To compare ventral- and dorsal-onlay buccal mucosal graft (BMG) urethroplasty in patients with urethral stricture, as the optimal placement of BMG in urethroplasty for bulbar urethral strictures remains debated.
A systematic search was conducted in PubMed, Scopus, Web of Science, and Cochrane Library. Studies comparing dorsal- and ventral-onlay BMG urethroplasty were analysed. Pooled effect sizes were calculated using a random-effects model. Subgroup analyses and publication bias assessments were performed.
Eight studies with 655 patients were included. The success rate showed no significant difference between the dorsal- and ventral-onlay techniques (relative risk [RR] 1.00, 95% confidence interval [CI] 0.94-1.06; P = 0.97, I = 0%). The maximum urinary flow rate at 3 months (mean difference [MD] -0.64, 95% CI -2.14 to 0.86 mL/s; P = 0.41) and 12 months (MD -0.57, 95% CI -2.00 to 0.85 mL/s; P = 0.43) was comparable. Transient erectile dysfunction (ED) was significantly lower with the ventral technique (RR 0.24, 95% CI 0.08-0.67; P = 0.006), while permanent ED rates were similar (RR 0.57, 95% CI 0.03-12.20; P = 0.72). Sensitivity analysis confirmed robustness, and no publication bias was detected.
Dorsal- and ventral-onlay BMG urethroplasty have similar success rates and urinary flow outcomes. However, ventral onlay may reduce transient ED. International Prospective Register of Systematic Reviews (PROSPERO) registration number: CRD420250654329.

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