EURURO-9338; No.

of Pages 12

E UROP E AN U RO LO GY XXX (2 021) XXX– XXX

available at www.sciencedirect.com
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Platinum Priority – Review – Reconstructive Urology

Editorial by XXX on pp. x–y of this issue

Free Graft Augmentation Urethroplasty for Bulbar Urethral

Strictures: Which Technique Is Best? A Systematic Review

Rachel Barratt a,*, Garson Chan b, Roberto La Rocca c, Konstantinos Dimitropoulos d,

Francisco E. Martins e, Félix Campos-Juanatey f, Tamsin J. Greenwell a, Marjan Waterloos g,
Silke Riechardt h, Nadir I. Osman i, Yuhong Yuan j, Franceso Esperto l, Achilles Ploumidis k,
Nicolaas Lumen g, on behalf of the European Association of Urology Urethral Strictures
Guidelines Panel
a b
Department of Urology, University College London Hospital, London, UK; Division of Urology, University of Saskatchewan, Saskatoon, Canada;
c
Department of Urology, University of Naples Federico II, Naples, Italy; d Department of Urology, Aberdeen Royal Infirmary, Aberdeen, UK; e Department of
Urology, Santa Maria University Hospital, University of Lisbon, Lisbon, Portugal; f Urology Department, Marques de Valdecilla University Hospital, Santander,
Spain; g Division of Urology, Gent University Hospital, Gent, Belgium; h
Department of Urology, University Medical Center Hamburg-Eppendorf, Hamburg,
Germany; i Department of Urology, Sheffield Teaching Hospitals, Sheffield, UK; j Department of Medicine, Health Science Centre, McMaster University,
Hamilton, ON, Canada; k Department of Urology, Athens Medical Centre, Athens, Greece; l Department of Urology, Campus Biomedico University of Rome

Article info Abstract

Article history: Context: Four techniques for graft placement in one-stage bulbar urethroplasty have
Accepted March 24, 2021 been reported: dorsal onlay (DO), ventral onlay (VO), dorsolateral onlay (DLO), and
dorsal inlay (DI). There is currently no systematic review in the literature comparing
Associate Editor: these techniques.
J.-N. Cornu Objective: To assess if stricture recurrence and secondary outcomes vary between the
four techniques and to assess if one technique is superior to any other.
Evidence acquisition: The EMBASE, MEDLINE, and Cochrane Systematic Reviews—
Keywords: Cochrane Central Register of Controlled Trials (CENTRAL; Cochrane HTA, DARE, HEED)
Bulbar urethral stricture databases and ClinicalTrials.gov were searched for publications in English from 1996 on-
wards. Randomised controlled trials (RCTs), nonrandomised comparative studies
Free graft augmentation
(NRCSs), observational studies (cohort, case-control/comparative, single-arm), and case
urethroplasty series with 20 adult male participants were included.
Graft placement Evidence synthesis: A total of 41 studies were included involving 3683 patients from one
Ventral onlay RCT, four NRCSs, and 36 case series. Owing to the overall low quality of the evidence, a
Dorsal onlay narrative synthesis was performed.
Conclusions: No single technique appears to be superior to another for bulbar free graft
urethroplasty. Both DO and VO are suitable for bulbar augmentation urethroplasty, with
a 20% recurrence rate over medium-term follow-up. No recommendations can be
made regarding DI or DLO techniques owing to the paucity of evidence. Secondary
outcomes including sexual function, and complications are infrequently reported.
Recurrence rates deteriorate in the long term for both DO and VO procedures.

* Corresponding author. Department of Urology, University College London Hospital, 16–18 West-
moreland Street, London W1G 8PH, UK.
E-mail address: rachelbarratt@nhs.net (R. Barratt).

https://doi.org/10.1016/j.eururo.2021.03.026
0302-2838/© 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.

Please cite this article in press as: Barratt R, et al. Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which
Technique Is Best? A Systematic Review. Eur Urol (2021), https://doi.org/10.1016/j.eururo.2021.03.026
EURURO-9338; No. of Pages 12

2 E U RO P E A N UROL OGY X X X ( 20 21 ) X X X –X X X

Patient summary: We reviewed the evidence for four different skin-graft techniques
used to repair narrowing of a section of the urethra (bulbar urethra, under the scrotum
and perineum) in men. Two of the techniques seem to give consistent results, with
recurrence rates lower than 20%. Recurrence rates increase over time, so patients should
continue to monitor their symptoms. There is poorer reporting of other outcomes such as
sexual function, urinary symptoms, and complications, and it is possible that these occur
more frequently than the current data suggest.
© 2021 European Association of Urology. Published by Elsevier B.V. All rights reserved.

