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Shalkamy O, Elsalhy M, Alghamdi SM, Beaiti M, Abdel-Al I, Faisal M, Abouelgreed TA, Badran Y, Abdrabu A, Al-Ayafi M, Bosily MJ, Shebl SE, Nematallah I, Shafiea A, Elatreisy A. Erectile function after different techniques of bulbar urethroplasty: does urethral transection make a difference? BMC Urol 2023; 23:140. [PMID: 37620812 PMCID: PMC10463440 DOI: 10.1186/s12894-023-01281-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Accepted: 06/28/2023] [Indexed: 08/26/2023] Open
Abstract
PURPOSE We aimed to compare the impact of urethral transection after different techniques of bulbar urethroplasty on erectile function outcome. MATERIALS AND METHODS We retrospectively reviewed the records for 245 patients who underwent different urethroplasty techniques for bulbar urethral stricture between February 2013 and January 2021. The comparison between the transecting and non-transecting cohorts included patients' demographics, clinicopathological features of the urethral stricture, post-urethroplasty erectile function, and success of urethroplasty. Outcomes were erectile function status verified by IIEF5-15 score at preoperative, three months, and 12 months post-surgery. We defined Post-urethroplasty ED as a decrease of 5 points or more. RESULTS The urethroplasty success rate of the entire cohort was 86.9% after a mean follow-up of 45.59 ± 21 months. Out of 245 patients, 18 (7.3%) experienced 90-day complications. Transecting bulbar urethroplasty techniques were performed in 74 patients (30.2%), while non-transecting techniques were performed in 171 patients (69.8%). there were no differences between the cohorts regarding urethroplasty success (87.8% Vs. 86.5%, Mantel-Cox test p = 0.93) or postoperative complications (8.1% Vs. 7%, p = 0.73). Transient ED was evident in the transecting cohort as reported in 8.1% compared to 2.9% for the non-transecting (p = 0.07).Still, but de novo permanent ED was comparable (4.1% Vs. 2.9%, p = 0.65), for transecting and non-transecting, respectively. CONCLUSIONS Unfortunately, some patients who undergo transecting techniques of bulbar urethroplasty experience transient erectile dysfunction that can improve within the first post- urethroplasty year; however, de novo permanent erectile dysfunction is uncommon after different techniques of bulbar urethroplasty and is not predisposed by urethral transection.
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Affiliation(s)
- Osama Shalkamy
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
| | - Mohamed Elsalhy
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | | | - Mohammed Beaiti
- Department of Urology, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Ibrahim Abdel-Al
- Department of Urology, Faculty of Medicine, Assiut Branch, Al-Azhar University, Assiut, Egypt
| | - Mahmoud Faisal
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Tamer A Abouelgreed
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Yasser Badran
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Abdrabu Abdrabu
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mahdi Al-Ayafi
- Department of Urology, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Mohanad Jebril Bosily
- Department of Urology, Armed Forces Hospital Southern Region, Khamis Mushait, Saudi Arabia
| | - Salah E Shebl
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ibrahim Nematallah
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Shafiea
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Adel Elatreisy
- Department of Urology, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
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Shalkamy O, Elatreisy A, Salih E, Safar O, Aljubran A, Abouelgreed TA, Khogeer A, Ibrahim A. Erectile and voiding function outcomes after buccal mucosa graft urethroplasty for long-segment bulbar urethral stricture: ventral versus dorsal onlay technique. World J Urol 2023; 41:205-210. [PMID: 36460798 DOI: 10.1007/s00345-022-04220-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 10/18/2022] [Indexed: 12/05/2022] Open
Abstract
PURPOSE To compare the impact of dorsal versus ventral onlay buccal mucosa graft bulbar urethroplasty on postoperative erectile function status. MATERIALS AND METHODS We retrospectively reviewed the records for 232 patients who underwent dorsal and ventral onlay buccal mucosa graft bulbar urethroplasty from March 2012 to April 2021. Outcomes were urinary and erectile function status as assessed by IIEF5-15 score at preoperative, three months, and 12 months post-urethroplasty. We compared the dorsal and ventral only techniques at the different follow-up visits using difference-in-differences analysis. RESULTS 165 patients met our inclusion criteria; the overall success rate was 87.9% after a mean follow-up of 52.3 ± 18.5 months. Of the patients, 17.6% experienced a 90-day complication. When comparing dorsal and ventral only techniques, there were no significant differences in terms of success rate (88.3% vs. 87.1%, Mantel-Cox test p = 0.68) or postoperative complications (15.5% Vs. 19.4%, p = 0.3). Likewise, there was no significant difference between both techniques regarding postoperative erectile function as assessed by IIEF5-15 score after three months (26.28 ± 2.53 Vs. 26.37 ± 2.41; p = 0.836) and twelve months (26.88 ± 2.45 Vs. 26.48 ± 1.98; p = 0.532). We detected a post-urethroplasty transient ED in (3.9% vs. 1.6%; p = 0.41), and permanent ED in (1.9% vs. 3.2%; p = 0.6) for dorsal and ventral onlay, respectively. CONCLUSIONS Onlay Buccal mucosa graft urethroplasty is a highly effective surgery in treating long-segment bulbar urethral stricture. The dorsal and ventral only techniques were comparable regarding urinary and erectile function outcomes. Additionally, both techniques have no significant negative impact on post-urethroplasty erectile function status.
