Efficacy of ventral onlay autologous tunica vaginalis graft in bulbar urethroplasty: An 11- year experience

Efficacy of ventral onlay autologous tunica vaginalis graft in bulbar urethroplasty: An 11- year experience | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Efficacy of ventral onlay autologous tunica vaginalis graft in bulbar urethroplasty: An 11- year experience Kenan YALÇIN, Engin KÖLÜKÇÜ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8930131/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background: Urethral stricture disease in men has historically been one of the most challenging urological problems. The treatment of complex urethral strictures, in particular, poses a major challenge due to urethral scarring and fibrosis of the surrounding corpus spongiosum. Although various tissue types have been proposed for surgical reconstruction, the optimal graft material remains a subject of ongoing debate. In this study, we aimed to analyze the efficacy of using a ventral onlay autologous tunica vaginalis graft (TVOG) in bulbar urethroplasty. Methods: Data from 43 patients diagnosed with bulbar urethral stricture and treated with the ventral onlay TVOG technique at our clinic between 2011 and 2022 were retrospectively reviewed. Patient age, American Society of Anesthesiologists (ASA) score, stricture length, number of internal urethrotomies performed, operative time, etiological factors, body mass index (BMI), length of hospital stay, time-dependent uroflowmetry Qmax values, and postoperative complications were recorded. Criteria for success were defined as patient satisfaction, a Qmax value exceeding 16 mL/s, patent urethrogram findings, and the absence of any need for dilation or further instrumentation during the follow-up period. Results: The overall success rate was 74,4%. Failure occurred in 6 cases due to severe wound infection. Recurrent urethral stricture was detected in 5 cases. Superficial surgical site infection or hematoma was observed in 6 cases. No diverticulum formation was observed in any patient. Successful voiding was achieved in a total of 33 cases, with uroflowmetry Qmax values measured at 17 mL/s or higher. Comparison of Qmax values demonstrated a statistically significant difference (p < 0.05). Furthermore, no patient reported scrotal pain or discomfort during the follow-up period. Conclusions: The outcomes of using ventral onlay TVOG in bulbar urethroplasty appear favorable. Based on the data obtained from our study, it can be concluded that TVOG may be considered an alternative method in this field. Urethral stricture autologous tunica vaginalis graft ventral onlay bulbar male Figures Figure 1 Figure 2 Figure 3 Introduction Urethral stricture arises from the narrowing of the urethral lumen due to fibrosis occurring in the epithelial tissue and the corpus spongiosum [ 1 ]. The most frequently affected segment is the bulbar urethra, accounting for approximately 45% of cases [ 2 ]. Various surgical methods are utilized in the treatment of bulbar urethral strictures. The length of the stricture, the severity of spongiofibrosis, and the experience of the surgeon are key factors in treatment selection. In the majority of patients with urethral stricture, the therapeutic approach has shown a trend toward urethroplasty. An increasing number of reconstructive urologists prefer urethroplasty techniques over repeated endoscopic dilations or multiple internal urethrotomy applications [ 3 ]. This paradigm shift has been facilitated by the high cure rates achieved in both augmentation and anastomotic urethroplasties. In patients with a stricture length of less than 2 cm, stricture excision and primary anastomosis remains the most widely used treatment method due to its favorable long-term outcomes [ 4 ]. Substitution urethroplasty using a buccal mucosal graft (BMG) has been established as the gold standard for treating bulbar urethral strictures longer than 2 cm to prevent the risk of penile chordee or shortening associated with excision and reanastomosis [ 5 , 6 ]. However, the ideal graft tissue for urethroplasty remains a matter of ongoing debate [ 7 ]. TVOG is an easier method to harvest and faster to apply compared to other materials. The proximity of the donor site to the surgical field and the abundant availability of the tissue provide significant advantages. The use of a tunica vaginalis graft has the potential to substantially shorten the operative time. Reducing the duration of surgery offers important benefits, particularly in preventing complications that may develop due to prolonged high lithotomy positioning. However, the number of urethroplasty studies using TVOG in the literature is quite limited. Nevertheless, it is reported that the results of existing studies in this area are promising [ 8 , 9 ]. In an experimental study conducted on an animal model, a tunica vaginalis graft was used instead of buccal mucosa in dorsal urethroplasty, and radiographic and histological analyses demonstrated that a patent and functional urethra was successfully maintained in all animals. Furthermore, no infection or fistula formation was encountered [ 10 ]. Additionally, TVOG has been successfully used as a protective interposition layer in peyronie's disease surgery and during hypospadias repair [ 11 – 14 ]. In this study, we aimed to evaluate the efficacy of the outcomes in 43 patients who underwent the ventral onlay TVOG method during bulbar urethroplasty. Methods Ethical approval and consent to participate This study was conducted in accordance with the approval of the Local Ethics Committee of the Tokat Gaziosmanpaşa University Faculty of Medicine (Approval No: 26-MOBAEK 052 Date: February 20, 2026). Data from 43 patients diagnosed with bulbar urethral stricture and treated with the ventral onlay TVOG method at our clinic between 2011 and 2022 were analyzed. The research was planned in compliance with the Declaration of Helsinki, and written informed consent was obtained from all participants prior to their inclusion in the study. Study Design Forty-three patients who were diagnosed with bulbar urethral stricture at our clinic between 2011 and 2022, were not suitable for end-to-end urethral anastomosis, and underwent repair with ventral onlay TVOG were included in the study. Patients with urethral strictures outside the bulbar urethra, neurogenic bladder, a diagnosis of lichen sclerosus, a history of prior radiotherapy, a history of failed hypospadias repair, or prior scrotal surgery were excluded from the study. Male patients who underwent ventral onlay TVOG urethroplasty due to a bulbar urethral stricture longer than 2 cm and had at least 2 years of follow-up were retrospectively evaluated for age, ASA scores, stricture lengths, number of previous internal urethrotomies, operative times, etiological causes, BMI, length of hospital stay, time-dependent uroflowmetry Qmax values, and postoperative complications. Various urethroplasty procedures were performed at our center over an eleven-year period; in this study, substitution urethroplasty using TVOG was performed on 43 patients who met the inclusion criteria mentioned above. No other graft material was used by the same surgeon in any of these patients. Surgical technique Preoperative evaluation for all patients included clinical history, physical examination, urine culture, uroflowmetry, and retrograde and voiding cystourethrography (Fig. 1 a). A third-generation cephalosporin antibiotic (50–100 mg/kg) was administered prophylactically to all cases prior to surgery. General or spinal anesthesia was administered to all patients. Before proceeding with the surgical intervention, the external genitalia were re-evaluated by examination under anesthesia. Cystoscopy was performed on all patients, the starting point of the stricture was identified, and if a lumen was present in the urethra, a guide wire was advanced into the bladder. Subsequently, while the patient was in the lithotomy position, the bulbocavernosus muscle was divided via a midline perineal incision, and the bulbar urethra was exposed. The ventral urethral surface was incised in the midline until the catheter tip and the urethral lumen were revealed. The urethrotomy was then extended both distally and proximally, incising the stricture along its entire length. Following the complete opening of the stricture, the length and width of the remaining urethral