1. Introduction 2.2. Types of study design included

Urethral stricture disease is commonly encountered in
urological practice, with an incidence estimated at 229–627
per 100 000 males [1]. The anterior urethra is most
frequently affected, predominantly in the bulbar segment
[2]. Urethroplasty provides the highest chance of long-term
patency and is considered the gold standard treatment for
bulbar urethral strictures, despite the ease and widespread
availability of endoscopic procedures [3,4].
Various techniques for bulbar urethroplasty have been
described [4]. The choice of repair depends on multiple
factors, including stricture length, degree of spongiofibrosis,
stricture tightness, and previous interventions [4]. Augmen-
tation urethroplasty is the principal option for bulbar
strictures not amenable for excision and primary anasto-
mosis. For bulbar strictures, restoration of a normal-calibre
lumen via augmentation urethroplasty is usually accom-
plished using a free graft (oral mucosa, genital, or
extragenital skin) as a patch [5–9].
A number of techniques have been described, with four
commonly used: dorsal onlay (DO), dorsolateral onlay
(DLO), dorsal inlay (DI), and ventral onlay (VO) [10–14]. Each
has its own specific merits and complications, but there is
limited evidence in the current literature to recommend
one procedure over another. The aim of this systematic
review was to identify which, if any, technique for
augmentation urethroplasty in bulbar urethral stricture is
superior with regard to patency rates or complications.
2. Evidence acquisition
2.1. Search strategy, selection of studies, and data extraction
The EMBASE, MEDLINE, and Cochrane Systematic Reviews—
Cochrane Central Register of Controlled Trials (CENTRAL;
Cochrane HTA, DARE, HEED) databases and ClinicalTrials.
gov were searched for publications in the English language
from 1996 onwards (year of publication of the seminal
paper describing DO [10]). The literature search strategy is
provided in the Supplementary material.
Abstract screening and full-text selection were per-
formed independently by three authors (R.B., G.C., and R.L.
R.; Fig. 1). Data extraction was subsequently performed by
one author (R.B.) and corroborated by a second author
(G.C.); both authors performed the risk of bias (RoB)
assessment. Any potential conflicts or queries were
independently reviewed by a separate author (K.D.).
Randomised controlled trials (RCTs), nonrandomised com-
parative studies (NRCSs), observational studies (cohort,
case-control/comparative, single-arm studies), and case
series were included providing there was a minimum
cohort size of 20 and minimum mean/median follow-up of
12 mo. Reviews, case reports, conference abstracts, and
letters were excluded.
2.3. Types of participant included
The study population included men aged 18 yr with a
diagnosis of bulbar urethral stricture. Transgender patients
were excluded.
2.4. Types of intervention included
All four techniques for one-stage free graft bulbar urethro-
plasty (DO, VO, DLO, and DI) using any autologous graft
were included as potential interventions, with any pairwise
comparisons allowed (including no comparator).
Exclusion criteria included any other urethroplasty
technique (pedicled flap, augmented anastomotic, DO with
VO [Palminteri’s technique [15]], tubularised graft, two-
stage technique), stricture location other than the bulbar
urethra, multisegment strictures, and tissue-engineered
grafts.
2.5. Types of outcome measure included
The primary outcome was stricture recurrence, defined as a
new stricture requiring additional urethral intervention
(including endoluminal procedures) to re-establish urethral
patency.
The secondary outcomes measured included postop-
erative sexual dysfunction (erectile dysfunction [ED],
ejaculatory dysfunction, or other form of sexual dysfunc-
tion); postoperative lower urinary tract symptoms
(LUTS); patient satisfaction; requirement for postopera-
tive urinary diversion (including perineal urethrostomy);
periprocedural complications (within 30 d); and contrast
extravasation on postoperative urethrography. These
outcomes were reported descriptively as defined by
individual triallists.
The review plan was to report outcomes at 12-, 18-, 24-,
and 36-mo follow-up; if these data were not available, a
descriptive text is provided.

Please cite this article in press as: Barratt R, et al. Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which
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EURURO-9338; No. of Pages 12

EU ROP E AN U RO LO GY XXX (2 021) XXX– XXX 3

Idenficaon
Records idenfied through Addional records idenfied
database searching through other sources
(n = 2962) (n = 0)

Records aer duplicates removed and me criterion (>1996) applied

(n = 1518)
Screening

Records screened Records excluded

(n = 1518) (n = 1350)

Full-text arcles assessed Full-text arcles excluded, with

for eligibility reasons (n = 127)
Eligibility

(n = 168)
- Heterogeneous data set:unable to
extract outcome data for procedure
specific bulbar urethroplasty (n = 65)
- Total number in series <20 (n= 32)
Studies included in - Review/systemacreview (n = 6)
qualitave synthesis - Duplicate from secondliterature
(n = 41) search (n= 5)
- Alternave technique (n= 5)
- Inadequate follow-up <12mo (n =4)
- Descripon of technique only
Included

without outcome data (n= 4)

Studies included in - Arcle in Spanish (n= 3)
- Non-bulbar strictures only (n= 2)
quantave synthesis
- No primary outcomes reported
(meta-analysis) (n =1)
(n = 0)

Fig. 1 – PRISMA flow diagram of the study selection process.