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Affiliation(s)
- Osama Shalkamy
- Department of Urology, Faculty of Medicine, Al-Azhar University, 1 Al-Mokhaym Al-Daem, Nasr City, 11633, Cairo, Egypt.
| | - Adel Elatreisy
- Department of Urology, Faculty of Medicine, Al-Azhar University, 1 Al-Mokhaym Al-Daem, Nasr City, 11633, Cairo, Egypt
| | - Elsayed Salih
- Department of Urology, Faculty of Medicine, Al-Azhar University, 1 Al-Mokhaym Al-Daem, Nasr City, 11633, Cairo, Egypt
| | - Omar Safar
- Department of Urology, Armed Forces Hospital, Khamis Mushait, Aseer, Kingdom of Saudi Arabia
| | - Abdulkareem Aljubran
- Department of Urology, Armed Forces Hospital, Khamis Mushait, Aseer, Kingdom of Saudi Arabia
| | - Tamer A Abouelgreed
- Department of Urology, Faculty of Medicine, Al-Azhar University, 1 Al-Mokhaym Al-Daem, Nasr City, 11633, Cairo, Egypt
| | - Abdulghani Khogeer
- Department of Surgery, Division of Urology, McGill University Health Center, Montreal, QC, Canada.,Department of Surgery, Faculty of Medicine, Rabigh, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ahmed Ibrahim
- Department of Surgery, Division of Urology, McGill University Health Center, Montreal, QC, Canada
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Pang KH, Osman NI, Chapple CR, Eardley I. Erectile and Ejaculatory Function Following Anterior Urethroplasty: A Systematic Review and Meta-analysis. Eur Urol Focus 2022; 8:1736-1750. [PMID: 35430159 DOI: 10.1016/j.euf.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/23/2022] [Accepted: 03/30/2022] [Indexed: 01/25/2023]
Abstract
CONTEXT The degree of change in erectile (EF) and ejaculatory function (EjF) according to validated questionnaires following anterior urethroplasty and different techniques is unclear. OBJECTIVE To investigate the evidence on EF and EjF evaluated via validated questionnaires following anterior urethroplasty. EVIDENCE ACQUISITION A systematic review (PROSPERO ID: CRD42021229797) of the literature was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. The PubMed and CENTRAL databases were searched on February 1, 2021, with an updated search performed on December 1, 2021. Studies evaluating EF and/or EjF using validated questionnaires in men aged ≥18 yr following anterior urethroplasty were included. EVIDENCE SYNTHESIS Overall, 29 studies (two randomised and 27 nonrandomised) were included. The questionnaire most commonly used to evaluate EF and EjF was the International Index of Erectile Function (IIEF) and Male Sexual Health Questionnaire (MSHQ), respectively. The incidence of postoperative erectile dysfunction (ED) was 0-38% and the mean change in EF score according to the IIEF ranged from -4.0 to 2.5. The incidence of postoperative ejaculatory dysfunction (EjD) was 7.7-67% and the mean change in EjF score according to the MSHQ-EjD was 0.7-7.0. Meta-analyses revealed a mean difference of -0.87 (95% confidence interval [CI] -1.50 to -0.23; p = 0.008) in IIEF-EF score and 1.77 (95% CI 0.61-2.93; p = 0.003) in MSHQ-EjF score following anterior urethroplasty. CONCLUSIONS EF and EjF may be affected following anterior urethroplasty and men should be counselled appropriately. Owing to the variation in questionnaires and cutoff scores used, EF and EjF outcomes following different urethroplasty techniques are heterogeneous, with limited data from randomised controlled trials. An agreement on questionnaires and cutoff scores should be established to allow consistent reporting. Future research should aim to investigate best approaches for minimising sexual dysfunction. PATIENT SUMMARY Surgical repair of the urethra (urethroplasty) used to treat narrowing of the urethra (urethral stricture) may affect erectile and ejaculatory function. Different questionnaires and definitions are used to evaluate sexual function, so it is hard to compare data. The degree of disruption can be affected by different techniques and the severity of disease.
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Affiliation(s)
- Karl H Pang
- Institute of Andrology, University College Hospital, University College London Hospital NHS Foundation Trust, London, UK
| | - Nadir I Osman
- Section of Functional and Reconstructive Urology, Department of Urology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Christopher R Chapple
- Section of Functional and Reconstructive Urology, Department of Urology, Royal Hallamshire Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Ian Eardley
- Section of Andrology, Pyrah Department of Urology, St. James's Hospital, The Leeds Teaching Hospital NHS Trust, Leeds, UK.
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Calleja Hermosa P, Campos-Juanatey F, Varea Malo R, Correas Gómez MÁ, Gutiérrez Baños JL. Sexual function after anterior urethroplasty: a systematic review. Transl Androl Urol 2021; 10:2554-2573. [PMID: 34295743 PMCID: PMC8261436 DOI: 10.21037/tau-20-1307] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 01/27/2021] [Indexed: 11/09/2022] Open
Abstract
Background Urethral surgery outcomes are often evaluated by assessing urinary flow and urethral patency. However, sexual consequences may appear after urethroplasty, impairing quality of life and patient’s perception of success. The aim of this study is to assess the relationship between anterior urethral reconstruction and postoperative sexual dysfunction, including the proposed factors predicting sexual outcomes. Methods We searched in PubMed database using the terms: “anterior urethroplasty”, bulbar urethroplasty” or “penile urethroplasty”, and “sexual dysfunction”, “erectile function” or “ejaculation”. Articles were independently evaluated for inclusion based on predetermined criteria. Systematic data extraction was followed by a comprehensive summary of evidence. Results Thirty-eight studies were included for final analysis. No randomised trial on the topic was found. Urethral surgery might affect different aspects of sexual function: erectile function, ejaculatory function, penile shape and length, and genital sensitivity, leading to severe sexual dysfunction. Patient perception of sexual impairment was related to post-operative satisfaction. Conclusions Sexual dysfunction after anterior urethral reconstruction is an important issue that must be appropriately discussed during preoperative patient counselling. Reported outcomes after anterior urethroplasty should include sexual consequences and relevance, evaluated using validated tools.