plate were measured (Fig. 2 a, 2 b). These measurements were taken to determine the exact extent and length of the stricture expansion. The tunica vaginalis graft was harvested through the same incision line in dimensions appropriate to the length and width of the urethral defect (Fig. 2 c). The graft was cleared of overlying fatty tissues and preserved in saline until it was ready for placement at the recipient site. Starting from the proximal end of the opened urethra, the graft was sutured to the urethral mucosa using 5/0 continuous sutures. After one edge was sutured, an 18 Fr silicone catheter was placed into the reconstructed urethra. The suturing of the other edge was then completed, and the graft was fully spread and quilted (Fig. 2 d–g). The muscle and serosa of the urethra were closed over the graft as a second layer (Fig. 2 h). Subsequently, the other layers were anatomically closed, and the surgical procedure was concluded. Follow-up A non-adherent compressive bandage was applied and left in place for three days. In the postoperative period, patients were administered parenteral antibiotics and non-steroidal anti-inflammatory drugs until discharge. Patients were discharged within 2–4 days postoperatively, with instructions that the 18 Fr silicone catheter would be removed after 21 days. Following the removal of the urethral catheter, patients were evaluated with retrograde urethrogram and uroflowmetry. Subsequently, patients were monitored with uroflowmetry during follow-up visits at the 3rd, 6th, 12th, and 24th months, respectively. Urethroscopy was performed in cases where stricture was suspected. The success of the treatment was evaluated based on the criteria of patient satisfaction, a Qmax value exceeding 16 mL/s, patent urethrogram findings, and the absence of any need for dilation or instrumentation during the follow-up period. Statistical analysis Statistical analyses were performed using the MedCalc (version 20.009; Ostend, Belgium) statistical software package. The Kolmogorov–Smirnov test was used to evaluate whether the data conformed to a normal distribution. Continuous data were expressed as mean ± standard deviation (SD) when they followed a normal distribution, and as median with 25th and 75th percentile values when they did not. Categorical data were defined as frequency and percentage. The Friedman test was used to compare preoperative and postoperative 3rd, 6th, 12th, and 24th-month Qmax (mL/s) values. Post-hoc analyses were performed at the α = 0.05 level, and time-dependent changes in Qmax (mL/s) values were indicated with different letters in the table. Comparisons of Qmax (mL/s) values were presented visually in a bar chart as median (95% confidence intervals). In the interpretation of the results, a statistical significance level of p < 0.05 was accepted. Results The median age of the patients participating in the study was 59.0 years, and the average duration of the operations was calculated as 104.5 ± 8.4 minutes. The median length of the stricture observed in the bulbar urethra was 4.0 cm, while the mean number of internal urethrotomies performed prior to surgery was determined to be 4.0. The median ASA score of the patients was 2.0 and their median BMI was 27.0 kg/m². The etiological causes of the strictures were identified as iatrogenic, idiopathic, and traumatic, with rates of 55.8% (24 patients), 25.6% (11 patients), and 18.6% (8 patients), respectively. The median length of stay in hospital was determined to be 3 days. Surgical failure was recorded in six patients (14.0%) due to severe wound infection. Additionally, recurrent urethral stricture was reported in five patients (11.6%), while superficial infection or hematoma development was observed in six patients (14.0%). However, no diverticulum formation was observed in any patient (Table 1 ). Successful voiding was achieved in thirty-three cases, with uroflowmetry Qmax values measured at 17 mL/s or higher (Table 2 ). A statistically significant difference was found when comparing preoperative Qmax values with those measured at the 3rd, 6th, 12th, and 24th postoperative months (p < 0.05) (Table 2 , Fig. 3 ). Table 1 Demographic characteristics and clinical findings Ventral Onlay N = 43 Age (years) , Median (25p-75p) 59,0 (46–63) ASA score , Median (25p-75p) 2,0 (1–2) BMI (kg/m²) , Median (25p-75p) 27,0 (25–28) Stricture length (cm) , Median (25p-75p) 4,0 (3–5) Number of internal urethrotomies , Median (25p-75p) 4,0 (3–4) Etiological factors , n (%) Idiopathic 11 25,6 Iatrogenic 24 55,8 Traumatic 8 18,6 Operation Duration (min) , Mean ± SD 104,5 ± 8,4 Length of hospital stay (days) , Median (25p-75p) 3,0 (3–3) Severe wound infection , n (%) Present 6 14,0 None 37 86,0 Recurrent urethral stricture , n (%) Present 5 11,6 None 38 88,4 Superficial infection or hematoma , n (%) Present 6 14,0 None 37 86,0 Diverticulum , n (%) None 43 100,0 Abbreviations: ASA: American Society of Anesthesiologists BMI: Body mass index Table 2 Comparison of Qmax (mL/s) values over time Qmax (mL/s) N = 43 Median 25p 75p F P-value Pre-op 7 a 7 8 46,5 < 0,00001 * Post-op (3rd month) 19 b 18 20 Post-op (6 months) 18 c 17 18,25 Post-op (12 months) 18 c 17 19 Post-op (24 months) 18 c 17 19 *: Significant differences according to the Friedman test are indicated by different letters (p < 0.05). p: Percentile Six patients who developed superficial infection or hematoma postoperatively were successfully treated with warm baths, antibiotics, and oral anti-inflammatory drugs. However, surgical intervention resulted in failure in six patients due to severe wound infection. These patients were followed with a suprapubic catheter for approximately six months. At least six months after the initial surgery, re-urethroplasty was performed using TVOG from the contralateral side. No recurrence of stricture was observed in these patients during the follow-up period. Furthermore, five patients who developed recurrent urethral stricture are being monitored with internal urethrotomy and urethral dilation; due to the short length of their strictures, re-urethroplasty was not deemed necessary for these patients. No scrotal pain or discomfort was detected in any patient during the follow-up period. Overall, patient satisfaction rates were at a very high level. Discussion While there is a general consensus in the literature that stricture excision and primary anastomosis yield high success rates in the treatment of short bulbar urethral strictures, various risks are associated with treating longer urethral segments via primary anastomosis [ 5 , 15 ]. Therefore, graft urethroplasty methods, which have reported high success rates, are recommended for the management of longer bulbar urethral strictures. Although dorsal, ventral, and dorso-lateral anastomosis techniques have been described, there is no strong evidence indicating that any of these methods possesses a significantly higher success rate than the others [ 16 ]. In the dorsal graft placement technique, the entire urethra is mobilized, and the graft is placed onto the corporal bodies. In the ventral technique, a ventral urethrotomy is performed at the stenotic segment, and the graft is placed over the urethrotomy defect. In the dorso-lateral technique, the urethra is mobilized unilaterally, and the graft is placed over the dorso-lateral urethrotomy defect [ 17 ]. The literature contains a limited number of studies regarding urethroplasty using TVOG. These studies reported promising results with dorsal graft placement [ 8 , 9 ]. In our study, the graft was placed ventrally, and the outcomes were found to be encouraging. Furthermore, we consider it significant that this study is among the pioneering works in this field. Researchers who advocate that dorsal graft placement is more appropriate suggest that this approach reduces the risk of diverticulum formation, provides better neovascularization as the graft is placed onto the corporal bodies, and that these advantages cannot be achieved with ventral graft placement. Conversely, proponents of ventral graft placement state that this technique provides more effective access to the proximal segment of the stricture, requires less urethral mobilization, and allows for the preservation of urethral vascularity. Additionally, it is argued that the bulbocavernosus muscle plays a role in preventing diverticulum formation [ 18 ]. In our clinical practice, we prefer