2.6. Assessment of risk of bias
The risk of bias (RoB) for RCTs was assessed using the
Cochrane RoB assessment tool for RCTs [16]. NRCS RoB was
assessed using a modified Cochrane tool including addi-
tional items to assess the risk of confounding bias (factoring
if prespecified confounders were reported, balanced, and
adjusted) [17]. Following expert panel discussion, five
confounders were identified a priori: diabetes mellitus,
smoking, prior pelvic radiotherapy, stricture length, and
previous urethroplasty. For case series, a five-criterion
quality appraisal checklist was used (Supplementary
material).
2.7. Data analysis
As only one RCT was included in this review,
meta-analysis and quantitative analysis were not
appropriate so a narrative synthesis approach was used
instead.
A subgroup analysis was planned for graft type (oral
mucosa graft urethroplasty [OMGU], penile/preputial skin
graft urethroplasty [PSGU], and other autologous grafts [eg,
extragenital skin, other mucosa]) and for outcomes at
specified time points (12–17 mo, 18–23 mo, 24–35 mo, and
36 mo). However, this was not possible owing to the low
level of evidence of studies, and therefore a narrative review of
outcomes according to graft type and time was performed.
3. Results
3.1. Quantity of evidence identified
Up to July 2020, a total of 1518 abstracts were screened and
168 studies were retrieved for full-text assessment (Fig. 1).
This process yielded 41 studies involving a total of
3683 patients that met the inclusion criteria for data
extraction: one RCT (80 patients) [18], four NRCSs
(490 patients) [19–22], and 36 case series (3113 patients)
[6,10,13,23–55].

Please cite this article in press as: Barratt R, et al. Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which
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EURURO-9338; No. of Pages 12

4 E U RO P E A N UROL OGY X X X ( 20 21 ) X X X –X X X

3.2. Characteristics of the studies included cases [26,33,48]. VO OMGU was reported in ten studies
[13,28,34,35,38,41,44,45,50,54] and both OMGU and PSGU
Supplementary Tables 1 and 2 list the characteristics of the in one study [43]. Only one study reported DI urethroplasty
studies included in the review. using OMGU [47]. One study reported both DO and VO using
OMGU [6] and one study reported cases of DO (with both
3.2.1. Characteristics of RCTs OMGU and PSGU) and VO and DI with OMGU [27]. Finally,
Only one RCT was identified [18], comparing the outcome of one study reported on cases of DO using OMGU and PSGU,
DO OMGU versus VO OMGU. and VO using OMGU [55].

3.2.2. Characteristics of NRCSs
A prospective study design was used in one NRCS [20] but the
remaining three studies were retrospective [19,21,22]. Two
studies compared DO with VO urethroplasty [19,20] and one
of these included OMGU and PSGU DO cases [19]. One study
compared DI with VO OMGU [21] and the remaining study
compared DO, DLO, and VO procedures [22].
3.2.3. Characteristics of case series
Thirty-six case series studies were identified [6,10,13,23–
55]. For DO urethroplasty, 13 studies reported on OMGU
[23,24,30,36,37,39,40,42,46,49,51–53], five on PSGU
[10,25,29,31,32], and three on a mix of OMGU and PSGU
3.3. RoB and confounding assessment for the studies included
The RoB assessments are summarised in Figure 2 for the
RCTs, Figure 3 for the NRCSs, and Figure 4 for case series. The
single RCT had high risk of performance and detection bias,
but low risk for all other domains except other bias (short-
term follow-up of 12 mo), which was unclear. This study
was judged to be at low RoB overall.
In general, the NRCSs were considered at high RoB.
Selection, performance, detection, and attrition biases were
judged as high for the majority of the studies, with unclear
or high reporting bias. With respect to confounders, none of
the NRCSs considered or corrected for diabetes mellitus,

Fig. 2 – Risk of Bias graph and summary - RCT: Review authors' judgements about each risk-of-bias item for each randomised control trial included
presented individually and as a percentage.

Please cite this article in press as: Barratt R, et al. Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which
Technique Is Best? A Systematic Review. Eur Urol (2021), https://doi.org/10.1016/j.eururo.2021.03.026
EURURO-9338; No. of Pages 12

EU ROP E AN U RO LO GY XXX (2 021) XXX– XXX 5

Fig. 3 – Risk of Bias graph and summary - NRCS: Review authors’ judgements about each risk-of-bias item presented for each individual study and as a
percentage across all non-randomised comparative studies included.

smoking, or prior pelvic radiotherapy. Stricture length and
previous urethroplasty were considered but not adjusted
for in three studies [19–21] and two studies [19,21],
respectively. All case series were at high RoB.
3.4. Comparison of intervention and comparator outcomes
3.4.1. Primary outcome
3.4.1.1. Stricture recurrence
3.4.1.1.1. Dorsal onlay. A total of 1471 DO free graft urethro-
plasty cases are reported from 28 studies, of which
1093 represent OMGU and the remaining 378 PSGU
[6,10,18–20,22–27,29–33,36,37,39,40,42,46,48,49,51–53
,55]. Nine studies reported short-term mean or median
follow-up (<24 mo) [18,20,22–24,33,36,39,53], 12 studies
had medium-term follow-up (24–60 mo)
[6,10,30,31,37,40,42,46,48,49,51,52], and seven had long-
term follow-up of >5 yr, although these cohorts are from
the same institution and may represent duplicate data
[19,25,23–27,29,32,55].
The stricture recurrence rate (SRR) for all cases ranges
from 0% to 42.4% (Table 1) [27–33]. The SRR reported for
OMGU cohorts is as low as 0% (13.5-mo mean follow-up)
[33] up to 32% with extended follow-up [27]. In the PSGU
cohorts, SRR ranges from 5% [10] to 42.4% [27]. The majority
of the studies report SRR of <20% for DO OMGU cases, with

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EURURO-9338; No. of Pages 12

6 E U RO P E A N UROL OGY X X X ( 20 21 ) X X X –X X X

Fig. 4 – Risk of Bias graph and summary - Case series: Review authors’ judgements about each risk-of-bias item presented for each individual study
and as a percentage across all case series included.