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Affiliation(s)
| | - Felix Campos-Juanatey
- Urology Department, Marques de Valdecilla University Hospital, Santander, Spain.,Valdecilla Research Institute (IDIVAL), Santander, Spain
| | - Raquel Varea Malo
- Urology Department, Marques de Valdecilla University Hospital, Santander, Spain
| | - Miguel Ángel Correas Gómez
- Urology Department, Marques de Valdecilla University Hospital, Santander, Spain.,Medical and Surgical Sciences Department, School of Medicine, University of Cantabria, Santander, Spain
| | - Jose Luis Gutiérrez Baños
- Urology Department, Marques de Valdecilla University Hospital, Santander, Spain.,Medical and Surgical Sciences Department, School of Medicine, University of Cantabria, Santander, Spain
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Heinsimer K, Wiegand L. Erectile and Ejaculatory Dysfunction After Urethroplasty. Curr Urol Rep 2021; 22:19. [PMID: 33554283 DOI: 10.1007/s11934-021-01039-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE OF THE REVIEW The goal of this paper was to evaluate the impact on erectile and ejaculatory function after anterior and posterior urethroplasty. RECENT FINDINGS With a rise in the use of urethroplasty, its impact on sexual function has come into question. For anterior urethroplasties, some degree of erectile dysfunction is common, but this tends to be transient, with most patients having a resolution of any de novo dysfunction by 12 months. Patients with posterior urethral strictures have a very high rate of erectile dysfunction prior to surgery and may show improvement after urethroplasty. Ejaculatory function tends to improve in patients due to alleviation of obstruction while some patients notice degradation in force of ejaculation. While urethroplasty has a minimal permanent effect on sexual function for most patients, there are some patients who notice improvement and others worsening. Patients should be counseled on these risks prior to urethroplasty.
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Affiliation(s)
- Kevin Heinsimer
- Department of Urology, University of South Florida, Tampa General Circle, STC Floor 6, Tampa, FL, 33606, USA.
| | - Lucas Wiegand
- Department of Urology, University of South Florida, Tampa General Circle, STC Floor 6, Tampa, FL, 33606, USA
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Fougerousse JA, Selph JP. Sexual Dysfunction Following Urethroplasty for Urethral Stricture Disease. CURRENT SEXUAL HEALTH REPORTS 2020. [DOI: 10.1007/s11930-020-00288-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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7
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Akpayak IC, Shuaibu SI, Ofoha CG, Oshagbemi AO, Dakum NK, Ramyil VM. Dorsal onlay buccal mucosa graft urethroplasty for bulbar urethral stricture: a single centre experience. Pan Afr Med J 2020; 36:305. [PMID: 33282088 PMCID: PMC7687486 DOI: 10.11604/pamj.2020.36.305.21398] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 07/13/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction the successful treatment for urethral strictures demands not just attention to surgical details but careful selection of the reconstructive technique. For long segment urethral strictures substitution urethroplasty is required. This study sought to determine the success rate and complications of dorsal onlay buccal mucosal graft (BMG) urethroplasty for long segment urethral strictures in our hospital. Methods this was a retrospective study carried out at Jos University Teaching Hospital from March 2015 to March 2018. The case notes of male patients who had dorsal onlay buccal mucosal graft urethroplasty for long segment bulbar urethral stricture within the study period were retrieved. Patients´ demographics, cause and nature of urethral strictures, duration of follow up, the success rate and complications were collected and subjected to statistical analysis using SPSS® version 22. Results twenty-four men with mean age of 45 years (range 14-67 years) had dorsal onlay buccal mucosal graft urethroplasty during the study period. The mean stricture length was 4.5cm (range, 2-7cm). After a mean follow up duration of 2 years (range, 1 4 years), 21(87.5%) patients had a successful urethroplasty as they were able to pass urine at one year post urethroplasty without lower urinary tract symptoms, while 3(12.5%) had recurrence of the urethral stricture. At the recipient site, 2(8.3%) patients had primary bleeding that did not require blood transfusion. Also, 2(8.3%) patients had superficial wound infection which was treated with antibiotics. At the donor site, 4(16.7%), 2(8.3%), 4(16.7%) had donor site swelling, transient bleeding and soreness respectively. Conclusion dorsal onlay BMG urethroplasty has a good success rate and minor complications and therefore suitable for long segment bulbar urethral strictures.