the ventral graft placement method for bulbar urethroplasty. This technique allows for better access to the proximal part of the stricture, ensures less urethral mobilization, and more effectively preserves the vascular integrity of the urethra. Moreover, it is believed that this method permits the muscle and serosa of the urethra to be properly closed over the graft as a second layer, and that diverticulum formation is prevented by the anatomically correct closure of the bulbocavernosus muscle. In our study, no diverticulum formation was observed in any patient where ventral graft placement was utilized. Pathak et al. reported that ventral graft placement is technically easier than dorsal placement in terms of positioning and suturing the graft at the proximal anastomosis site. They also stated that ventral graft placement is the most likely factor in reducing stricture rates at the proximal anastomosis site compared to dorsal or dorso-lateral placement. Although the outcomes of ventral BMG placement appeared superior, no statistically significant difference was found. Nevertheless, they recommend considering ventral onlay graft placement as an option for treating bulbar strictures, particularly when the stricture involves the proximal bulbar urethra [ 19 ]. In our study, consistent with the results reported in the literature and independent of the graft type used, no significant difference in success rates was observed among ventral graft urethroplasties. Foinquinos et al.[ 8 ], in their initial study involving 11 patients who underwent tunica vaginalis dorsal graft urethroplasty, reported that all patients voided without issues during a follow-up period ranging from 7 weeks to 5 months, with uroflowmetry values exceeding 14 mL/s. Similarly, in a 10-year experience study of 52 patients by Hassan Ashmawy and Praise T. Magama involving tunica vaginalis dorsal graft urethroplasty, it was reported that voiding was successful in 42 cases, with a mean flow rate of 20 mL/s [ 9 ]. In contrast, evaluating the results of our 43 patients who underwent ventral rather than dorsal graft urethroplasty, our study found that successful voiding was achieved in 33 cases, with uroflowmetry Qmax values of 17 mL/s or higher during the two-year follow-up period. In the study conducted by Hassan Ashmawy and Praise T. Magama, the overall success rate was reported as 80.8%. Surgical intervention failed in five patients due to severe wound infection; however, tunica vaginalis urethroplasty was successfully re-performed in these patients 6–12 months later. Additionally, recurrent urethral stricture was observed in five cases over periods ranging from 3 to 18 months. Superficial surgical site infection developed in seven patients, but no patient reported postoperative testicular discomfort [ 9 ]. In the research by Foinquinos and colleagues, a postoperative complication developed in one patient in the early period, involving a small scrotal hematoma that resolved with drainage. Likewise, no patient in that study reported postoperative testicular discomfort [ 8 ]. In our own study, the overall success rate was determined to be 74.4%. Surgical failure developed in six patients due to severe wound infection; however, the tunica vaginalis urethroplasty procedure was successfully re-performed in these cases after six months. Five patients who developed recurrent urethral stricture are being monitored with internal urethrotomy and urethral dilation. Six patients who developed superficial infection or hematoma recovered with warm baths, antibiotics, and oral anti-inflammatory drug therapy. No scrotal pain or discomfort was detected in any patient during the follow-up process. These findings appear to be consistent with the limited existing literature on the subject. In an experimental study conducted on an animal model, the use of a tunica vaginalis graft instead of buccal mucosa was evaluated in a dorsal urethroplasty application. Radiographic and histological analyses demonstrated the presence of a patent and functional urethra in all animals, and no infection or fistula formation was encountered [ 10 ]. In a combined urethroplasty animal study conducted by Xiaoliang Hua et al. using dual tunica vaginalis grafts (both dorsal and ventral), the urethras of all rabbits were found to be patent. Histological analyses revealed that the tunica vaginalis graft fully integrated with the urethra by the fourth week after surgery and transformed into a urinary pseudostratified epithelium by the twelfth week [ 20 ]. These studies indicate that the tunica vaginalis graft can be successfully used in urethral stricture models. In our study, this graft was utilized effectively, and the results were found to be promising. Limitations We acknowledge that our study has several limitations. The relatively small sample size, the single-center and retrospective design, and the need for comparisons with a broader range of surgical techniques are the primary limiting factors. However, the objective of this study was not to compare the outcomes of penile skin, buccal mucosa, and tunica vaginalis among the graft materials used for urethroplasty. The main goal was to define a new alternative in reconstructive urethral surgery and to propose the use of tunica vaginalis as a graft material. Conclusions In our study, encouraging results were obtained using the tunica vaginalis free graft urethroplasty technique over an eleven-year period. This method is easily applicable, safe, and time-efficient. Nevertheless, further advanced studies comparing this technique with existing urethral substitution procedures by surgeons working in the field of reconstructive genitourinary surgery are needed. To the best of our knowledge, this study is considered to be the first long-term research utilizing the ventral onlay TVOG urethroplasty technique. Abbreviations TVOG: Autologous tunica vaginalis graft, BMI: Body mass index, BMG: Buccal mucosal graft, ASA: American Society of Anesthesiologists Declarations Ethical approval and consent to participate This study was conducted in accordance with the approval of the Local Ethics Committee of the Tokat Gaziosmanpaşa University Faculty of Medicine (Approval No: 26-MOBAEK 052 Date: February 20, 2026). Data from 43 patients diagnosed with bulbar urethral stricture and treated with the ventral onlay TVOG method at our clinic between 2011 and 2022 were analyzed. The research was planned in compliance with the Declaration of Helsinki, and written informed consent was obtained from all participants prior to their inclusion in the study. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding Not applicable. Authors` contributions KY developed the study design, performed the statistical analysis, and was responsible for the clinical management of patients. KY also drafted the manuscript and critically revised it for important intellectual content. KY, EK contributed to the development of the study design and provided guidance during the study. KY, EK were involved in the clinical management of patients. KY supervised the study. References Rourke K, Hickle J. The clinical spectrum of the presenting signs and symptoms of anterior urethral stricture: detailed analysis of a single institutional cohort. Urology. 2012 May;79 (5):1163-7. Palminteri E, Berdondini E, Verze P, De Nunzio C, Vitarelli A, Carmignani L. Contemporary urethral stricture characteristics in the developed world. Urology. 2013 Jan;81 (1):191-6. Lacy JM, Cavallini M, Bylund JR, Strup SE, Preston DM. Trends in the management of male urethral stricture disease in the veteran population. Urology . 