Although a short bulbar stricture can be treated by dilation or endoscopic urethrotomy, longer or recurrent strictures are best treated by urethroplasty as it provides the best chance of success [
Out of 258 male patients who underwent urethroplasty between October 2010 and February 2014, 90 patients with a bulbar stricture only were planned to be treated with AR or FGU and eligible to participate in this prospective study. Only native Dutch speaking patients who signed the informed consent (Institutional Review Board Approval EC UZG 2008/234) and who filled in the preoperative questionnaires and at least one postoperative questionnaire (at 6 weeks and/or 6 months) were included in this analysis. Finally, 47 patients were included for further analysis and divided into two groups: AR ( urinary symptoms: maximum urinary flow ( erectile function: the abridged 5-item version of the International Index of Erectile Function (IIEF-5) [ ejaculation/orgasm: the sum of questions 9 and 10 from IIEF (long version) [ postoperative genital sensitivity: a nonvalidated in-house questionnaire containing 3 dichotomous questions on glans tumescence, alterations in genital sensitivity, and cold feeling in the glans; further analysis of glans tumescence was only done in patients reporting normal erectile function (IIEF-5 ≥ 20) in order to avoid contamination of diminished glans tumescence due to globally diminished penile tumescence.
Patients were evaluated preoperatively, after 6 weeks and 6 months. In the first six months, no phosphodiesterase-5 inhibitors were prescribed to stimulate sexual rehabilitation. In case of suspicion of stricture recurrence (
Flowchart of patient inclusion.
Patients were operated on in a single center (GUH) by two surgeons (Nicolaas Lumen and Willem Oosterlinck). AR was preferred whenever a tension-free anastomosis could be made (stricture length < 3 cm on urethrography and/or peroperative findings). For longer strictures, FGU was performed. For both techniques, a midline perineal incision is made; the bulbospongiosus muscle is incised at the midline and dissected away from the corpus spongiosum. In case of AR, the corpus spongiosum is circumferentially freed at the level of the stricture. The corpus spongiosum and urethra are transected at this site. The fibrotic urethra and spongiosus edges are resected until healthy urethra is present at both the distal and proximal ends. The urethra is then spatulated in order to obtain a broad oblique anastomosis, which is finalized by 8–10 interrupted resorbable 4.0 sutures. In case of FGU, the stricture is opened ventrally on the tip of the catheter. The stricture length is measured and a graft is taken accordingly. The graft is sutured into the urethra in a ventral onlay fashion. The corpus spongiosum is closed over the graft for vascular supply and mechanical support (spongioplasty). The urethral catheter is maintained for 14 days and a voiding cystourethrogram is made upon removal.
Descriptive statistics were performed to evaluate the whole population and both subgroups. To compare both groups, continuous variables were evaluated by independent-samples
Patients treated by AR were significantly younger (37 versus 48 years;
Patients’ characteristics (SD = standard deviation; FGU = free graft urethroplasty; AR = anastomotic repair; DVIU = direct vision internal urethrotomy;
All ( |
FGU ( |
AR ( |
|
||
---|---|---|---|---|---|
Age (years) | Mean (SD) | 40 (16) | 48 (18) | 37 (13) |
|
Follow-up (months) | Mean (SD) | 23.3 (10.9) | 25.2 (12.5) | 22.2 (10) | 0.376 |
Stricture length (cm) | Mean (SD) | 3 (2.4) | 5.4 (2.6) | 1.8 (0.8) |
|
Stricture etiology | |||||
Traumatic | Number (%) | 4 (8.5) | 0 (0) | 4 (12.9) | 0.071 |
Inflammatory | Number (%) | 1 (2.1) | 0 (0) | 1 (3.2) | |
Iatrogenic | Number (%) | 14 (29.8) | 8 (50) | 6 (19.4) | |
Idiopathic | Number (%) | 28 (59.6) | 8 (50) | 20 (64.5) | |
Previous interventions | |||||
None | Number (%) | 4 (8.5) | 2 (12.5) | 2 (6.5) | 0.877 |
DVIU/dilation(s) | Number (%) | 34 (72.3) | 11 (68.8) | 23 (74.2) | |
Urethroplasty(ies) | Number (%) | 9 (19.1) | 3 (18.8) | 6 (19.4) | |
Preop |
Mean (SD) | 6.3 (4.6) | 6.9 (4) | 6 (5) | 0.629 |
Preop IPSS (…/35) | Mean (SD) | 22 (8) | 23 (7) | 21 (8) | 0.368 |
Preop IIEF-5 (…/25) | Mean (SD) | 20 (7) | 18 (8) | 22 (6) | 0.202 |
Preop EOS (…/10) | Mean (SD) | 8 (3) | 7 (4) | 9 (3) | 0.135 |
Suprapubic catheter | |||||
Yes | Number (%) | 8 (17) | 2 (12.5) | 6 (19.4) | 0.697 |
No | Number (%) | 39 (83) | 14 (87.5) | 25 (80.6) |
Mean paired differences (Δ) of the maximum urinary flow (
Δ |
|
ΔIPSS (6 weeks versus preop) |
|
ΔIPSS (6 months versus preop) |
|
|
---|---|---|---|---|---|---|
All | +19.8 (13.9) |
|
−17 ( |
|
−20 ( |
|
FGU | +13.8 (11.7) |
|
−16 ( |
|
−21 ( |
|
AR | +22.3 (14.3) |
|
−17 ( |
|
−20 ( |
|
Evolution of International Prostate Symptom Score (a), International Index of Erectile Function-5 (b), and Ejaculation/Orgasm Score (c) for all patients and subdivided for anastomotic repair (AR) and free graft urethroplasty (FGU) (
IPSS
IIEF-5
EOS
Thirty-three patients, respectively, 19 and 14 patients in the AR- and FGU-group, reported to have sexual intercourse and filled in the IIEF-5 (Table
Mean paired differences (Δ) of the 5-Item International Index of Erectile Function (IIEF-5) and Ejaculation/Orgasm Score (EOS). The standard deviation is provided between brackets (FGU = free graft urethroplasty; AR = anastomotic repair).