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Affiliation(s)
| | | | - Chima Gideon Ofoha
- Urology Division, Surgery Department, Jos University Teaching Hospital, Jos, Nigeria
| | | | - Nuhu Kutan Dakum
- Urology Division, Surgery Department, Jos University Teaching Hospital, Jos, Nigeria
| | - Venyir Mamzhi Ramyil
- Urology Division, Surgery Department, Jos University Teaching Hospital, Jos, Nigeria
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8
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Omar RG, Khalil MM, Alezaby H, Sebaey A, Sherif H, Mohey A. Evaluation of erectile function after anastomotic vs substitutional urethroplasty for bulbar urethral stricture. Arab J Urol 2020; 18:226-232. [PMID: 33312733 PMCID: PMC7717595 DOI: 10.1080/2090598x.2020.1805965] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Objective Patients and methods Results Conclusion
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Affiliation(s)
- Rabea G. Omar
- Department of Urology, Faculty of Medicine, Benha University, Benha, Egypt
| | - Mostafa M. Khalil
- Department of Urology, Faculty of Medicine, Benha University, Benha, Egypt
| | - Hesham Alezaby
- Department of Urology, Faculty of Medicine, Benha University, Benha, Egypt
| | - Ahmed Sebaey
- Department of Urology, Faculty of Medicine, Benha University, Benha, Egypt
| | - Hammouda Sherif
- Department of Urology, Faculty of Medicine, Benha University, Benha, Egypt
| | - Ahmed Mohey
- Department of Urology, Faculty of Medicine, Benha University, Benha, Egypt
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9
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Kałużny A, Krukowski J, Matuszewski M. Erectile dysfunction after urethroplasty. Cent European J Urol 2020; 72:402-407. [PMID: 32015911 PMCID: PMC6979548 DOI: 10.5173/ceju.2019.1737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/17/2019] [Accepted: 11/24/2019] [Indexed: 11/22/2022] Open
Abstract
Introduction The aim of this study was to analyze the influence of urethroplasty on sexual function. Material and methods We analyzed 75 operations: 41 anastomotic, 13 labial graft, 6 thigh skin mesh graft, and 15 penile skin flap urethroplasties. The severity of erectile dysfunction was assessed in the International Index of Erectile Function (IIEF5) questionnaire, preoperatively and at least 3 months after the surgery. The appearance of possible penile deformities was also evaluated postoperatively. Results The etiology and location of the stricture had no impact on the erectile dysfunction in men with untreated urethral stricture. The difference in mean IIEF5 score before and after the first urethroplasty was not statistically significant (12.58 ±9.01 and 10.88 ±9.28; t(42) = 1.25, p = 0.220). The length of the stricture had no impact on the preoperative and postoperative IIEF5 score. Stricture in penile urethra caused a risk of postoperative penile curvature (p = 0.023). Conclusions Patients with urethral stricture have a higher rate of erectile dysfunction than healthy men. Proper therapy should not negatively affect erectile function in a significant way, regardless of the length or location of the stricture, though it may have some influence on the penile anatomy.
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Affiliation(s)
- Adam Kałużny
- Medical University of Gdańsk, University Clinical Centre, Department of Urology, Gdańsk, Poland
| | - Jakub Krukowski
- Medical University of Gdańsk, University Clinical Centre, Department of Urology, Gdańsk, Poland
| | - Marcin Matuszewski
- Medical University of Gdańsk, University Clinical Centre, Department of Urology, Gdańsk, Poland
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10
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Urkmez A, Yuksel OH, Ozsoy E, Topaktas R, Sahin A, Koca O, Ozturk MI. The effect of urethroplasty surgery on erectile and orgasmic functions: a prospective study. Int Braz J Urol 2019; 45:118-126. [PMID: 30521166 PMCID: PMC6442143 DOI: 10.1590/s1677-5538.ibju.2018.0276] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 06/17/2018] [Indexed: 01/17/2023] Open
Abstract
Objectives: to examine the effects of urethroplasty surgery on sexual functions by taking into account age, location of stenosis, length of stenosis and surgical technique parameters. Materials and Methods: The prospective study was conducted between January 2015 and August 2017 with 60 cases. Patients were categorized according to age groups (19-65 / 65-75 years), surgery technique and stricture localization and length. Before the urethroplasty operation and postoperative 6th month follow-up, the international index of erectile function (IIEF) form (15 questions), was filled, the relevant domains of sexual function; erectile function (Q1,2,3,4,5,15), orgasmic function (Q9,10) and overall satisfaction (Q13,14) were assessed. Results: The mean age of the cases is 54 ± 13. However, preoperative IIEF, sexual satisfaction and orgasmic function averages of patients with a stenosis segment length of 1-3 cm was found to be significantly higher than that of patients with a stenosis segment length of 4-7 cm. Between stenosis segment length groups, there was no statistical difference in terms of preoperative and postoperative sexual functions. And also, there was no statistically significant change in patients’ preoperative and postoperative sexual function scores in terms of localization of stricture and surgery techniques. However, there were statistically significant change in the postoperative IIEF and sexual satisfaction averages according to preoperative averages. Conclusion: Our study suggests that urethroplasty surgery itself does not significantly affect erectile function, orgasmic function, and general sexual satisfaction regardless of the type of surgery, localization and length of stenosis. Besides, there was a significant decrease in erectile function in senior adults.