Please cite this article in press as: Barratt R, et al. Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which
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EURURO-9338; No. of Pages 12

EU ROP E AN U RO LO GY XXX (2 021) XXX– XXX 7

Table 1 – Results for bulbar urethroplasty with a dorsal onlay

a
Study ID Re-stricture rate (%) Mean FU for series (mo) Prospective or retrospective Study design

OMG PSG Combined

D’Hulst et al, 2020 [36] 6.6 – – 12 Prospective CS

Redmond et al, 2020 [49] 1.7 – – 50 Retrospective CS
Furr et al, 2019 [40] 5.0 – – 51 Retrospective CS
Barbagli et al, 2019 [27] 32.0 42.4 37.9 134 (OMG) 241 (PSG) Retrospective CS
Fu et al, 2017 [39] 7.7 – – 12 Retrospective CS
Pathak et al, 2017 [22] 30.0 – – 12 Retrospective NRCS
Spilotros et al, 2017 [51] 9.5 – – >24 Retrospective CS
Spilotros et al 2017 [52] 12.1 – – 45 Retrospective CS
Vasudeva et al, 2015 [18] 7.5 – – 12 Prospective RCT
Barbagli et al, 2014 [55] 19.8 36.3 24.6 118 Retrospective CS
Kaggwa et al, 2014 [20] 20.0 – – 12 Prospective NRCS
Tabassi and Ghoreifi 2014 [53] 6.1 – – 18 Retrospective CS
Ahmad et al, 2011 [23] 13.0 – – 16 Retrospective CS
Arlen et al, 2010 [24] 9.5 – – 11 Retrospective CS
Barbagli et al, 2008 [19] 22.7 34.2 30.0 41 (OMG) 111 (PSG) Retrospective NRCS
Barbagli et al, 2008 [29] b – 34.2 – 111 Retrospective CS
O’Riordan et al, 2008 [46] 14.3 – – 34 Prospective CS
Levine et al, 2007 [42] 14.3 – – 53 Retrospective CS
Barbagli et al, 2007 [26] b 22.7 34.2 30.0 73 Retrospective CS
Barbagli et al, 2006 [25] – 26.7 – 71 Retrospective CS
Raber et al, 2005 [48] 15.4 23.5 20.0 51 Prospective CS
Dubey et al, 2005 [37] 9.8 – – 36 Retrospective CS
Barbagli et al, 2005 [30] 14.8 – – 42 Retrospective CS
Barbagli et al, 2004 [32] c – 26.7 – 71 Retrospective CS
Barbagli et al, 2001 [31] – 15.0 – 43 Retrospective CS
Andrich et al, 2001 [6] 4.8 – – 48 Retrospective CS
Barbagli et al, 1998 [33] 0 9.7 8.1 22 Retrospective CS
Barbagli et al, 1996 [10] – 5.0 – 46 Retrospective CS

CS = case series; FU = follow-up; NRCS = nonrandomised controlled trial; OMG = oral mucosal graft; PSG = penile/preputial skin graft; RCT = randomised
controlled trial.
a
Study design in terms of how the data were handled for the purposes of this review.
b
Overlapping cases with Barbagli 2008 [19].
c
Overlapping cases with Barbagli 2006 [25].

only five reporting rates 20% [19,20,22,26,27]. For PSGU
cases there are only a handful of studies with probable
duplication of data, so the broad SRR spread is difficult to
comment on. Two studies reported on the timing of
stricture recurrence and found that the majority of
recurrences occur in the first 2 yr (57–66%) [32,46].
In the NRCSs and RCT, DO was not shown to be superior
to any other technique.
3.4.1.1.2. Ventral onlay. Nineteen studies report on 2070 VO
cases, of which all but 33 (PSGU) represent OMGU [6,13,18–
22,27,28,34,35,38,41,43–45,50,54,55]. The mean/median fol-
low-up reported was short-term (<24 mo) in five studies
[18,20,22,38,45], medium-term (24–60 mo) in 11 studies
[6,13,19,21,34,35,41,43,44,50,54], and long-term (>60 mo; may
include duplicate data) in only three studies [27,28,55].
The SRR for all studies reporting on VO cohorts ranges
from 5.6% to 25.7% (Table 2) [41,44]. All studies but one [44]
report SRR  20%. Only one study reported on VO PSGU in a
cohort of 33 patients, with SRR of 6.1% [43]. One study
reported a mean time to recurrence of 10 mo [34].
VO was not found to be superior to any other technique
in terms of SRR in any of the comparative studies reviewed.
3.4.1.1.3. Dorsal inlay. Three studies reported outcomes for
DI OMGU in 94 patients, with all studies achieving
medium-term follow-up [21,27,47]. SRRs range from 8%
to 21.6% [27,47]. No statistically significant difference
was found in primary outcome between DI and other
techniques.
3.4.1.1.4. Dorsolateral onlay. Only one study (one arm of an
NRCS) reported on DLO OMGU with sufficient numbers in
the cohort to meet the inclusion criteria for this review. SRR
was 21% over short-term follow-up of 12 mo for 48 patients
[22].
3.4.2. Secondary outcomes
Secondary outcome data were sparsely reported for most
studies and are described below in terms of the technique
used where data are available.
3.4.2.1. Postoperative sexual dysfunction
3.4.2.1.1. Dorsal onlay. Where reported specifically for DO
procedures, ED rates range from 0% [20,21,24,37,42,53] to
12.1% [46,49,52]. Andrich et al [6] reported on pooling of
semen, which was found in all patients but reported as
bothersome by only 17%.
Two studies reported on postoperative sexual dysfunc-
tion. Furr et al [40] reported that postoperative Sexual
Health Inventory for Men scores were >15 (denotes mild or

