Buccal mucosal onlay graft – or “BMG” as the cool kids call it, is one version of urethrolplasty. Because I have a urethral stricture, and because the only “real” treatment (by which I mean “a treatment where the fix has a good chance of staying fixed”) is urethroplasty, I’ve been doing more than my fair share (and more than is healthy, I’m sure) of research about it.
There are several variations of urethroplasty, going from end-to-end anastomosis all the way to “2-stage.” Those are in order of complexity and invasiveness. You can read all about each type of urethroplasty in my article, The Treatments For Stricture Of The Urethra. But there is some potential overlap between these different versions of urethroplasty.
My doctor told me that I will be having an end-to-end anastomosis, which is a fancy way of saying “cutting out a section and sewing the remaining ends together.” Of course, the section they cut out is the part containing the stricture. I was happy to hear this because in my research, it appeared as though end-to-end did not require a graft from inside my mouth. Oddly, I seem to be OK with them cutting up my urethra, but snipping a thin layer of buccal tissue (inside of the cheek) terrifies me.
The next level up in complexity and invasiveness (how much they have to invade my body with pointy things) is buccal mucosal onlay graft. They cut a slice into your urethra where the stricture is, pull the sides apart to create a sort of almond-shaped opening in the urethra, and then sew a piece of your cheek over that hole, making the diameter of the urethra much larger. Of course that lets more urine flow through much easier.
At first I was a bit confused when I read the descriptions (and saw the diagrams and pictures) about whether the stricture – a blob of scar tissue inside the urethra – was cut out when doing the buccal mucosal onlay graft (I’ll just call it a BMG from now on since I am a cool kid:)). I didn’t know if the slice/incision was made through the middle of the stricture, of if the stricture were cut out, etc. I mean, it seemed like the stricture should be removed since it causes pain, right?
Well my doctor set me straight on that. First of all, no – the stricture is not cut out or sliced during a BMG. It is just left alone. The fix occurs due to the permanent widening of the urethra at that site. And the pain that is felt by folks with urethral stricture disease is actually caused by the bladder trying to force pee through the narrowing (like a neck) caused by the stricture. If you remember your fluid dynamics, you’ll remember that as the cross-sectional area (basically the diameter) of a pipe decreases, the velocity increases (like squirting water out of a hose faster by putting your thumb across the opening, decreasing the cross-sectional area). Add that to the bladder’s attempt to push harder to get the pee out, and you get pain. But when you widen the neck caused by the stricture, the velocity goes down and the bladder stops trying so hard to push. THAT is why the stricture doesn’t hurt any more after a BMG, even though it’s still there.
I found that very interesting and thought you would too.
And as for the graft and the whole cutting-cheek-tissue thing, my doc says that if a surgeon just leaves the site alone after harvesting the graft, it heals in a few days just fine. It’s only when they decide to try and stitch the graft site closed that you get tightening inside the cheek, and likely more pain.
So that’s basically a BMG in a nutshell (no pun intended).
I am just over two weeks out from having a urethroplasty. It was a 9cm stricture that the Doctor used a graft from the inner left cheek of my mouth. The moth has been healing very well. I have been looking for information in regards to nocturnal erections and how is it that no damage is done to the repair when these happen. This website that you have put together seems to have some of the better information out there so I thought I would try to ask the question here.
Thanks for the info.
Hi Chris,
Are you sure that it was 9 centimeters? Or did you mean millimeters? 9 centimeters is quite long. If that is correct (I’m not doubting you, just surprised as strictures that long seem not to be the norm), then I’m assuming you did NOT have end-to-end anastomosis? The max size for end-to-end is usually between 2.5 and 4 cm, with 4 really pushing it.
Actually, since this comment is on the “Buccal Mucosal Onlay Graft (BMG) To Treat Urethral Stricture” post, that’s probably what you had, right? It’s really interesting that you ask about the nocturnal erections, because I was telling my wife about having those and the extra pain it caused me just last night. In the case of an end-to-end, it would seem that erections would try to pull apart the repair, since the urethra is shorter. But apparently (reminder that I am not a doctor), the urethra is pretty slippery and stretchy and can accommodate pulling caused by an erection if the amount cut out is short enough, hence the reason they only do it (end-to-end) on short strictures. There HAVE been horror stories of penile curvature being caused in men who had end-to-end with too much of the urethra cut out.