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Affiliation(s)
- Ahmet Urkmez
- Department of Urology, University of Health Sciences, Haydarpasa Numune Research & Training Hospital, Istanbul, Turkey
| | - Ozgur H Yuksel
- Department of Urology, University of Health Sciences, Fatih Sultan Mehmet Research & Training Hospital, Istanbul, Turkey
| | - Emrah Ozsoy
- Department of Urology, University of Health Sciences, Haydarpasa Numune Research & Training Hospital, Istanbul, Turkey
| | - Ramazan Topaktas
- Department of Urology, University of Health Sciences, Haydarpasa Numune Research & Training Hospital, Istanbul, Turkey
| | - Aytac Sahin
- Department of Urology, University of Health Sciences, Fatih Sultan Mehmet Research & Training Hospital, Istanbul, Turkey
| | - Orhan Koca
- Department of Urology, University of Health Sciences, Haydarpasa Numune Research & Training Hospital, Istanbul, Turkey
| | - Metin I Ozturk
- Department of Urology, University of Health Sciences, Haydarpasa Numune Research & Training Hospital, Istanbul, Turkey
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11
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Baradaran N, Hampson LA, Edwards TC, Voelzke BB, Breyer BN. Patient-Reported Outcome Measures in Urethral Reconstruction. Curr Urol Rep 2018; 19:48. [PMID: 29774434 DOI: 10.1007/s11934-018-0797-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
PURPOSE OF REVIEW Treatment of anterior urethral stricture disease (USD) has shifted from endoscopic approaches to urethroplasty with significantly higher success rates among reconstructive urologists. This academic stance has led to a critical evaluation of "success" and developing disease-specific instruments to assess surgical outcomes focusing on patients' satisfaction rather than the historical goal of avoiding secondary procedures. RECENT FINDINGS Many disease non-specific and/or non-validated patient-reported outcome measures (PROMs) have been utilized to evaluate the voiding symptoms and sexual of function of patients after urethroplasty in the literature. Urethral Stricture Surgery PROM (USS PROM) is the first validated, disease-specific PROM for anterior USD which has been designed in 2001. Urethral Stricture Symptoms and Impact Measure (USSIM) is a comprehensive PROM and is currently being validated at multiple institutions. This article reviews the tools used to assess success after urethroplasty and elaborates the need to develop a comprehensive USD-specific PROM.
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Affiliation(s)
- Nima Baradaran
- Department of Urology, University of California - San Francisco, San Francisco, CA, USA
| | - Lindsay A Hampson
- Department of Urology, University of California - San Francisco, San Francisco, CA, USA
| | - Todd C Edwards
- Department of Health Services, Seattle Quality of Life Group, University of Washington, Seattle, WA, USA
| | - Bryan B Voelzke
- Department of Urology, University of Washington - Harborview Medical Center, Seattle, WA, USA
| | - Benjamin N Breyer
- Department of Urology, University of California - San Francisco, San Francisco, CA, USA. .,Zuckerberg San Francisco General Hospital and Trauma Center, University of California - San Francisco, 1001 Potrero Suite 3A, San Francisco, CA, 94110, USA.
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12
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Siegel JA, Morey AF. Editorial - The case for excision and primary anastomotic urethroplasty for bulbar urethral stricture. Int Braz J Urol 2016; 42:868-871. [PMID: 27716454 PMCID: PMC5066880 DOI: 10.1590/s1677-5538.ibju.2016.05.02] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Affiliation(s)
- Jordan A Siegel
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Allen F Morey
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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13
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Haines T, Rourke KF. The effect of urethral transection on erectile function after anterior urethroplasty. World J Urol 2016; 35:839-845. [PMID: 27562579 DOI: 10.1007/s00345-016-1926-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 08/18/2016] [Indexed: 12/11/2022] Open
Abstract
PURPOSE To prospectively assess the effect of urethral transection on erectile function after anterior urethroplasty. METHODS From February 2012 to December 2014, 104 patients were enrolled in a prospective study assessing erectile function (EF) after anterior urethroplasty. Participants completed the International Index of Erectile Function (IIEF) questionnaire preoperatively and 6 months postoperatively. Outcome measures were the incidence of erectile dysfunction (ED) defined by ≥5-point change in EF and mean change in the EF domain. Factors examined were urethral transection, stricture location, patient age and other demographics. Fisher's exact test, Student's t test and linear regression were used to evaluate associations when appropriate. RESULTS Seventeen patients were excluded because of poor EF, leaving 87 patients for analysis. Twenty-two patients (25.3 %) had urethral transection during urethroplasty, while 65 underwent non-transecting techniques (74.7 %). For the entire cohort, IIEF scores remain unchanged (20.16 versus 20.14; p = 0.98). Eighteen patients (20.7 %) developed ED, while 15 (17.2 %) experienced an improvement in EF. Urethral transection was not associated with ED (p = 0.22) or mean change in EF (-0.8 versus +0.2; p = 0.71). Stricture location was not associated with ED, but patient age ≥50 was associated with a decrease in mean postoperative EF (-2.84 versus +1.85; p = 0.04). On linear regression analysis patient age remained independently associated with adverse change in EF (p = 0.05). CONCLUSIONS Urethroplasty can result in a decline in erectile function in some patients but overall is associated with minimal change in erectile function. Urethral transection is not associated with adverse change in erectile dysfunction after urethroplasty however, advanced patient age is.
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Affiliation(s)
- Trevor Haines
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada
| | - Keith F Rourke
- Division of Urology, Department of Surgery, University of Alberta, Edmonton, AB, Canada.
