The patient is placed in lithotomy position after spinal anesthesia.

Dilute Methylene Blue dye is

injected through the meatus into the urethra. The penis and perineum are massaged to push the
dye proximally. I apply a 6 F feeding tube as a tourniquet to lightly compress the urethra below the
glance penis. A midline perineal incision is made the bulbar urethra is dissected from corpora
cavernosa. I place two stay sutures ventrally at 6 O’ Clock position on the facia over corpora
spongiosa. These stay sutures allow me to rotate the bulbar urethra to open the urethra exactly at
12 O’ Clock (dorsal) position over a dilator distal to the stricture. The urethra is spatulated through
the stricture proximally into normal urethra minimum to a distance of 1.5 cm.

Buccal mucosa graft harvesting : the graft can be taken under general or local anesthesia. A
retractor is placed to wide open the jaws. A roller gauze is packed into the pharynx to block
aspiration of blood during dissection. The Stensons Duct opening opposite the second upper molar
tooth is marked with Methylene Blue. Injury to the duct opening is avoided by making an incision
from the angle of mouth towards the lower jaw. Xylocaine with 2% Adrenaline is injected with a
fine needle from the angle of mouth to anterior tonsiler pillar below the buccal mucosa. A stay
suture is taken at the angle of mouth just inside the vermilion border. Two parallel incisions 1.5 cm
apart are made from the angle of mouth to the anterior tonsil pillar. The buccal mucosa graft is
harvested. Any injury to the Buccinator muscle is avoided. Bleeders if any are coagulated with
bipolar diathermy. Initially I use to close the defect in the buccal mucosa at 3 – 0 chromic catgut
continues sutures. Now for last five years, I have rarely closed the wound. The buccal mucosa graft
is kept in a bowl of saline to which Gentamycin injection is added. The graft defatting of the graft is
performed. Some surgeons perform aggressive defatting to make the graft very thin and
transparent. Moderate defatting is sufficient in my opinion. Some surgeons pin down the graft
with multiple needles on a silicon block to facilitate defatting. The buccal mucosa graft is
transferred to the perineal surgeon. The graft is placed over the corpora cavernosa with mucosa
facing towards the lumen. The graft is spread and fixed to the corpora cavernosa. Quilting sutures
with absorbable material allow the graft to be fixed to the underlying structures. This prevents
collection of seroma below the graft and tiny holes created with the suture material allow the
serous fluid to drain. Some surgeons make multiple incisions in the graft similar to skin graft. It
allows narrow a graft to cover wider area. I personally do not use it. The edge of the corpora
spongiosa is sutured to the buccal mucosa with continuous sutures to the right side. A 14 F silastic
catheter is inserted into the bladder. Then the left edge of corpora spongiosa is sutured to the
buccal mucosa with continuous sutures. Each stitch incorporates the underlying corpora
cavernosa, the buccal mucosa and the corpora spongiosa (three in one stitch). Care must be taken
while suturing to avoid inadvertent needle entry into the periurethral catheter.
The success of dorsal onlay buccal mucosa graft urethroplasty depends upon the width of the
urethral plate. If the stricture is tight and long, the urethral plate will be too narrow. With a
narrow urethral plate (less than 5mm) we can not suture edge of the urethral mucosa to the
BMG. If we do this the effective lumen will be 20F. So edge of the corpora spongiosa is sutured to
the BMG leaving strips of exposed spongiosa on both sides of the urethral plate. This violates the
principle of primary healing and it will heal by secondary intention and may lead to restricture
formation.