Vessel-sparing Excision and Primary Anastomosis

Summary

Here, we present an elaborate and efficient protocol to treat isolated short bulbar or posterior urethral strictures with vessel-sparing excision and primary anastomosis.

Abstract

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures.

Introduction

Urethroplasty is considered the standard treatment for urethral strictures as it provides excellent long-term success rates^1,2. A numerous amount of surgical techniques has been described, challenging the reconstructive urologist to choose the best approach, considering various stricture modalities such as the number of strictures, the stricture length, the stricture location, the etiology, comorbidities, and previous urethral interventions. For isolated short bulbar urethral strictures, the International Consultation on Urologic Diseases (ICUD) recommends urethroplasty by excision and primary anastomosis (EPA....

Protocol

All patients provided a signed written informed consent and the approval of the local Ethics Committee (EC/2014/0438) was obtained.

NOTE: The inclusion criteria for the presented protocol were: male; age ≥18 years; signed written informed consent; fit for operation; isolated urethral stricture; urethral stricture ≤3 cm; urethral stricture only at the bulbar or membranous site. The exclusion criteria were: female; transgender; age <18 years; absence of signed written informed consent; unfit for operation; >1 concomitant urethral strictures; urethral stricture >3 cm; urethral stricture outside of the b....

Results

Between 2011 and 2017, a total of 117 patients with isolated short bulbar (n = 91) or posterior (n = 26) urethral strictures were treated with vsEPA at Ghent University Hospital. The baseline characteristics are displayed in Table 1. The median follow-up was 35 and 45 months for bulbar and posterior strictures, respectively. The strictures were longer in the patients who underwent posterior vsEPA and, accordingly, the number of patients with a calculated.......

Discussion

Urethral stricture repair by vessel-sparing excision and primary anastomosis was initially performed at Ghent University Hospital in 2010. Thereafter, it became a standard of practice in the hospital's management of patients with isolated short bulbar or posterior urethral strictures. As the bulb remains attached to the perineal body, access to the posterior urethra and the resection of the fibrotic tissue at that site can be compromised. A distortion of the pubic rami due to a pelvic fracture might further impede ac.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
iso-Betadine Dermicum 125 mL (1)	Meda Pharma	A-472825
Sterile gown (3)	According to surgeon's preference	NA
Sterile gloves (3 pairs)	According to surgeon's preference	NA
Sterile drapes (4)	Medline	AGBBA073A
Bard-Parker scalpel number 3 (1)	Zepf Medical Instruments	06-1003-00
Bard-Parker scalpel number 4 (1)	KLS Martin Group	10-100-04
Scalpel blade number 15 (1)	Swann-Morton	0205
Scalpel blade number 24 (1)	Swann-Morton	0211
Surgical forceps 14 cm (2)	KLS Martin Group	12-301-14
Monopolar electrocauter Valleylab  (1)	Medtronic	E2100
Electrocauter blade 15 cm (1)	Comepa	CO 150i
Debakey forceps 20 cm (2)	Düfner	06232-20
3-layered compress 30 cm x 45 cm (5)	Mölnlycke Health Care	175260
Surgical compress 10 cm x 10 cm (10)	Hartmann	232088
Mayo-Hegar needle driver 18 cm (1)	Zepf Medical Instruments	24-1804-18
Mayo-Hegar needle driver 25 cm (1)	Zepf Medical Instruments	24-1804-25
Jones scissor 18 cm (1)	Düfner	04940-18
Mayo-Stille scissor 17 cm (1)	Zepf Medical Instruments	08-1700-17
Lone Star retractor (1)	CooperSurgical, Trumbull, CT, USA	72403867
Lone Star elastic stays (4)	CooperSurgical, Trumbull, CT, USA	3311-1G
Vessel loop 45 cm (1)	Braun	1095137
Halsted-Mosquito (6)	KLS Martin Group	13-317-21
20Fr silicone urethral catheter (1)	Yushin Medical Co.	1037B-20
3Fr ureteral catheter (1)	Teleflex	223602
20Fr metal sound (1)	Custom made	NA
Vicryl 4-0 wire (6)	Ethicon	V734D
Vicryl 3-0 wire (2)	Ethicon	VCP316H
Vicryl Rapide 3-0  wire (1)	Ethicon	VF2260
10Fr Drain needle (1)	Vygon	658.10
10Fr Suction drain (1)	Oriplast	203102
Vacuum flask 400 mL (1)	Oriplast	213215AL/QL
Zetuvit 10 cm x 20 cm (1)	Hartmann	413771