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Mondal S, Bandyopadhyay A, Mandal MM, Pal DK. Erectile dysfunction in anterior urethral strictures after urethroplasty with reference to vascular parameters. Med J Armed Forces India 2016; 72:344-349. [PMID: 27843181 DOI: 10.1016/j.mjafi.2016.07.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2016] [Accepted: 07/10/2016] [Indexed: 10/21/2022] Open
Abstract
BACKGROUND Relation of erectile dysfunction (ED) with urethroplasty has long been a subject of debate. Very few studies on subcontinent population are available in this regard and still rarer are studies assessing vascular parameters of ED following urethroplasty. The objective of the study was to assess the incidence and prevalence of ED in patients of urethral stricture disease, and to find out effect of urethroplasty on ED after six months of operation including vasculogenic aetiology after operation. METHODS From January 2014 to December 2015, 35 subjects underwent urethroplasty. They were assessed pre- and postoperatively by International Index of Erectile Function (IIEF-5) and Pharmacological Colour Doppler Ultrasonography (PCDU) for a period of 6 months. RESULTS Preoperative prevalence of ED assessed by IIEF was found to be 82.8%. Postoperative incidence of ED was 28.5% and new onset ED is 50%. There was no significant change in IIEF values and values of peak systolic velocity and resistive index of cavernosal artery over time. CONCLUSION There is significant prevalence of ED with urethral stricture. Despite significant postoperative incidence of ED after urethroplasty, the surgical procedure per se does not result in ED.
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Affiliation(s)
- Soumya Mondal
- Post Doctoral Trainee, Department of Urology, Institute of Postgraduate Medical Education & Research, Kolkata 700020, India
| | - Anindya Bandyopadhyay
- Assistant Professor, Department of Radiology, Institute of Postgraduate Medical Education & Research, Kolkata 700020, India
| | - Murari Mohan Mandal
- Demonstrator, Department of Community Medicine, Institute of Postgraduate Medical Education & Research, Kolkata 700020, India
| | - Dilip Kumar Pal
- Professor and Head, Department of Urology, Institute of Postgraduate Medical Education & Research, Kolkata 700020, India
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Rosenbaum CM, Schmid M, Ludwig TA, Kluth LA, Dahlem R, Fisch M, Ahyai S. Redo buccal mucosa graft urethroplasty: success rate, oral morbidity and functional outcomes. BJU Int 2016; 118:797-803. [DOI: 10.1111/bju.13528] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Clemens M. Rosenbaum
- Department of Urology; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - Marianne Schmid
- Department of Urology; University Medical Center Hamburg-Eppendorf; Hamburg Germany
- Department of Urology; University Medical Centre Göttingen; Göttingen Germany
| | - Tim A. Ludwig
- Department of Urology; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - Luis A. Kluth
- Department of Urology; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - Roland Dahlem
- Department of Urology; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - Margit Fisch
- Department of Urology; University Medical Center Hamburg-Eppendorf; Hamburg Germany
| | - Sascha Ahyai
- Department of Urology; University Medical Center Hamburg-Eppendorf; Hamburg Germany
- Department of Urology; University Medical Centre Göttingen; Göttingen Germany
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Abstract
There is a paucity of published literature on the andrological consequences of urethral repair. Until recently authors have focused mainly on technical aspects and objective results. Reported outcomes of urethral reconstruction surgery have traditionally focused only on urodynamic parameters such as flow rates. Patient reported outcome measures have largely been neglected and there is a scarcity of well conducted systematic studies on the subject. For these reasons whether the different components of sexual life are more or less affected by different types of urethral reconstruction remains largely unknown. In an attempt to clarify the available scientific evidence, the authors make a critical review of available literature, systematizing it by sexual domain and study type. Brief pathophysiological correlations are discussed.
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Abstract
Introduction: Broadly defined, urethral strictures are narrowing of the urethral lumen that is surrounded by corpus spongiosum, i.e., urethral meatus through the bulbar urethra. Urethral stenosis is narrowing of the posterior urethra, i.e., membranous urethra through bladder neck/prostate junction, which is not enveloped by corpus spongiosum. The disease has significant quality of life ramifications because many times younger patients are affected by this compared to many other urological diseases. Methods: A review of the scientific literature concerning urethral stricture, stenosis, treatment, and outcomes was performed using Medline and PubMed (U.S. National Library of Medicine and the National Institutes of Health). Abstracts from scientific meetings were included in this review. Results: There is level 3 evidence regarding the etiology and epidemiology of urethral strictures, stenoses, and pelvic fracture urethral injuries. Outcomes data from literature regarding intervention for urethral stricture are largely limited to level 3 evidence and expert opinion. There is a single level 1 study comparing urethral dilation and direct vision internal urethrotomy. Urethroplasty outcomes data are limited to level 3 case series. Conclusions: Progress is being made toward consistent terminology, and nomenclature which will, in turn, help to standardize treatment within the field of urology. Treatment for urethral stricture and stenosis remains inconsistent between reconstructive and nonreconstructive urologists due to varying treatment algorithms and approaches to disease management. Tissue engineering appears to be future for reconstructive urethral surgery with reports demonstrating feasibility in the use of different tissue substitutes and grafts.
