Crafting the graft: an umbrella review of long-term outcomes and complications for various graft usage in urethral reconstruction

The optimal graft choice for urethral reconstruction remains debated. This umbrella review synthesised evidence from systematic reviews and meta-analyses on graft materials, focusing on success, complications, and long-term outcomes. PubMed and Scopus were searched to March 2025 for reviews of patients undergoing graft-based urethral reconstruction. Eligible studies reported outcomes including success, donor-site morbidity, complications, stricture recurrence, stricture-free survival, operative efficiency, and postoperative parameters. GRADE assessed certainty, with analyses stratified by graft type and, where available, by sex or indication. Twelve reviews (2012–2025) covering 9,829 patients met criteria. Ten examined males—nine adults (three mixed etiologies, others strictures) and one pediatric hypospadias. Two included both sexes, with female cases limited to anterior strictures. Buccal mucosa grafts (BMG) were most studied, showing success > 80%. Meta-analyses found no significant difference between BMG and penile skin grafts (OR 0.83, 95% CI 0.55–1.23, I²=88%) or lingual mucosa grafts (OR 1.18, 95% CI 0.79–1.77, I²=63%). Low review quality was found in studies involving females, children, and some males, due to small sample sizes, risk of bias, lack of PROSPERO registration, and inconsistencies with meta-analysis methods, resulting in low GRADE certainty. BMG remains most effective, but evidence for women and children is scarce. Future studies should prioritise sex-stratified data, scoping reviews, and clinical algorithms.