But for BMG, the urethra is not shortened. It stays the same length, with added width (created by the graft) in the area that has the stricture. So nocturnal erections, which would really only apply stress along the length of the urethra, shouldn’t put any stress on a BGM. That’s my take on it. As with everything, you should ask your doctor about that to be sure.
Thanks for the compliment on this site! There aren’t many of us out there, and there also aren’t that many urologists specializing in strictures and urethroplasty. So we have to share what we learn.
Good luck with the recovery!
Ken
Had a second retrograde urethrogram last week following a internal urethrotomy procedure 18 months ago that has failed. My stricture is in fact 3mm, not 3 cm as I thought. It’s in the bulbar region and about an inch or so below my prostate. The urologist says it’s in an easy location to reach and being so small it’s good candidate for the end-to-end procedure. (Yippee!!) (Slightly higher success rate, less time with a catheter.) He did say he was concerned about a shadow area he saw upstream that could be an additional stricture that might require a graph but he won’t know for sure until the surgery. Here’s hoping! I delayed the surgery until October to finish up on a few things and to give myself time to prepare. My largest fear now is infection. I plan to eat a lot of fruits and vegetables and get plenty of exercise in the next two months in the hope of being as healthy as I can be before entering the hospital.
I had this done back in April of 2012 with Dr. Wright in Baltimore where I had the damaged portion of the urethra cut out and the 2 ends of the non-scarred portion of the urethra stitched together. While I’m not doing terribly today, I still sense I’m not done with the urethra stricture problem. For 8 years I’ve dealt with this problem. The thing is my doctor told me that if I didn’t have a problem after 6 months following the surgery that I would be cured forever. I really don’t sense that even though I wouldn’t categorize my urine flow as bad. My hope is that if the worst case scenario happens and the stricture recurs that it will be a much shorter stricture (easier to treat) than before. In fact I’m considering having an x-ray done in the next week on my urethra to make sure it’s healthy and holding up. There is nothing more that will frustrate the hell out of you than a urethra stricture. There simply just can’t seem to be a perfect cure for it.
Thanks for sharing your story, Joe! Over a year, huh? Yeah, good idea to have the X-ray done to see if you have another stricture. One thing I’m still a bit curious about is the non-standard methods (seemingly) being used in the weeks and months leading up to a urethroplasty. For example, my urologists were adamant that I spend 3 months in “bladder rest” status, during which time I had a suprapubic catheter. The reason given for this – by my surgeon – was to allow the area above the stricture, and the stricture itself, to “scar down.” This is in order to get an accurate idea of the size and location of the stricture. Since the bladder is constantly pushing outward, if we are not catheterized the constant pressure against the stricture area when we try to pee causes inflammation in addition to the scarring. That could cause the doc to over-estimate the size of the ACTUAL scar-tissue that makes up the stricture.
However, all the guys who have commented here have said they were NOT told to go through 3 months of bladder rest before their urethroplasties.
Were you told anything like that? How long was it from the diagnosis to the urethroplasty?
Thanks so much for your comment. And good luck going forward. Here’s to hoping it isn’t another stricture!
Ken
Hi Ken. It’s interesting you brought up the actual size of the scar tissue. The key thing I learned here is get a GREAT doctor who specializes in this. I went to Dr. Armenacus in NY and he looked at the x-ray of my stricture and said that I would need a skin graft from my cheek in order to repair the stricture. I actually scheduled the surgery with him, but canceled just because of my mind not be able to handle what I was about to encounter. It’s actually a good thing I did cancel it, because if I didn’t I wouldn’t have been able to do the end to end repair after i had this doctor in Baltimore tell me differently in that I only needed an end to end repair. But to answer your questions, I actually was going to have suprapubic put in me but my doctor told me that I would only have it put in me if my urine flow was completely cut off because they couldn’t dialate the urethra or have any other minor procedure on it since I would have to wait at least 3 months before they would look at the urethra again. I felt like my urine flow wasn’t ever going to stop completely, but I got so warned down and mentally tired of trying to pee through a peep hole like urethra that I finally decided to finally go through with the surgery. I was actually lucky because my doctor granted me the surgery a month after diagnosis since it was a real stress for me. So because of this I decided to hold out hope I wouldn’t have a problem before the surgery so I wouldn’t have to wear the suprapubic tube. Luckily my urine flow didn’t cut off leading into the surgery. The surgery wasn’t bad and I recommend it to anyone having a problem. I was like you though I’m petrified of any skin graft procedure. In fact it’s one of the reasons I canceled the procedure for the NY guy. If I have another open procedure with the guy in Baltimore he told me he would use a skin flap from my penis as the graft. I mean if skin from a cheek is bad, I don’t even want to comprehend what a skin graft from my penis is like. So I’m hoping any future stricture problems can be treated with the minor procedures like dilation or internal urechtomy.