ΔIIEF-5 (6 weeks versus preop) |
|
ΔIIEF-5 (6 months versus preop) |
|
|||
---|---|---|---|---|---|---|
All |
|
−2.3 (5.8) |
|
|
−0.2 (6) | 0.907 |
FGU |
|
+0.9 (2) | 0.115 |
|
+2.3 (5.8) | 0.313 |
AR |
|
−4.8 (6.5) |
|
|
−2.1 (5.6) | 0.263 |
|
||||||
ΔEOS (6 weeks versus preop) |
|
ΔEOS (6 months versus preop) |
|
|||
|
||||||
All |
|
−0.7 (2.5) | 0.111 |
|
0 (1.9) | 1 |
FGU |
|
+0.6 (1.3) | 0.12 |
|
+0.6 (2.2) | 0.448 |
AR |
|
−1.4 (2.8) |
|
|
−0.4 (1.6) | 0.431 |
Thirty-seven patients, respectively, 23 and 14 patients in the AR- and FGU-group, tried to have ejaculation/orgasm (by masturbation or sexual intercourse) and completed the EOS (Table
At 6 weeks and 6 months, respectively, 45 and 25 patients filled in the questionnaire on genital sensitivity and on cold feeling in the glans. At 6 weeks, 28 patients (62.2%) reported to have altered genital sensitivity. This proportion was not significantly different between AR and FGU (66.7 versus 53.3%;
Although this series is a prospective study, no randomization was done between AR and FGU because the use of AR is limited by the stricture length. The limit for AR is usually set at 2-3 cm [
The success rate of 90.3% for AR in this series is in line with the 93.8% composite success rate reported by the SIU/ICUD consultation [
An increasing number of papers report on sexual dysfunction after urethroplasty [
Other authors did not find a significant decline in erectile function [
We speculate that the observed transient decline in erectile function with AR might be related to the following: more extensive and circumferential dissection of the corpus spongiosum containing the bulbar urethra; proximal dissection and mobilization of the corpus spongiosum nearby the urogenital diaphragm and in the intracrural space might provoke neuropraxia and/or thermal damage (coagulation) of erectile nerves penetrating the corporal bodies at that location (Figure complete transection of the corpus spongiosum that might be associated with a higher risk of bleeding and with postoperative haematoma and inflammation; this needs some time to recover; this might withhold patients to have satisfactory sexual activity or might provoke psychological problems.
In this series, ventral FGU was performed, with no significant decrease in sexual functioning at 6 weeks and 6 months. It would be interesting to know whether dorsal FGU affects sexual functioning. One would expect a higher incidence of sexual dysfunction if the hypothesis of more extensive and circumferential dissection of the bulbar corpus spongiosum is (in part) responsible for sexual dysfunction.
Peroperative photographs of AR (a) and FGU (b): a more extensive dissection with AR can be appreciated; 1: circumferentially mobilized bulbar urethra; 2: transected urethra;
In this series, a transient decline in EOS was seen with AR, whereas there was no significant difference observed with FGU. Erickson et al. found an improvement of ejaculatory function after urethroplasty (mix of AR and FGU) [
In this series, postoperative changes in genital sensitivity were present in approximately 2 out of 3 and 1 out of 2 patients after, respectively, 6 weeks and 6 months. Changes in genital sensitivity were not significantly different among subgroups. Palminteri et al. found a change in genital sensitivity after FGU in 50% of patients [
This series again underlines the concern of possible alterations in sexual functioning and genital sensitivity after bulbar urethroplasty. Therefore it should be part of the evaluation of patients treated by urethroplasty. Jackson et al. recently validated patient reported outcome measures (PROMs) for urethroplasty [
Furthermore, it would be interesting to evaluate whether modifications in urethroplasty techniques such as muscle- and nerve-sparing bulbar urethroplasty [
Important limitations of the present series are the small sample size and the missing data in the postoperative questionnaires.
AR is associated with a transient decline in erectile and ejaculatory function. This was not observed with FGU. Bulbar urethroplasty is likely to provoke changes in genital sensitivity. Further prospective studies with validated and internationally accepted patient reported outcome measures (PROMs) are needed for further confirmation.
The authors have no conflict of interests.