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Affiliation(s)
- Thomas G Smith
- Scott Department of Urology, Baylor College of Medicine, Houston, TX, USA
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Wessells H. Ventral onlay graft bulbar urethroplasty using buccal mucosa. AFRICAN JOURNAL OF UROLOGY 2016. [DOI: 10.1016/j.afju.2015.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Blakely S, Caza T, Landas S, Nikolavsky D. Dorsal Onlay Urethroplasty for Membranous Urethral Strictures: Urinary and Erectile Functional Outcomes. J Urol 2015; 195:1501-1507. [PMID: 26602890 DOI: 10.1016/j.juro.2015.11.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/11/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE We evaluated urinary and erectile functional outcomes after dorsal onlay urethroplasty for bulbomembranous urethral strictures. Our aim was to understand the functional implications of dissection of the posterior urethra. MATERIALS AND METHODS We report on men who underwent membranous urethral stricture repair by buccal mucosal graft dorsal onlay substitution urethroplasty. Continence and erectile function were assessed preoperatively and postoperatively. Tissue routinely excised from the intercrural space during dissection of the dorsal aspect of the membranous urethra was evaluated for scar, striated muscle and nerves. RESULTS A total of 16 consecutive men with a mean age of 48.3 years (range 26 to 72) who had strictures with a mean length of 56 mm (range 15 to 170) involving the membranous urethra were included in analysis. Of the 16 men 15 were continent preoperatively and remained continent postoperatively. Three of 10 men (30%) with a preoperative SHIM (Sexual Health Inventory for Men) score of 17 to 25 had a decrease after urethroplasty. All 16 men had an improved maximum urinary flow rate with a mean improvement of 22 ml per second. I-PSS (International Prostate Symptom Score) improved from a median of 23 to 4 postoperatively with a median bother score improvement of 5 to 0. Histopathological assessment identified striated muscle and nerves in 6 (46%) and 9 (69%) of 13 specimens. Overall nerves and muscle comprised an average of less than 15% of the specimen. CONCLUSIONS The dorsal onlay technique with a buccal mucosal graft for membranous urethral stricture repair does not compromise continence or erectile function in most patients. Dissection at the level of the membranous urethra should be limited because striated muscle and cavernous nerves are present.
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Affiliation(s)
- Stephen Blakely
- State University of New York Upstate Medical University, Department of Urology, Syracuse, New York; State University of New York Upstate Medical University, Department of Pathology (TC, SL), Syracuse, New York
| | - Tiffany Caza
- State University of New York Upstate Medical University, Department of Urology, Syracuse, New York; State University of New York Upstate Medical University, Department of Pathology (TC, SL), Syracuse, New York
| | - Steve Landas
- State University of New York Upstate Medical University, Department of Urology, Syracuse, New York; State University of New York Upstate Medical University, Department of Pathology (TC, SL), Syracuse, New York
| | - Dmitriy Nikolavsky
- State University of New York Upstate Medical University, Department of Urology, Syracuse, New York; State University of New York Upstate Medical University, Department of Pathology (TC, SL), Syracuse, New York.
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Anastomotic Repair versus Free Graft Urethroplasty for Bulbar Strictures: A Focus on the Impact on Sexual Function. Adv Urol 2015; 2015:912438. [PMID: 26494997 PMCID: PMC4606193 DOI: 10.1155/2015/912438] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/01/2015] [Accepted: 06/09/2015] [Indexed: 11/17/2022] Open
Abstract
Objectives. To evaluate alterations in sexual function and genital sensitivity after anastomotic repair (AR) and free graft urethroplasty (FGU) for bulbar urethral strictures. Methods. Patients treated with AR (n = 31) or FGU (n = 16) were prospectively evaluated before, 6 weeks and 6 months after urethroplasty. Evaluation included International Prostate Symptom Score (IPSS), 5-Item International Index of Erectile Function (IIEF-5), Ejaculation/Orgasm Score (EOS), and 3 questions on genital sensitivity. Results. At 6 weeks, there was a significant decline of IIEF-5 for AR (−4.8; p = 0.005), whereas there was no significant change for FGU (+0.9; p = 0.115). After 6 months, differences with baseline were not significant overall and among subgroups. At 6 weeks, there was a significant decline in EOS for AR (−1.4; p = 0.022). In the FGU group there was no significant change (+0.6; p = 0.12). Overall and among subgroups, EOS normalized at 6 months. After 6 weeks and 6 months, respectively, 62.2 and 52% of patients reported alterations in penile sensitivity with no significant differences among subgroups. Conclusions. AR is associated with a transient decline in erectile and ejaculatory function. This was not observed with FGU. Bulbar AR and FGU are likely to alter genital sensitivity.