In short though I’m hanging in there. But I wish the best of luck to you if you have had the procedure already or are going to have the procedure. If you haven’t had it, there isn’t any pain you experience from it, it’s just that it’s a pain in the ass to wear the catheter for 3 weeks and you experience itching from the healing on the scrotum.
Joe,
Thanks for the clarification and additional info! It sounds like you experienced a LOT less pain than Chris and I did. We are both still (correct me if I’m wrong, Chris) feeling pain 4-6 weeks post-surgery. For others just reading this – we are talking about the end-to-end urethroplasty surgery. Obviously pain is relative to a certain extent, and different folks will feel more or less of it. But speaking from my own experience, the pain, primarily surface pain in the perineum and scrotum, was significant for the first 24 hours. After that, it was more a level 4-5, but such that it very much limits my activity. For example, 4 and a half weeks on, I still cannot sit down on a normal chair without my donut pillow. For short periods of time, I can sit on a soft surface if I lean/slouch back. But that’s it. I may be on the outer-end of the curve for healing time. But just so folks who have NOT had the surgery can get an idea what a few of us have experienced, I felt I needed to say that. More stories of post-surgery tenderness and pain can be found in this thread here https://www.medhelp.org/posts/Urology/Recently-had-a-Urethroplasty-done/show/1680722
Thanks again, and good luck!
Ken
Just wanted to let you know that I just set up a forum on the site! It might make it easier for all of us to keep up with each other rather than having to use the comments sections across multiple posts. Right now I have a “General Discussion” forum and a “Urethral Strictures And Their Treatments” forum. You can find the forums page here: https://livingwithacatheter.com/community-forums/
I’ll be putting this comment on multiple posts so everyone who has been involved in our discussions is aware, so I apologize in advance for the possible duplicate e-mails you may get.
Cheers!
Ken
Quick question we are going in to make the surgury appt tomorrow and my bf has chosen the cheek graph. whats the difference the doctor pretty much said that was the only option for him just sounds so painful and we want this all to be over with. any ideas on what to ask to be sure this IS the only option??
Jamie,
That’s a great question. The cheek graft will almost certainly ensure a better outcome. And if the stricture is long, is definitely the best option. Other options after that (the scary ones, in my opinion) involve slicing the penis open, etc. So while it might not be the “only” option, it is likely to be the best.
I should remind you here that I’m not a doctor or nurse:). But anyway, with really small strictures, it’s often possible to just cut out that section of the urethra and then pull together the 2 healthy ends and sew them together. That’s probably the best of the long-lasting solutions (and what I had). But if, when the docs get in there and see how big the stricture actually is, they realize that they have to cut out more than they thought, it may not be wise to pull/stretch the 2 parts of the urethra together without seriously shortening it, which can create penile curvature (during erection), shortening of the length, etc. So to prevent that stuff happening, they supplement the repair with a the buccal (cheek) tissue. The way my docs described it to me before my surgery was that they would stitch just one tiny area of the 2 healthy ends back together, so they only have to stretch along one side of the urethra. Then they fill the gap between the still-unconnected ends of the urethra with the buccal tissue. This puts much less stress/pull on the urethra. He will have pain in his mouth where they harvested the graft. But that heals very quickly.
I hope that helps! Good luck with it!
