Anterior urethral stricture disease is increasingly managed with substitution urethroplasty, yet graft-versus-flap selection remains nuanced in complex phenotypes. Contemporary practice has shifted toward the oral mucosa, and new evidence emphasizes outcomes beyond patency. This review summarizes current evidence and practical considerations for selecting grafts and flaps in anterior urethroplasty.
Oral mucosa grafting remains the dominant substitution approach due to its broad applicability and reliable integration in suitable beds, with lingual mucosa serving as a practical alternative when additional graft length is required. Comparative literature generally demonstrates similar anatomic outcomes between oral mucosa and genital skin substitution in appropriately selected patients, while lichen sclerosus remains a key contraindication to genital skin transfer and often necessitates staged reconstruction. Studies on patient-reported outcomes show high patient satisfaction overall, but highlight that recurrence, persistent lower urinary tract symptoms, sexual dysfunction, and donor-site morbidity drive dissatisfaction more than tissue type alone. Tissue-engineered oral mucosa and selected nonoral graft sources represent evolving options, particularly when oral mucosa is limited.
Substitution tissue selection should be substrate-driven and etiology-driven: graft-first for most bulbar and single-segment disease with adequate bed quality, and flap-selective for hostile beds, extensive panurethral disease, or limited oral mucosa. Future research should prioritize standardized outcome definitions incorporating robust comparative data in underrepresented high-risk cohorts.
Current opinion in urology. 2026 Mar 23 [Epub ahead of print]
Behzad Abbasi, Navid Jabalameli, Benjamin N Breyer, Mikołaj Frankiewicz, Trauma, Reconstructive Urology Working Party of the European Association of Urology Young Academic Urologists
Department of Urology., Department of Urology, Medical University of Gdańsk, Gdańsk, Poland.