Please cite this article in press as: Barratt R, et al. Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which
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Table 2 – Results for bulbar urethroplasty with a ventral onlay

a
Study ID Re-stricture rate (%) Mean FU for Prospective or Study design
series (mo) retrospective
OMG PSG Combined

Elkady et al, 2019 [38] 10.0 – – 19 Prospective CS

Vetterlein et al, 2019 [54] 17.2 – – 32 Retrospective CS
Barbagli et al, 2019 [27] 18.2 – – 91 Retrospective CS
Pathak et al, 2017 [22] 11.4 – – 12 Retrospective NRCS
Rosenbaum et al, 2016 [50] 14.3 – – 26 Retrospective CS
Barbagli et al, 2014 [55] 18.5 – – 118 Retrospective CS
Chen et al, 2014 [35] 10.0 – – 57 Retrospective CS
Kaggwa et al, 2014 [20] 15.6 – – 12 Prospective NRCS
Mellon and Bihrle 2014 [44] 25.7 – – 39 Retrospective CS
Vasudeva et al, 2015 [18] 10.0 – – 12 Prospective RCT
Barbagli et al, 2013 [28] 14.5 – – 62 Retrospective CS
Chen et al, 2013 [34] 17.4 – – 58 Retrospective CS
Haque et al, 2012 [41] 5.6 – – 36 Prospective CS
Palminteri et al, 2012 [21] 4.1 – – 43 Retrospective CS
Barbagli et al, 2008 [19] 8.6 – – 36 Retrospective NRCS
Lumen et al, 2008 [43] 12.5 6.1 – 36 Retrospective CS
Kane et al, 2002 [13] 5.7 – – 25 Retrospective CS
Meneghini et al, 2001 [45] 20.0 – – 13 Retrospective CS
Andrich et al, 2001 [6] 13.8 – – 48 Retrospective CS

CS = case series; FU = follow-up; NRCS = nonrandomised controlled trial; OMG = oral mucosal graft; PSG = penile/preputial skin graft; RCT = randomised
controlled trial.
a
Study design in terms of how the data were handled for the purposes of this review.

mild to moderate ED) in 69% of DO cases, with a mean
ejaculatory score of 1.59 (range 1–5, 1 = no bother). This
study also reported other types of sexual dysfunction, all in
<20% of cases. Raber et al [48] assessed patients in OMGU
and PSGU cohorts and found no statistically significant
difference between pre- and postoperative International
Index of Erectile Function scores for the ED domain for
either group, but did find a significant decrease in orgasmic
function at 18 mo for PSGU cases.
One NRCS comparing DO and VO OMGU reported an ED
rate of 0% for both techniques [20].
3.4.2.1.2. Ventral onlay. Two NRCSs reported on ED rates in VO
cohorts and both had a rate of 0% for all techniques (VO vs
DO and VO vs DI, respectively) [20,21].
Aside from comparative studies, one study reported a
1.7% rate of ED [34], one reported ejaculatory dysfunction in
24% of cases [38], and one reported post-ejaculation semen
pooling in 21% of subjects [6].
3.4.2.1.3. Dorsal inlay. One NRCS reported an ED rate of 0% in a
DI OMGU cohort that was equivalent for the comparative
VO OMGU cohort [21].
LUTS; one study, reporting on both PSGU and OMGU [48],
showing that this had improved from a score in the
moderate range pre-operatively (only reported in successful
cases).
3.4.2.2.2. Ventral onlay. Two VO case series reported solely on
PMD, with rates of 20% [38] and 21% [6].
3.4.2.3. Postoperative patient satisfaction
3.4.2.3.1. Dorsal onlay. Two DO case series found high
satisfaction rates. Furr et al [40] reported patient satisfac-
tion (available for 80% of the cohort) at 96.9% (failure rate
5%) and O’Riordan et al [46] reported that 6.1% of their
cohort were dissatisfied with urinary flow (failure rate
14.3%).
One study of PSGU and OMGU cases [48] reported an
improvement in the International Prostate Symptom Score
quality-of-life domain score from 5.1 preoperatively (poor
quality of life) to 1.0 postoperatively (only for cases without
recurrence).
3.4.2.4. Postoperative requirement for urinary diversion