2014 Dec;84 (6):1506-9. Pansadoro V, Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: long-term followup. J Urol. 1996 Jul;156 (1):73-5. Bhargava S, Chapple CR. Buccal mucosal urethroplasty: is it the new gold standard? BJU Int. 2004 Jun;93 (9):1191-3. Barbagli G, Selli C, Tosto A, Palminteri E. Dorsal free graft urethroplasty . J Urol. 1996 Jan;155 (1):123-6. Rogers HS, McNicholas TA, Blandy JP. Long-term results of one-stage scrotal patch urethroplasty. Br J Urol. 1992 Jun;69 (6):621-8. Foinquinos RC, Calado AA, Janio R, Griz A, Macedo A Jr, Ortiz V. The tunica vaginalis dorsal graft urethroplasty: initial experience. Int Braz J Urol. 2007 Jul-Aug;33 (4):523-9; discussion 529-31. Hassan Ashmawy, Praise T. Magama, Tunica vaginalis free graft urethroplasty: 10 years experience, African Journal of Urology. Volume 24, Issue 1,2018, Pages 37-40, Calado AA, Macedo A Jr, Delcelo R, de Figueiredo LF, Ortiz V, Srougi M. The tunica vaginalis dorsal graft urethroplasty: experimental study in rabbits. J Urol. 2005 Aug;174 (2):765-70. Churchill BM, van Savage JG, Khoury AE, McLorie GA. The dartos flap as an adjunct in preventing urethrocutaneous fistulas in repeat hypospadias surgery. J Urol. 1996 Dec;156 (6):2047-9. Yalçın K, Kölükçü E, Fırat F. Is the autologous testicular tunica vaginalis graft effective in persistent urethrocutaneous fistulas after hypospadias surgery? A comparative study . J Urol Surg. 2025;12 (3):158-164. Hatzichristodoulou G, Osmonov D, Kübler H, Hellstrom WJG, Yafi FA. Contemporary Review of Grafting Techniques for the Surgical Treatment of Peyronie's Disease. Sex Med Rev. 2017;5 (4):544-552. Yalçın, K., Kölükçü, E., Fırat, F., & Erdemir, F. (2024). Is testicular tunica vaginalis autologous graft successful in the surgical treatment of peyronie’s disease?. Androl Bul . 2024 Dec; 26 (4): 270-276. Barbagli G, Selli C, di Cello V, Mottola A. A one-stage dorsal free-graft urethroplasty for bulbar urethral strictures. Br J Urol. 1996 Dec;78 (6):929-32. Mangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures. Eur Urol. 2011 May;59 (5):797-814. Horiguchi A. Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews. Int J Urol. 2017 Jul;24 (7):493-503. Vasudeva P, Nanda B, Kumar A, Kumar N, Singh H, Kumar R. Dorsal versus ventral onlay buccal mucosal graft urethroplasty for long-segment bulbar urethral stricture: A prospective randomized study. Int J Urol. 2015 Oct;22 (10):967-71. Pathak HR, Jain TP, Bhujbal SA, Meshram KR, Gadekar C, Parab S. Does site of buccal mucosa graft for bulbar urethra stricture affect outcome? A comparative analysis of ventral, dorso-lateral and dorsal buccal mucosa graft augmentation urethroplasty. Turk J Urol. 2017 Sep;43 (3):350-354. Hua X, Chen J, Xu Y, Li B. Combined Dorsal Plus Ventral Double Tunica Vaginalis Graft Urethroplasty: An Experimental Study in Rabbits. Urology. 2019 Apr;126:209-216. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 30 Apr, 2026 Reviews received at journal 29 Apr, 2026 Reviews received at journal 24 Apr, 2026 Reviewers agreed at journal 22 Apr, 2026 Reviewers agreed at journal 21 Apr, 2026 Reviewers invited by journal 02 Apr, 2026 Editor invited by journal 16 Mar, 2026 Editor assigned by journal 21 Feb, 2026 Submission checks completed at journal 21 Feb, 2026 First submitted to journal 20 Feb, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8930131","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":617730124,"identity":"6a21df7d-89b7-4e95-8b15-893842243367","order_by":0,"name":"Kenan YALÇIN","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA10lEQVRIiWNgGAWjYBACCTBZwMDDwN7AwEyCFgOgFp4DJGoBshKI1CI5+/gziR8GdjLmkm8MPxdU2DDwt3cn4NUizZdjJtljkMxjOTvHWHrGmTQGiTNnN+DVIsfDwybBY3CAx+B2joE0b9thBgOJXEJa2J9J/gFpuXnG+DdRWqR5GMykwbbc4DEjzhbJHh5jaxmgXwzOpJVZ85xJ4yHoF4kz7A9vvqmwszc4fnjzbZ4KGzn+9l78WoCABRI3DByg2AHGKRGA+QOEZn9AjOpRMApGwSgYgQAAswk8fV/pgXsAAAAASUVORK5CYII=","orcid":"","institution":"Tokat Gaziosmanpaşa University","correspondingAuthor":true,"prefix":"","firstName":"Kenan","middleName":"","lastName":"YALÇIN","suffix":""},{"id":617730127,"identity":"277bc436-915a-41f6-9d57-e3e5a45dcc53","order_by":1,"name":"Engin KÖLÜKÇÜ","email":"","orcid":"","institution":"Tokat Gaziosmanpaşa University","correspondingAuthor":false,"prefix":"","firstName":"Engin","middleName":"","lastName":"KÖLÜKÇÜ","suffix":""}],"badges":[],"createdAt":"2026-02-21 03:08:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8930131/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8930131/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":106724307,"identity":"55957ce0-a9a7-4c88-b597-406f9e5fc390","added_by":"auto","created_at":"2026-04-12 18:27:22","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":17311,"visible":true,"origin":"","legend":"\u003cp\u003eRetrograde cystourethrography image of bulbar urethral stricture (yellow arrow: narrowed area)\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8930131/v1/8471111113f666d92eb6e070.jpg"},{"id":106468976,"identity":"ddae730a-050b-4250-b074-7570776e733b","added_by":"auto","created_at":"2026-04-09 00:44:56","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":345989,"visible":true,"origin":"","legend":"\u003cp\u003eStages of bulbourethroplasty surgery performed using TVOG\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8930131/v1/0f055150e4bacc5d7eff3db5.png"},{"id":106994250,"identity":"984baea3-4c18-46d5-a65c-eaafb698715a","added_by":"auto","created_at":"2026-04-15 15:06:51","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":20424,"visible":true,"origin":"","legend":"\u003cp\u003eQmax (mL/s) values over time\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8930131/v1/63c38e47d6269cfee48647a2.jpg"},{"id":106994908,"identity":"c12a03b4-2c57-4345-8012-ce483b5786ae","added_by":"auto","created_at":"2026-04-15 15:20:27","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1036096,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8930131/v1/f692f277-1c17-4300-b280-ae7b4b8c0c78.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Efficacy of ventral onlay autologous tunica vaginalis graft in bulbar urethroplasty: An 11- year experience","fulltext":[{"header":"Introduction","content":"\u003cp\u003eUrethral stricture arises from the narrowing of the urethral lumen due to fibrosis occurring in the epithelial tissue and the corpus spongiosum [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The most frequently affected segment is the bulbar urethra, accounting for approximately 45% of cases [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Various surgical methods are utilized in the treatment of bulbar urethral strictures. The length of the stricture, the severity of spongiofibrosis, and the experience of the surgeon are key factors in treatment selection.\u003c/p\u003e \u003cp\u003eIn the majority of patients with urethral stricture, the therapeutic approach has shown a trend toward urethroplasty. An increasing number of reconstructive urologists prefer urethroplasty techniques over repeated endoscopic dilations or multiple internal urethrotomy applications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. This paradigm shift has been facilitated by the high cure rates achieved in both augmentation and anastomotic urethroplasties. In patients with a stricture length of less than 2 cm, stricture excision and primary anastomosis remains the most widely used treatment method due to its favorable long-term outcomes [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Substitution urethroplasty using a buccal mucosal graft (BMG) has been established as the gold standard for treating bulbar urethral strictures longer than 2 cm to prevent the risk of penile chordee or shortening associated with excision and reanastomosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. However, the ideal graft tissue for urethroplasty remains a matter of ongoing debate [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eTVOG is an easier method to harvest and faster to apply compared to other materials. The proximity of the donor site to the surgical field and the abundant availability of the tissue provide significant advantages. The use of a tunica vaginalis graft has the potential to substantially shorten the operative time. Reducing the duration of surgery offers important benefits, particularly in preventing complications that may develop due to prolonged high lithotomy positioning. However, the number of urethroplasty studies using TVOG in the literature is quite limited. Nevertheless, it is reported that the results of existing studies in this area are promising [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In an experimental study conducted on an animal model, a tunica vaginalis graft was used instead of buccal mucosa in dorsal urethroplasty, and radiographic and histological analyses demonstrated that a patent and functional urethra was successfully maintained in all animals. Furthermore, no infection or fistula formation was encountered [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Additionally, TVOG has been successfully used as a protective interposition layer in peyronie's disease surgery and during hypospadias repair [\u003cspan additionalcitationids=\"CR12 CR13\" citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this study, we aimed to evaluate the efficacy of the outcomes in 43 patients who underwent the ventral onlay TVOG method during bulbar urethroplasty.