Comparative outcomes of buccal mucosa graft versus inner preputial flap substitution urethroplasty for long-segment anterior urethral stricture: A retrospective cohort study

Introduction: Long bulbar urethral strictures not amenable to excision and primary anastomosis are best managed with substitution urethroplasty. Buccal mucosa grafts (BMGs) and inner preputial flaps (IPFs) are the most established options, each with advantages and limitations. Materials and Methods: A total of 100 patients (age 26–62 years, mean stricture length 3.5 cm) underwent single-stage dorsal onlay substitution urethroplasty using either BMG ( n = 60) or IPF ( n = 40). Preoperative evaluation included retrograde urethrography, uroflowmetry (Qmax), postvoid residual volume, and questionnaires (International Prostate Symptom Score IPSS; International Index of Erectile Function-5). Surgical success was defined as Qmax ≥15 mL/s, IPSS <8, and no obstructive symptoms or re-intervention. Patients were followed at 6 and 12 months. Stricture-free survival was analyzed using Kaplan–Meier estimates. Results: Both groups demonstrated significant improvement in urinary flow and symptom scores at follow-up, with preservation of erectile function. At 6 months, composite surgical success was observed in 85% of patients undergoing BMG urethroplasty and 78% of those undergoing IPF urethroplasty ( P = 0.09). At 12 months, stricture-free survival was 92% in the BMG group and 84% in the IPF group (log-rank P = 0.12). Complication rates were low and comparable between groups, with no Clavien–Dindo grade ≥ III events. Conclusion: Both BMG and IPF urethroplasty achieve excellent 1-year outcomes. BMG shows a trend toward greater durability and technical simplicity, whereas IPF remains a valuable option when oral harvest is contraindicated.