Ken
I have been looking at different surgery for my stricture. Don’t know what size it is but it is at the external sphincter muscle. They found it when I was in the hospital in august of 2014. They tried to catheter me 5 times and could not get it in the bladder . I see my doctor in April to see what we are going to do. I have to have it done because I have had 5 bladder infection in 2014 and I just got over one now. I think the one is best is the BMG Graft surgery is the best for me. I’m 59 and I don’t what to have a end to end. I would per fur not to have any of the urethra cut out. I have read on another site that doctors do not tell you about penile shorting At my age I may not fool around much but still would love to. The worst story I read was a 40 year old man with a 0.5 stricture. He had the end to end surgery. When he woke up the doctor told him that they had to cut 3 1/2 in off. Now he can’t have sex with his wife. I don’t know about any men that has to have this surgery that would like to have 3 1/2 in less when he woke up That would be a shock. He’s depressed is wife is upset and they can do anything about it. I know I will be talking to my doctor and asking a lot of question before any surgery… Take care
Ken,
It is NOT the norm for shortening like that to happen. I know it can be scary when one person shares a bad experience. But you can’t paint ALL surgeries based on a single story. We can never fully validate the veracity of a story like that. And even if there is a true incidence like that, for every bad one there are hundreds of successful surgeries. It helps a LOT if you have a proper exploratory procedure to pinpoint the location AND size prior to the surgery. No reputable surgeon would continue with an end-to-end if they discovered that the size of the stricture was not appropriate for that kind of procedure. And you wouldn’t even be scheduled for an end-to-end if the exploratory procedure revealed a stricture longer than what can reasonably be done without causing the kind of damage you’re talking about. I encourage you to look into the the track record of your surgeon with regard to urethroplasty results. then choose accordingly. If you have any reason to believe your surgeon would be so irresponsible as to attempt an end-to-end that would shorten your penis size by 3-4 inches, then you basolutely should look elsewhere.
BTW, the urethral is extremely flexible. So removal of, say, a 3 cm stricture does NOT mean the erect penis will be 3cm shorter afterward.
I hope that helps. Good luck!
Ken
Although I’m only in my early 30’s, I’ve had to deal with a urethral stricture a few times since childhood. I recently had my first (hopefully last) BMG done about 4 weeks ago, I had the foley catheter removed a few days ago. Urinating has been fine, I’m still pretty scarred where they did the cutting around my penis and my cheeks still feel swollen from time to time, usually after I’ve eaten. The doctor said that it’s normal and they are still healing. What I am unsure of is my erections, and while i had the catheter in, after about a week at home, I got erections almost every single night until the catheter came out… now it’s about 4 days after that, and my erections are still uncomfortable or slightly painful. It almost feels like my penis is trying to extend in a position it’s not supposed to. It kind of feels like it’s making a sharp right turn but isnt capable of bending into it… The doctor did say that there were some things in place that still had to dissolve over time, but I’m very concerned about how the function and look of my penis is going to turn out… I’m confident that I will heal alright but I’m nervous about how this will effect my sexual performance and overall pleasure for myself…. has anybody made it past this stage yet? Does it get better? Am I just overreacting?
P.S. Originally the doctor told me I would need 6 weeks to recover from surgery, and that would include no sexual activity. I’m about 4 weeks in now, and when he removed the catheter he said if I felt up to it, sexual activity would be ok but i would most likely bleed. Though I’m in no rush because i want to heal as best as I can, my current condition is still leaving me unsure about my overall outcome.
Tony,
Though I can’t speak with any experience about the BMG (since I had the end-to-end), one thing I do know is that 4 weeks is super early to expect much in the way of total healing. It took many months for me to feel that everything had healed up completely – somewhere around 11 months actually. And that is a number I’ve heard from others. So take heart and know that it’s still early days for you. It’s difficult – I know very well – to be patient in all this. But when my expectations were reset (understanding it could take up to a year for things to get back to normal), I felt much better. I hope that helps. And as with anything, do not hesitate to call and ask your doctor when you have a question.
Cheers!
Ken
I’ve been considering this procedure for an iatrogenically induced urethral stricture; as a boy at 8 years of age I was involved in a traumatic coma inducing head injury ((run over by a dump truck) that necessitated catheterization with resultant cumulative intraurethral scar tissue formation. I am now 60. 2 years ago I had a transurethral resection, which was great, but now urination has again greatly slowed and micturition is uncomfortable, nearing a painful experience as it was 2 years ago. In my consideration, with my eyes wide open, my greatest quandary is how this will effect my sex life. I’m also concerned with healing time. I have an appointment for follow up examination/consultation at the end of this month and I’m making a list of considerations I have for my specialist. I appreciate honest input from those who have been or are going through the urethras buccal mucosal graft.