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e \u003cstrong\u003eEthical approval and consent to participate\u003c/strong\u003e \u003cp\u003e This study was conducted in accordance with the approval of the Local Ethics Committee of the Tokat Gaziosmanpaşa University Faculty of Medicine (Approval No: 26-MOBAEK 052 Date: February 20, 2026). Data from 43 patients diagnosed with bulbar urethral stricture and treated with the ventral onlay TVOG method at our clinic between 2011 and 2022 were analyzed. The research was planned in compliance with the Declaration of Helsinki, and written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy Design\u003c/h2\u003e \u003cp\u003eForty-three patients who were diagnosed with bulbar urethral stricture at our clinic between 2011 and 2022, were not suitable for end-to-end urethral anastomosis, and underwent repair with ventral onlay TVOG were included in the study. Patients with urethral strictures outside the bulbar urethra, neurogenic bladder, a diagnosis of lichen sclerosus, a history of prior radiotherapy, a history of failed hypospadias repair, or prior scrotal surgery were excluded from the study. Male patients who underwent ventral onlay TVOG urethroplasty due to a bulbar urethral stricture longer than 2 cm and had at least 2 years of follow-up were retrospectively evaluated for age, ASA scores, stricture lengths, number of previous internal urethrotomies, operative times, etiological causes, BMI, length of hospital stay, time-dependent uroflowmetry Qmax values, and postoperative complications. Various urethroplasty procedures were performed at our center over an eleven-year period; in this study, substitution urethroplasty using TVOG was performed on 43 patients who met the inclusion criteria mentioned above. No other graft material was used by the same surgeon in any of these patients.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical technique\u003c/h3\u003e\n\u003cp\u003ePreoperative evaluation for all patients included clinical history, physical examination, urine culture, uroflowmetry, and retrograde and voiding cystourethrography (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea). A third-generation cephalosporin antibiotic (50\u0026ndash;100 mg/kg) was administered prophylactically to all cases prior to surgery. General or spinal anesthesia was administered to all patients. Before proceeding with the surgical intervention, the external genitalia were re-evaluated by examination under anesthesia. Cystoscopy was performed on all patients, the starting point of the stricture was identified, and if a lumen was present in the urethra, a guide wire was advanced into the bladder. Subsequently, while the patient was in the lithotomy position, the bulbocavernosus muscle was divided via a midline perineal incision, and the bulbar urethra was exposed. The ventral urethral surface was incised in the midline until the catheter tip and the urethral lumen were revealed. The urethrotomy was then extended both distally and proximally, incising the stricture along its entire length. Following the complete opening of the stricture, the length and width of the remaining urethral plate were measured (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea, \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb). These measurements were taken to determine the exact extent and length of the stricture expansion. The tunica vaginalis graft was harvested through the same incision line in dimensions appropriate to the length and width of the urethral defect (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ec). The graft was cleared of overlying fatty tissues and preserved in saline until it was ready for placement at the recipient site. Starting from the proximal end of the opened urethra, the graft was sutured to the urethral mucosa using 5/0 continuous sutures. After one edge was sutured, an 18 Fr silicone catheter was placed into the reconstructed urethra. The suturing of the other edge was then completed, and the graft was fully spread and quilted (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ed\u0026ndash;g). The muscle and serosa of the urethra were closed over the graft as a second layer (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eh). Subsequently, the other layers were anatomically closed, and the surgical procedure was concluded.\u003c/p\u003e\n\u003ch3\u003eFollow-up\u003c/h3\u003e\n\u003cp\u003eA non-adherent compressive bandage was applied and left in place for three days. In the postoperative period, patients were administered parenteral antibiotics and non-steroidal anti-inflammatory drugs until discharge. Patients were discharged within 2\u0026ndash;4 days postoperatively, with instructions that the 18 Fr silicone catheter would be removed after 21 days. Following the removal of the urethral catheter, patients were evaluated with retrograde urethrogram and uroflowmetry. Subsequently, patients were monitored with uroflowmetry during follow-up visits at the 3rd, 6th, 12th, and 24th months, respectively. Urethroscopy was performed in cases where stricture was suspected. The success of the treatment was evaluated based on the criteria of patient satisfaction, a Qmax value exceeding 16 mL/s, patent urethrogram findings, and the absence of any need for dilation or instrumentation during the follow-up period.\u003c/p\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analyses were performed using the MedCalc (version 20.009; Ostend, Belgium) statistical software package. The Kolmogorov\u0026ndash;Smirnov test was used to evaluate whether the data conformed to a normal distribution. Continuous data were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) when they followed a normal distribution, and as median with 25th and 75th percentile values when they did not. Categorical data were defined as frequency and percentage. The Friedman test was used to compare preoperative and postoperative 3rd, 6th, 12th, and 24th-month Qmax (mL/s) values. Post-hoc analyses were performed at the α\u0026thinsp;=\u0026thinsp;0.05 level, and time-dependent changes in Qmax (mL/s) values were indicated with different letters in the table. Comparisons of Qmax (mL/s) values were presented visually in a bar chart as median (95% confidence intervals). In the interpretation of the results, a statistical significance level of p\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was accepted.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe median age of the patients participating in the study was 59.0 years, and the average duration of the operations was calculated as 104.5\u0026thinsp;\u0026plusmn;\u0026thinsp;8.4 minutes. The median length of the stricture observed in the bulbar urethra was 4.0 cm, while the mean number of internal urethrotomies performed prior to surgery was determined to be 4.0. The median ASA score of the patients was 2.0 and their median BMI was 27.0 kg/m\u0026sup2;. The etiological causes of the strictures were identified as iatrogenic, idiopathic, and traumatic, with rates of 55.8% (24 patients), 25.6% (11 patients), and 18.6% (8 patients), respectively. The median length of stay in hospital was determined to be 3 days. Surgical failure was recorded in six patients (14.0%) due to severe wound infection. Additionally, recurrent urethral stricture was reported in five patients (11.6%), while superficial infection or hematoma development was observed in six patients (14.0%). However, no diverticulum formation was observed in any patient (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Successful voiding was achieved in thirty-three cases, with uroflowmetry Qmax values measured at 17 mL/s or higher (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). A statistically significant difference was found when comparing preoperative Qmax values with those measured at the 3rd, 6th, 12th, and 24th postoperative months (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic characteristics and clinical findings\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eVentral Onlay\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;43\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge (years)\u003c/b\u003e, Median (25p-75p)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(46\u0026ndash;63)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eASA score\u003c/b\u003e, Median (25p-75p)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(1\u0026ndash;2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u0026nbsp;(kg/m\u0026sup2;)\u003c/b\u003e, Median (25p-75p)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e27,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(25\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eStricture length (cm)\u003c/b\u003e, Median (25p-75p)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3\u0026ndash;5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNumber of internal urethrotomies\u003c/b\u003e, Median (25p-75p)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3\u0026ndash;4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003eEtiological factors\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIdiopathic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e25,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eIatrogenic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e55,8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eTraumatic\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eOperation Duration (min)\u003c/b\u003e, Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e104,5\u0026thinsp;\u0026plusmn;\u0026thinsp;8,4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLength of hospital stay (days)\u003c/b\u003e, Median (25p-75p)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3,0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e(3\u0026ndash;3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSevere wound infection\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePresent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14,0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86,0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eRecurrent urethral stricture\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePresent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11,6\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88,4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e\u003cb\u003eSuperficial infection or hematoma\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003ePresent\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14,0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e86,0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiverticulum\u003c/b\u003e, n (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eNone\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e100,0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eAbbreviations:\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eASA: American Society of Anesthesiologists\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eBMI: Body mass index\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of Qmax (mL/s) values over time\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eQmax (mL/s)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25p\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e75p\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eP-value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePre-op\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 a\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e46,5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0,00001 *\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-op (3rd month)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e19 b\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-op (6 months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e18,25\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-op (12 months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePost-op (24 months)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 c\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003e*: Significant differences according to the Friedman test are indicated by different letters (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). p: Percentile\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSix patients who developed superficial infection or hematoma postoperatively were successfully treated with warm baths, antibiotics, and oral anti-inflammatory drugs. However, surgical intervention resulted in failure in six patients due to severe wound infection. These patients were followed with a suprapubic catheter for approximately six months. At least six months after the initial surgery, re-urethroplasty was performed using TVOG from the contralateral side. No recurrence of stricture was observed in these patients during the follow-up period. Furthermore, five patients who developed recurrent urethral stricture are being monitored with internal urethrotomy and urethral dilation; due to the short length of their strictures, re-urethroplasty was not deemed necessary for these patients. No scrotal pain or discomfort was detected in any patient during the follow-up period. Overall, patient satisfaction rates were at a very high level.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eWhile there is a general consensus in the literature that stricture excision and primary anastomosis yield high success rates in the treatment of short bulbar urethral strictures, various risks are associated with treating longer urethral segments via primary anastomosis [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Therefore, graft urethroplasty methods, which have reported high success rates, are recommended for the management of longer bulbar urethral strictures. Although dorsal, ventral, and dorso-lateral anastomosis techniques have been described, there is no strong evidence indicating that any of these methods possesses a significantly higher success rate than the others [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. In the dorsal graft placement technique, the entire urethra is mobilized, and the graft is placed onto the corporal bodies. In the ventral technique, a ventral urethrotomy is performed at the stenotic segment, and the graft is placed over the urethrotomy defect. In the dorso-lateral technique, the urethra is mobilized unilaterally, and the graft is placed over the dorso-lateral urethrotomy defect [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. The literature contains a limited number of studies regarding urethroplasty using TVOG. These studies reported promising results with dorsal graft placement [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In our study, the graft was placed ventrally, and the outcomes were found to be encouraging. Furthermore, we consider it significant that this study is among the pioneering works in this field.\u003c/p\u003e \u003cp\u003eResearchers who advocate that dorsal graft placement is more appropriate suggest that this approach reduces the risk of diverticulum formation, provides better neovascularization as the graft is placed onto the corporal bodies, and that these advantages cannot be achieved with ventral graft placement. Conversely, proponents of ventral graft placement state that this technique provides more effective access to the proximal segment of the stricture, requires less urethral mobilization, and allows for the preservation of urethral vascularity. Additionally, it is argued that the bulbocavernosus muscle plays a role in preventing diverticulum formation [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. In our clinical practice, we prefer the ventral graft placement method for bulbar urethroplasty. This technique allows for better access to the proximal part of the stricture, ensures less urethral mobilization, and more effectively preserves the vascular integrity of the urethra. Moreover, it is believed that this method permits the muscle and serosa of the urethra to be properly closed over the graft as a second layer, and that diverticulum formation is prevented by the anatomically correct closure of the bulbocavernosus muscle. In our study, no diverticulum formation was observed in any patient where ventral graft placement was utilized.