3.4.2.2. Postoperative LUTS
3.4.2.2.1. Dorsal onlay. Postmicturition dribble (PMD) was
reported in several case series [6,40,46,48,51–53] and
ranged from 0% [53] to 28.1% [40]. Two studies reported
on postoperative symptom scores for LUTS [40,48]. Both
reported postoperative scores in the range indicative of mild
3.4.2.4.1. Dorsal onlay. A postoperative requirement for urinary
diversion was only reported in three DO case series
[29,32,48]. In two DO PSGU cohorts from the same centre,
the rates of postoperative urinary diversion in the form of
perineal urethrostomy were 13.3% and 18.4%, although it is
likely that these cohorts overlap [29,32]. Raber et al [48]
also reported a perineal urethrostomy rate of 6.7% in a

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Technique Is Best? A Systematic Review. Eur Urol (2021), https://doi.org/10.1016/j.eururo.2021.03.026
EURURO-9338; No. of Pages 12
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combined PSGU/OMGU cohort.
3.4.2.5. Postoperative 30-d complications
3.4.2.5.1. Dorsal onlay. In the RCT, the postoperative complica-
tion rate was 7.5% after DO OMGU compared to 15% in the
VO cohort without reaching statistical significance
[18]. Complication rates were also reported in one NRCS
(DO OMGU vs VO OMGU), which were 2.5% for DO versus
6.3% for VO (statistical analysis not performed) [20]. Five
retrospective and two prospective case series reported
complication rates ranging from 0% [6,30,32] to 7.3% [23,49],
and from 13.4% to 22.4% [46,48], respectively.
3.4.2.5.2. Ventral onlay. Comparative data did not find any
statistically significant difference in complications between
VO and DO OMGU, with rates in the VO population outlined
above [18,20]. Five retrospective and two prospective case
series describe rates ranging from 0% [6,45] to 7.4%
[13,34,43], and from 2.8% [41] to 4% [38], respectively.
Complications for VO included two cases of urethrocuta-
neous fistula [41] and one case of urethral diverticulum [34],
are unique to the procedure.
3.4.2.6. Contrast leak on postoperative urethrography
3.4.2.6.1. Dorsal onlay. Four case series reported extravasation
rates ranging from 2.4% to 19.2% [10,29,37,46].
3.4.2.6.2. Ventral onlay. Three case series and one NRCS
reported leakage rates ranging from 2% to 14.8%
[21,38,43,54].
3.4.2.6.3. Dorsal inlay. One NRCS reported an extravasation rate
of 6.3%. The rate in the comparative VO cohort was 4.1%; no
statistical analysis of these outcomes was performed [21].
4. Discussion
At the bulb, the urethra lies eccentric in the corpus
spongiosum, with sparse spongiosum dorsally but abun-
dant spongiosum ventrally. The dorsal aspect of the urethra
is also closely approximated to the corpora cavernosa. These
anatomic features partly explain the hypothetical advan-
tages and disadvantages of VO, DO, DI, and DLO. To evaluate
whether this translates to actual difference in clinical
outcomes, a systematic review is necessary to provide a
high level of evidence. A 2011 systematic review by
Mangera et al [56] covered all techniques for anterior
urethroplasty. We have updated this evidence, focusing on
single-stage free graft techniques for the bulbar urethra and,
further to the evidence provided by Mangera et al, report on
secondary outcome measures.
4.1. Principal findings
This systematic review extracted data from 41 studies
(3683 patients) on free graft urethroplasty using either DO,
VO, DLO, or DI approaches. Owing to a paucity of studies
Please cite this article in press as: Barratt R, et al. Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which
Technique Is Best? A Systematic Review. Eur Urol (2021), https://doi.org/10.1016/j.eururo.2021.03.026
9
reporting on DI and DLO with sufficient cohort size, it is
hard to draw any firm conclusions for these procedures. For
DO and VO procedures, outcomes often varied because of
incomplete outcome reporting, retrospective design, and
variable cohort sizes and follow-up duration.
The single RCT was assessed as having low to unclear RoB
overall, as RoB was low in general, except for the high risk of
performance and detection bias. All other studies included
were at high RoB and therefore the overall quality of
evidence is low from this perspective.
Most studies for both DO and VO OMGU report SRR of
20% at short- to medium-term follow-up (12 mo–5 yr).
Although there are only limited data available for DI and DLO
procedures, SRRs are 21%, again at short-medium term
follow-up. Reported SRRs are broadly in line with the findings
of Mangera et al [56], who reported average success rates of
88.8% at 34.3-mo follow-up for a VO cohort of 563 patients,
and 88.3% at 42.2-mo follow-up for DO cohort of 934 patients.
However, it should be noted that the majority of the studies
included are from a small number of high-volume centres and
therefore the SRR may not be replicable in other settings.
The RCT and NRCSs in our systematic review did not
exhibit any statistically significant difference in SRR
between any of the four techniques.
Only one retrospective study compared PSGU and OMGU
(DO cohort) and found no statistically significant difference
between the two graft sources [19]. Otherwise, no direct
comparative studies between PSGU and OMGU were
retrieved. Therefore, there is insufficient evidence to make
any recommendations with respect to graft material.
In this systematic review, 12 of the papers are from a
single institution under the authorship of Barbagli (includ-
ing one joint series with Kulkarni et al) and it is
acknowledged that these papers may include overlapping
cohorts [10,19,25–33,55]. However, these studies are able to
demonstrate a deterioration in SRR with extended follow-
