 1 urethral dilation/ internal urethrotomy or urethroplasty were excluded from the study. The method of randomization was every alternate patient with bulbar, pendulous or bulbopendulous stricture being assigned to the BM and PF groups. Preoperative assessment consisted of history, examina- tion, uroflowmetry, and retrograde and voiding cystoure- thrography. After initial assessment patients were random- ized to undergo substitution urethroplasty with either buccal mucosa or penile skin flap. Submitted for publication March 21, 2007. Nothing to disclose. * Correspondence: Department of Urology, Sanjay Gandhi Post- graduate Institute of Medical Sciences, Rae Bareli Rd., Lucknow 226014, India (e-mail: ddubey@sgpgi.ac.in). Editor’s Note: This article is the fourth of 5 published in this issue for which category 1 CME credits can be earned. Instructions for obtaining credits are given with the questions on pages 2706 and 2707. 0022-5347/07/1786-2466/0 Vol. 178, 2466-2469, December 2007 THE JOURNAL OF UROLOGY ® Printed in U.S.A. Copyright © 2007 by AMERICAN UROLOGICAL ASSOCIATION DOI:10.1016/j.juro.2007.08.010 2466