\u003c/p\u003e \u003cp\u003ePathak et al. reported that ventral graft placement is technically easier than dorsal placement in terms of positioning and suturing the graft at the proximal anastomosis site. They also stated that ventral graft placement is the most likely factor in reducing stricture rates at the proximal anastomosis site compared to dorsal or dorso-lateral placement. Although the outcomes of ventral BMG placement appeared superior, no statistically significant difference was found. Nevertheless, they recommend considering ventral onlay graft placement as an option for treating bulbar strictures, particularly when the stricture involves the proximal bulbar urethra [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our study, consistent with the results reported in the literature and independent of the graft type used, no significant difference in success rates was observed among ventral graft urethroplasties.\u003c/p\u003e \u003cp\u003eFoinquinos et al.[\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], in their initial study involving 11 patients who underwent tunica vaginalis dorsal graft urethroplasty, reported that all patients voided without issues during a follow-up period ranging from 7 weeks to 5 months, with uroflowmetry values exceeding 14 mL/s. Similarly, in a 10-year experience study of 52 patients by Hassan Ashmawy and Praise T. Magama involving tunica vaginalis dorsal graft urethroplasty, it was reported that voiding was successful in 42 cases, with a mean flow rate of 20 mL/s [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In contrast, evaluating the results of our 43 patients who underwent ventral rather than dorsal graft urethroplasty, our study found that successful voiding was achieved in 33 cases, with uroflowmetry Qmax values of 17 mL/s or higher during the two-year follow-up period.\u003c/p\u003e \u003cp\u003eIn the study conducted by Hassan Ashmawy and Praise T. Magama, the overall success rate was reported as 80.8%. Surgical intervention failed in five patients due to severe wound infection; however, tunica vaginalis urethroplasty was successfully re-performed in these patients 6\u0026ndash;12 months later. Additionally, recurrent urethral stricture was observed in five cases over periods ranging from 3 to 18 months. Superficial surgical site infection developed in seven patients, but no patient reported postoperative testicular discomfort [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In the research by Foinquinos and colleagues, a postoperative complication developed in one patient\u003c/p\u003e \u003cp\u003ein the early period, involving a small scrotal hematoma that resolved with drainage. Likewise, no patient in that study reported postoperative testicular discomfort [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In our own study, the overall success rate was determined to be 74.4%. Surgical failure developed in six patients due to severe wound infection; however, the tunica vaginalis urethroplasty procedure was successfully re-performed in these cases after six months. Five patients who developed recurrent urethral stricture are being monitored with internal urethrotomy and urethral dilation. Six patients who developed superficial infection or hematoma recovered with warm baths, antibiotics, and oral anti-inflammatory drug therapy. No scrotal pain or discomfort was detected in any patient during the follow-up process. These findings appear to be consistent with the limited existing literature on the subject.\u003c/p\u003e \u003cp\u003eIn an experimental study conducted on an animal model, the use of a tunica vaginalis graft instead of buccal mucosa was evaluated in a dorsal urethroplasty application. Radiographic and histological analyses demonstrated the presence of a patent and functional urethra in all animals, and no infection or fistula formation was encountered [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. In a combined urethroplasty animal study conducted by Xiaoliang Hua et al. using dual tunica vaginalis grafts (both dorsal and ventral), the urethras of all rabbits were found to be patent. Histological analyses revealed that the tunica vaginalis graft fully integrated with the urethra by the fourth week after surgery and transformed into a urinary pseudostratified epithelium by the twelfth week [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. These studies indicate that the tunica vaginalis graft can be successfully used in urethral stricture models. In our study, this graft was utilized effectively, and the results were found to be promising.\u003c/p\u003e\n\u003ch3\u003eLimitations\u003c/h3\u003e\n\u003cp\u003eWe acknowledge that our study has several limitations. The relatively small sample size, the single-center and retrospective design, and the need for comparisons with a broader range of surgical techniques are the primary limiting factors. However, the objective of this study was not to compare the outcomes of penile skin, buccal mucosa, and tunica vaginalis among the graft materials used for urethroplasty. The main goal was to define a new alternative in reconstructive urethral surgery and to propose the use of tunica vaginalis as a graft material.\u003c/p\u003e"},{"header":"Conclusions","content":"\u003cp\u003eIn our study, encouraging results were obtained using the tunica vaginalis free graft urethroplasty technique over an eleven-year period. This method is easily applicable, safe, and time-efficient. Nevertheless, further advanced studies comparing this technique with existing urethral substitution procedures by surgeons working in the field of reconstructive genitourinary surgery are needed. To the best of our knowledge, this study is considered to be the first long-term research utilizing the ventral onlay TVOG urethroplasty technique.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTVOG: Autologous tunica vaginalis graft, BMI: Body mass index, BMG: Buccal mucosal graft, ASA: American Society of Anesthesiologists\u0026nbsp;\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical approval and consent to participate\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted in accordance with the approval of the Local Ethics Committee of the Tokat Gaziosmanpaşa University Faculty of Medicine (Approval No: 26-MOBAEK 052 Date: February 20, 2026). Data from 43 patients diagnosed with bulbar urethral stricture and treated with the ventral onlay TVOG method at our clinic between 2011 and 2022 were analyzed. The research was planned in compliance with the Declaration of Helsinki, and written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors` contributions\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eKY developed the study design, performed the statistical analysis, and was responsible for the clinical management of patients. KY also drafted the manuscript and critically revised it for important intellectual content. KY, EK contributed to the development of the study design and provided guidance during the study. KY, EK were involved in the clinical management of patients. KY supervised the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eRourke K, Hickle J. The clinical spectrum of the presenting signs and symptoms of anterior urethral stricture: detailed analysis of a single institutional cohort.\u003cem\u003eUrology. \u003c/em\u003e2012 May;79\u003c/strong\u003e(5):1163-7. \u003c/li\u003e\n\u003cli\u003e\u003c/strong\u003ePalminteri E, Berdondini E, Verze P, De Nunzio C, Vitarelli A, Carmignani L. Contemporary urethral stricture characteristics in the developed world.\u003cem\u003eUrology.\u003c/em\u003e 2013 Jan;81\u003c/strong\u003e(1):191-6. \u003c/li\u003e\n\u003cli\u003eLacy JM, Cavallini M, Bylund JR, Strup SE, Preston DM. Trends in the management of male urethral stricture disease in the veteran population.\u003cem\u003eUrology\u003c/em\u003e. 2014 Dec;84\u003c/strong\u003e(6):1506-9. \u003c/li\u003e\n\u003cli\u003ePansadoro V, Emiliozzi P. Internal urethrotomy in the management of anterior urethral strictures: long-term followup. \u003c/strong\u003e\u003cem\u003eJ Urol.\u003c/em\u003e 1996 Jul;156\u003c/strong\u003e(1):73-5. \u003c/li\u003e\n\u003cli\u003eBhargava S, Chapple CR. Buccal mucosal urethroplasty: is it the new gold standard?\u003cem\u003eBJU Int.\u003c/em\u003e 2004 Jun;93\u003c/strong\u003e(9):1191-3. \u003c/li\u003e\n\u003cli\u003eBarbagli G, Selli C, Tosto A, Palminteri E. Dorsal free graft urethroplasty\u003c/strong\u003e. \u003cem\u003eJ Urol.\u003c/em\u003e 1996 Jan;155\u003c/strong\u003e(1):123-6. \u003c/li\u003e\n\u003cli\u003eRogers HS, McNicholas TA, Blandy JP. Long-term results of one-stage scrotal patch urethroplasty. \u003c/strong\u003e\u003cem\u003eBr J Urol.