up. The SRR increased for DO OMGU from 22.7% at 41 mo to
32% at 134 mo [19,27]. A similar deterioration was observed
for DO PSGU, with SRR of 42.4% at a mean follow-up of
241 mo compared to 26.7% at 71 mo [25,27].
Secondary outcomes were generally poorly reported.
RCT and NRCSs had limited secondary outcome reporting
and therefore these studies cannot provide any robust
comparative data to help in determining any differences
between techniques. The case series data are equally sparse,
with 15 studies reporting at least one secondary outcome in
DO cohorts and only seven studies in VO cohorts. Three
studies, all in DO cohorts, report extensively on secondary
outcomes with robust data collection measures, resulting in
higher rates compared to other studies [40,46,48]. There-
fore, it is likely that the true rate of secondary outcomes
may exceed currently published figures. On the basis of the
evidence, it is not possible to draw any firm conclusions
with respect to secondary outcomes.
4.2. Implications for clinical practice
Graft take is of utmost importance to provide a patent
urethra and prevent stricture recurrence, and requires a
EURURO-9338; No. of Pages 12
10 E U RO P E A N UROL OGY X X X ( 20 21 ) X X X –X X X
healthy, well-vascularised graft bed for graft imbibition
and inosculation. For VO, the graft bed is provided by the
ventral spongious tissue, which is abundant, particularly
in the proximal bulb. For DO, DI, and DLO, the graft bed is
provided by the tunica albuginea of the corpora caver-
nosa, which, as opposed to spongiosum, is not affected by
spongiofibrosis.
The only RCT failed to show a difference in SRR between
VO and DO, and the other studies did not provide any robust
evidence to prove superiority of one technique over the
other. It is reasonable to assume that both techniques
provide graft beds suitable for hosting a urethral substitute.
This review highlights a significant lack of data in the
literature on DLO and DI, with only one [22] and three
[21,27,47] studies, respectively, meeting inclusion criteria.
Therefore, no firm recommendations regarding the use of
these techniques can be made on the basis of current
evidence.
Studies with long-term follow-up included in this review
highlight the importance of counselling and monitoring
patients for long-term recurrence beyond 5 yr [27,55]. Al-
though an accurate prediction of risk of further recurrence
is not possible in this review, it is clear that SRRs do not
plateau and indeed continue to increase with follow-up
duration.
Aside from providing an adequate graft bed, each
technique has been devised with the aim of improving on
specific secondary outcomes.
It is thought that dorsal approaches using the firm
support of the tunica albuginea reduce the risk of urethral
diverticulum (and associated PMD) and urethrocutaneous
fistula compared with VO. However adequate tailoring of
the graft, spongioplasty, and multilayer closure over the
graft with VO procedures should mitigate this. Accordingly,
in this review only one case of diverticulum formation was
reported (in a VO cohort), and rates of PMD did not
markedly differ between DO and VO, although there was a
large range for the dorsal approach (0–28%). Urethrocuta-
neous fistula was universally rare, with no cases reported in
the DO cohort and only two for VO.
By contrast, VO and DI techniques (and to a lesser extent
DLO) were proposed because of the perceived potential for
lower ED rates as a result of minimising the degree of
urethral dissection required, in particular in relation to the
corporal bodies [11,12,14]. However, this review could not
identify any differences in ED (or sexual dysfunction)
between techniques from the limited data in the literature.
Overall, it is likely that the true rates of secondary
outcomes are not known and may exceed currently
published figures.
Finally, it is important to acknowledge that selection bias
by the operating surgeon is likely to be present in most
studies. Specific patient characteristics and surgeon expe-
rience may influence the choice of technique used and this
individual decision-making may affect SRRs. Given the lack
of strong data to recommend one technique over another, it
is probably most important for surgeons to be able to ensure
that they can achieve reproducible outcomes in the same
range as the literature presented here for whichever
Please cite this article in press as: Barratt R, et al. Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which
Technique Is Best? A Systematic Review. Eur Urol (2021), https://doi.org/10.1016/j.eururo.2021.03.026
technique they use. It is also important to stress that one
specific graft location is not sufficient to treat all bulbar
urethral strictures, and versatility in shifting from one
technique to another in the case of adverse intraoperative
findings may be more important to avoid recurrence than
the graft location.
4.3. Implications for further research
The low level of evidence available for this systematic
review highlights the urgent need for further research. It is
important to promote high-quality, low-RoB studies of
either comparative design or RCTs, although this can be
difficult in surgical settings. It is also not unreasonable to
produce further case series given the value they can bring
for less common procedures, but these must be well-
designed prospective studies with an a priori protocol,
robust outcome measurements, and minimal loss to follow-
up to minimise bias. Future projects should aim for robust
secondary outcome reporting, as we observed limited
reporting of these data, which are often valued highly by
patients.
We highlight the importance of standardising the
