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not be used for patients with lichen sclerosus or other conditions such as radiation that result in unhealthy
tissue.

Grafts
Graft augmentation urethroplasty has gained popularity, both in male and female patients. Free grafts may
be obtained from local tissue (vaginal, labial) and oral mucosa (buccal, lingual). Tables 3 and 4 compile the
past 10-year-period study outcomes of local and oral grafts, respectively [2,23,25,26,30,33-44] . Vaginal or labial graft
augmentation had an 80%-87% mean success rate, whereas oral mucosa grafts’ mean success rate ranged
between 89%-94% [4,20] . With an average follow-up of over 18 months, mean success closely matches that of
patients who underwent flap urethroplasty.

Using local tissue to harvest graft is not advised in patients with LS. Also, care needs to be taken when
considering estrogen-sensitive local grafts in post-menopausal patients. Hormone creams may be helpful
[28]
when using local grafts in these women, as suggested by Romero-Maroto et al. . Some authors advocate
the use of labia minora grafts [33,34] , whereas others prefer harvesting a vaginal mucosa graft [35,36] . Data reflects
that both techniques have proven to be equally efficacious with similar surgical outcomes.

On the other hand, buccal mucosa grafts have gained popularity, at least in part because of their versatility.
These are easy to harvest, with low donor site morbidity. They are easy to handle, have good graft take, and
minimal contracture; these unique characteristics make them an ideal substitute tissue for urethroplasties.
Sharma et al. presented their work using lingual mucosa grafts with acceptable results compared to the
[37]
available literature. In our experience, we only use lingual mucosa grafts when we have no available healthy
buccal mucosa to harvest.

Where to place the graft remains a subject of controversy. There exists a debate regarding a dorsal vs. a
ventral approach. The decision to place a ventral graft relies on the presumption that it is an easier
dissection and that it would preserve sexual function, although there is one study that showed that sexual
function is not affected with dorsal approach and, even more, it documented an improvement in sexual
function scores . In their respective series, none of the authors performing a dorsal approach reported a
[38]
decrease in sexual function [39-41] . A dorsal approach preserves ventral tissue planes in case there is a need for
a future continence procedure. Additionally, Gomez and Pfeifer proposed the idea that the dorsal
[45]
approach may entail a lesser risk of incontinence by preserving ventro-lateral supporting structures. Similar
de novo SUI rates were found in both approaches (3.6% with a dorsal approach vs. 5.8% with a ventral
approach) in a review by Sarin et al. . Although it has been suggested that the ventral approach might
[4]
increase the risk of urethro-vaginal fistula, there is no data available regarding this complication.
Coguplugil et al. suggest that performing a full-thickness vaginal dissection might prevent fistula
[43]
formation.

OUR TECHNIQUE
We favor the dorsal onlay buccal mucosal graft, although some might argue it is a more difficult approach.
The risk of sexual dysfunction with this dissection is low, as the plane of dissection is well away from
neurovascular clitoral structures. As stated above, leaving the ventral plane untouched might be convenient
for a possible continence procedure in the future if needed. In addition, it helps prevent sacculation of the
graft. We harvest, clean, and fenestrate a 4 cm × 2 cm buccal mucosal graft in the standard fashion.
Typically given the length of the female urethra, a longer graft is not required even in situations where the
stricture is panurethral. A semilunar, suprameatal incision is made. Careful dissection is carried outside the
corpus spongiosum until a healthy urethra is encountered. We typically open the meatus; however, a