\u003c/em\u003e 1992 Jun;69\u003c/strong\u003e(6):621-8. \u003c/li\u003e\n\u003cli\u003eFoinquinos RC, Calado AA, Janio R, Griz A, Macedo A Jr, Ortiz V. The tunica vaginalis dorsal graft urethroplasty: initial experience. \u003c/strong\u003e\u003cem\u003eInt Braz J Urol.\u003c/em\u003e 2007 Jul-Aug;33\u003c/strong\u003e(4):523-9; discussion 529-31. \u003c/li\u003e\n\u003cli\u003eHassan Ashmawy, Praise T. Magama, Tunica vaginalis free graft urethroplasty: 10 years experience, \u003c/strong\u003e\u003cem\u003eAfrican Journal of Urology.\u003c/em\u003e Volume 24, Issue 1,2018, Pages 37-40, \u003c/li\u003e\n\u003cli\u003eCalado AA, Macedo A Jr, Delcelo R, de Figueiredo LF, Ortiz V, Srougi M. The tunica vaginalis dorsal graft urethroplasty: experimental study in rabbits. \u003c/strong\u003e\u003cem\u003eJ Urol.\u003c/em\u003e 2005 Aug;174\u003c/strong\u003e(2):765-70. \u003c/li\u003e\n\u003cli\u003eChurchill BM, van Savage JG, Khoury AE, McLorie GA. The dartos flap as an adjunct in preventing urethrocutaneous fistulas in repeat hypospadias surgery.\u003cem\u003eJ Urol.\u003c/em\u003e 1996 Dec;156\u003c/strong\u003e(6):2047-9.\u003c/li\u003e\n\u003cli\u003eYal\u0026ccedil;ın K, K\u0026ouml;l\u0026uuml;k\u0026ccedil;\u0026uuml; E, Fırat F. Is the autologous testicular tunica vaginalis graft effective in persistent urethrocutaneous fistulas after hypospadias surgery? A comparative study\u003c/strong\u003e. \u003cem\u003eJ Urol Surg.\u003c/em\u003e 2025;12\u003c/strong\u003e(3):158-164.\u003c/li\u003e\n\u003cli\u003eHatzichristodoulou G, Osmonov D, K\u0026uuml;bler H, Hellstrom WJG, Yafi FA. Contemporary Review of Grafting Techniques for the Surgical Treatment of Peyronie\u0026apos;s Disease. \u003c/strong\u003e\u003cem\u003eSex Med Rev. \u003c/em\u003e2017;5\u003c/strong\u003e(4):544-552.\u003c/li\u003e\n\u003cli\u003eYal\u0026ccedil;ın, K., K\u0026ouml;l\u0026uuml;k\u0026ccedil;\u0026uuml;, E., Fırat, F., \u0026amp; Erdemir, F. (2024). Is testicular tunica vaginalis autologous graft successful in the surgical treatment of peyronie\u0026rsquo;s disease?. \u003c/strong\u003e\u003cem\u003eAndrol Bul\u003c/em\u003e. \u003c/strong\u003e2024 Dec; 26\u003c/strong\u003e(4): 270-276. \u003c/li\u003e\n\u003cli\u003eBarbagli G, Selli C, di Cello V, Mottola A. A one-stage dorsal free-graft urethroplasty for bulbar urethral strictures. \u003c/strong\u003e\u003cem\u003eBr J Urol.\u003c/em\u003e 1996 Dec;78\u003c/strong\u003e(6):929-32. \u003c/li\u003e\n\u003cli\u003eMangera A, Patterson JM, Chapple CR. A systematic review of graft augmentation urethroplasty techniques for the treatment of anterior urethral strictures.\u003cem\u003eEur Urol.\u003c/em\u003e 2011 May;59\u003c/strong\u003e(5):797-814. \u003c/li\u003e\n\u003cli\u003eHoriguchi A. Substitution urethroplasty using oral mucosa graft for male anterior urethral stricture disease: Current topics and reviews.\u003cem\u003eInt J Urol.\u003c/em\u003e 2017 Jul;24\u003c/strong\u003e(7):493-503. \u003c/li\u003e\n\u003cli\u003eVasudeva P, Nanda B, Kumar A, Kumar N, Singh H, Kumar R. Dorsal versus ventral onlay buccal mucosal graft urethroplasty for long-segment bulbar urethral stricture: A prospective randomized study. \u003c/strong\u003e\u003cem\u003eInt J Urol.\u003c/em\u003e 2015 Oct;22\u003c/strong\u003e(10):967-71. \u003c/li\u003e\n\u003cli\u003ePathak HR, Jain TP, Bhujbal SA, Meshram KR, Gadekar C, Parab S. Does site of buccal mucosa graft for bulbar urethra stricture affect outcome? A comparative analysis of ventral, dorso-lateral and dorsal buccal mucosa graft augmentation urethroplasty. \u003c/strong\u003e\u003cem\u003eTurk J Urol. \u003c/em\u003e2017 Sep;43\u003c/strong\u003e(3):350-354. \u003c/li\u003e\n\u003cli\u003eHua X, Chen J, Xu Y, Li B. Combined Dorsal Plus Ventral Double Tunica Vaginalis Graft Urethroplasty: An Experimental Study in Rabbits. \u003c/strong\u003e\u003cem\u003eUrology.\u003c/em\u003e 2019 Apr;126:209-216. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Urethral stricture, autologous tunica vaginalis graft, ventral onlay, bulbar, male","lastPublishedDoi":"10.21203/rs.3.rs-8930131/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8930131/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eUrethral stricture disease in men has historically been one of the most challenging urological problems. The treatment of complex urethral strictures, in particular, poses a major challenge due to urethral scarring and fibrosis of the surrounding corpus spongiosum. Although various tissue types have been proposed for surgical reconstruction, the optimal graft material remains a subject of ongoing debate. In this study, we aimed to analyze the efficacy of using a ventral onlay autologous tunica vaginalis graft (TVOG) in bulbar urethroplasty.\u003c/p\u003e\u003ch2\u003eMethods:\u003c/h2\u003e \u003cp\u003eData from 43 patients diagnosed with bulbar urethral stricture and treated with the ventral onlay TVOG technique at our clinic between 2011 and 2022 were retrospectively reviewed. Patient age, American Society of Anesthesiologists (ASA) score, stricture length, number of internal urethrotomies performed, operative time, etiological factors, body mass index (BMI), length of hospital stay, time-dependent uroflowmetry Qmax values, and postoperative complications were recorded. Criteria for success were defined as patient satisfaction, a Qmax value exceeding 16 mL/s, patent urethrogram findings, and the absence of any need for dilation or further instrumentation during the follow-up period.\u003c/p\u003e\u003ch2\u003eResults:\u003c/h2\u003e \u003cp\u003eThe overall success rate was 74,4%. Failure occurred in 6 cases due to severe wound infection. Recurrent urethral stricture was detected in 5 cases. Superficial surgical site infection or hematoma was observed in 6 cases. No diverticulum formation was observed in any patient. Successful voiding was achieved in a total of 33 cases, with uroflowmetry Qmax values measured at 17 mL/s or higher. Comparison of Qmax values demonstrated a statistically significant difference (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Furthermore, no patient reported scrotal pain or discomfort during the follow-up period.\u003c/p\u003e\u003ch2\u003eConclusions:\u003c/h2\u003e \u003cp\u003eThe outcomes of using ventral onlay TVOG in bulbar urethroplasty appear favorable. Based on the data obtained from our study, it can be concluded that TVOG may be considered an alternative method in this field.\u003c/p\u003e","manuscriptTitle":"Efficacy of ventral onlay autologous tunica vaginalis graft in bulbar urethroplasty: An 11- year experience","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-09 00:44:52","doi":"10.21203/rs.3.rs-8930131/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-30T20:14:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-29T10:19:07+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-24T17:16:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"140390815226425777024205496126108539371","date":"2026-04-23T01:19:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"272673873667891243743893670803383556717","date":"2026-04-21T09:33:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-02T08:16:31+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-03-16T10:25:20+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-21T11:17:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-21T11:12:45+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Urology","date":"2026-02-21T02:51:22+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-urology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"buro","sideBox":"Learn more about [BMC Urology](http://bmcurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/buro/default.aspx","title":"BMC Urology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"283530da-5ab1-43a6-8570-27d28210c6b6","owner":[],"postedDate":"April 9th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-04-30T20:14:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-29T10:19:07+00:00","index":35,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-11T18:39:10+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-09 00:44:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8930131","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8930131","identity":"rs-8930131","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}