reporting of urethroplasty outcomes: a standardised
definition of recurrence should be used, as well as pre-
and postoperative data and validated patient-reported
outcome measures to report secondary outcomes, so that
comparisons can be made with limited heterogeneity in
outcome measurement.
4.4. Limitations and strengths
Owing to the low quality of evidence, the overall high RoB,
and limited reporting of secondary outcomes, it is
impossible to draw any definitive conclusions; it is only
possible to observe potential trends and narratively report
the data. Moreover, owing to the inclusive nature of the
methodology for this systematic review (in terms of the
definitions of outcomes) a great degree of heterogeneity
across studies was observed. Unfortunately, owing to the
low number of NRCSs/RCTs, the planned subgroup analysis
could not be performed, so a narrative review of time to
recurrence and outcomes by graft type was conducted
instead. Finally, different geographical locations are
associated with marked differences in the aetiology,
presentation, and management of urethral stricture
disease, so the geographical spread of the studies included
(approximately 1:3 studies from well- vs low-resourced
countries, respectively, with 80% of all patients from a
well-resourced country) is an accepted limitation of this
study.
However, this systematic review has a rigorous, well-
designed methodology aimed at including as many relevant
cohorts as possible while maintaining standards to ensure
that the studies selected provided meaningful information.
The review also uniquely provides data on secondary
outcomes. By appropriately reporting the data using a
narrative synthesis, we have reduced the risk of drawing
EURURO-9338; No. of Pages 12
EU ROP E AN U RO LO GY XXX (2 021) XXX– XXX
inaccurate conclusions despite the variable study design,
heterogeneity, and high RoB.
5. Conclusions
Our systematic review revealed a paucity of well-designed,
robustly reported studies and trials on free graft bulbar
urethroplasty in the literature and this should be a subject
for future research. There is insufficient evidence to state
that DO is superior to VO (or the reverse) in terms of
stricture recurrence, sexual function, LUTS, diversion,
leakage, or complications. We judged that there are
insufficient data to comment on DI or DLO bulbar
urethroplasty. Results after bulbar free graft urethroplasty
tend to deteriorate with time.
Author contributions: Rachel Barratt had full access to all the data in the
study and takes responsibility for the integrity of the data and the
accuracy of the data analysis.
Study concept and design: Barratt, Chan, La Rocca, Dimitropoulos,
Martins, Juanatey, Greenwell, Waterloos, Riechardt, Osman, Esperto,
Ploumidis, Lumen.
Acquisition of data: Yuan, Barratt, La Rocca.
Analysis and interpretation of data: Barratt, Chan.
Drafting of the manuscript: Barratt, Chan, Dimitropoulos, Lumen.
Critical revision of the manuscript for important intellectual content:
Barratt, Chan, Dimitropoulos, Lumen.
Statistical analysis: None.
Obtaining funding: None.
Administrative, technical, or material support: Barratt, Chan, La Rocca.
Supervision: Dimitropoulos, Lumen.
Other: None.
Financial disclosures: Rachel Barratt certifies that all conflicts of
interest, including specific financial interests and relationships and
affiliations relevant to the subject matter or materials discussed in the
manuscript (eg, employment/affiliation, grants or funding, consultan-
cies, honoraria, stock ownership or options, expert testimony, royalties,
or patents filed, received, or pending), are the following: Nicolaas Lumen
has received grants/research support and speaker honoraria from Bayer
and Janssen and has participated in trials sponsored by Janssen
(Galamad), Roche (Ipatential), Pfizer Belgium, and AstraZeneca. Felix
Campos Juanatey is a consultant for Boston Scientific; has received
speaker honoraria from ROVI; and has received accommodation/travel
grants from Rubio, SOBI, Janssen, and Almirall S.A. Tamsin Greenwell has
participated in a speaker bureau for Allergan; has received accommoda-
tion/travel grants from SPE Pharma, Astellas, and Medtronic; has
received speaker honoraria from Genesis Medical, Allergan, Astellas,
and Colplast; has participated in trials sponsored by Medtronic and
Axonics; has received grants/research support from Contura, Laborie,
Boston Scientific, Medtronic, Allergan, Axonics, Ferring, Pierre Fabre,
Vesica Urology, and Aspire Pharma; is past chair of the BAUS FNUU
Committee; and is a member of the editorial board of the Journal of
Clinical Urology. Nadir Osman has received honoraria/consultation fees
from Astellas. Francesco Esperto is a database manager for Biohealth
Italia. Achilles Ploumidis is a director/employee of the Athens Private
Practice for robotics and endoscopic urology; has received speaker
honoraria from ESU, OLV Robotic Surgical Institute, and EUREP; has
Please cite this article in press as: Barratt R, et al. Free Graft Augmentation Urethroplasty for Bulbar Urethral Strictures: Which
Technique Is Best? A Systematic Review. Eur Urol (2021), https://doi.org/10.1016/j.eururo.2021.03.026
11
received accommodation/travel grants from Astellas; has participated in
an EAU/AUA exchange program; and is a member of the Hellenic Society
of Reproductive Medicine. The remaining authors have nothing to
disclose.
Funding/Support and role of the sponsor: None.
Appendix A. Supplementary data
Supplementary material related to this article can be
found, in the online version, at doi:https://doi.org/10.1016/j.
eururo.2021.03.026.
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