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Siegel JA, Morey AF. Substitution urethroplasty or anastomotic urethroplasty for bulbar urethra strictures? Or endoscopic urethrotomy? Opinion: Anastomotic Urethroplasty. Int Braz J Urol 2015; 41:615-8. [PMID: 26401851 PMCID: PMC4756987 DOI: 10.1590/s1677-5538.ibju.2015.0266] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Jordan A Siegel
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Allen F Morey
- Department of Urology, University of Texas Southwestern Medical Center, Dallas, TX, USA
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Psychometric validation of a German language version of a PROM for urethral stricture surgery and preliminary testing of supplementary ED and UI constructs. World J Urol 2015; 34:369-75. [PMID: 26049865 DOI: 10.1007/s00345-015-1610-8] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/31/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To validate a German language version of the patient-reported outcome measurement (PROM) following urethral stricture surgery (USS) in a cohort of men undergoing one-stage buccal mucosa graft urethroplasty (BMGU) for urethral stricture. Furthermore, to explore the responsiveness of erectile function (EF) and urinary incontinence (UI) constructs in the context of this intervention. METHODS The USS-PROM captures voiding symptoms (ICIQ-MLUTS) and health-related quality of life (HRQoL) (EQ-5D). To evaluate EF and UI, the IIEF-5 and ICIQ-UI SF were included. Between March 2012 and April 2013, all patients undergoing BMGU at our institution were prospectively enrolled in this study. Psychometric assessment included internal consistency, test-retest reliability, criterion validity and responsiveness. RESULTS Ninety-three men completed the USS-PROM before and 3 months after surgery, with 40 (43 %) also completing the USS-PROM 6 months after surgery to assess reliability. Internal consistency: for the ICIQ-MLUTS, Cronbach's α was 0.83. The test-retest intraclass correlation coefficient was 0.94. There was a negative correlation between change in ICIQ-MLUTS total score and change in Q max (r = -0.40). All values exceeded our predefined thresholds. Significant improvements of voiding symptoms and HRQoL demonstrate responsiveness to change (all p values <0.001). While ICIQ-UI scores did not change (p > 0.05), IIEF-5 scores improved significantly (p = 0.048). CONCLUSIONS The German language USS-PROM shows similar psychometric properties to the English language version. This instrument can be improved by assessing EF by the use of IIEF-5. Further studies with larger patient cohorts are needed to evaluate the significance of measuring UI in urethroplasty patients.
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Stricture Excision and Primary Anastomosis for Anterior Urethral Strictures. ADVANCED MALE URETHRAL AND GENITAL RECONSTRUCTIVE SURGERY 2014. [DOI: 10.1007/978-1-4614-7708-2_12] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Shenfeld O. Complications of Urethroplasty. ADVANCED MALE URETHRAL AND GENITAL RECONSTRUCTIVE SURGERY 2014. [DOI: 10.1007/978-1-4614-7708-2_21] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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Golab A, Slojewski M, Puszynski M, Soczawa M, Sikorski A. Dorso-ventral buccal mucosal graft for treating gunshot bulbar urethral damage. ANZ J Surg 2013; 84:590-2. [PMID: 24168062 DOI: 10.1111/ans.12272] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Adam Golab
- Department and Clinic of Urology and Urological Oncology, Pomeranian Medical University, Szczecin, Poland
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Blaschko SD, Sanford MT, Cinman NM, McAninch JW, Breyer BN. De novo erectile dysfunction after anterior urethroplasty: a systematic review and meta-analysis. BJU Int 2013; 112:655-63. [PMID: 23924424 PMCID: PMC3740455 DOI: 10.1111/j.1464-410x.2012.11741.x] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the likelihood of developing de novo erectile dysfunction (ED) after anterior urethroplasty and to determine if this likelihood is influenced by age, stricture length, number of previous procedures or timing of evaluation. MATERIALS AND METHODS PubMed, Embase, Cochrane, and Google Scholar databases were searched for the terms 'urethroplasty', 'urethral obstruction', 'urethral stricture', 'sexual function', 'erection', 'erectile function', 'erectile dysfunction', 'impotence' and 'sexual dysfunction'. Two reviewers evaluated articles for inclusion based on predetermined criteria. RESULTS In a meta-analysis of 36 studies with a total of 2323 patients, de novo ED was rare, with an incidence of 1%. In studies that assessed postoperative erectile function at more than one time point, ED was transient and resolved at between 6 and 12 months in 86% of cases. CONCLUSIONS Men should be counselled regarding the possibility of transient or permanent de novo ED after anterior urethroplasty procedures. Increasing mean age was associated with an increased likelihood of de novo ED, but this was not statistically significant.
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Affiliation(s)
- Sarah D Blaschko
- Department of Urology, University of California San Francisco, San Francisco, CA, USA
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Abstract
PURPOSE OF REVIEW To transect or not to transect the bulbar urethra in nontraumatic urethral strictures still remains an issue that is open to debate. Herewith, we evaluate and compare the results of these two different options in the treatment of bulbar urethral strictures. RECENT FINDINGS In 404 patients, bulbar urethroplasty using transecting techniques (end-to-end anastomosis and augmented anastomotic repair) provided a success rate ranging from 90 to 98.6%. In 522 patients, bulbar urethroplasty using nontransecting techniques (nontransecting anastomotic urethroplasty and simple oral grafting techniques) provided approximately the same success rate, ranging from 81.8 to 100%. SUMMARY Future studies, including more homogenous series of patients and subjective evaluation of urinary and sexual complications after repair, are necessary to surely establish the gold standard of treatment for nontraumatic strictures located in the proximal bulbar urethra.
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Ekerhult TO, Lindqvist K, Peeker R, Grenabo L. Low risk of sexual dysfunction after transection and nontransection urethroplasty for bulbar urethral stricture. J Urol 2013; 190:635-8. [PMID: 23485502 DOI: 10.1016/j.juro.2013.02.075] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2013] [Indexed: 10/27/2022]
Abstract
PURPOSE Open urethroplasty is the preferred treatment for recurrent bulbar urethral stricture. However, there are still some controversies regarding the optimal technique and the consequences of transecting the urethra in terms of sexual dysfunction, such as erectile dysfunction, penile shortening, impaired glans filling, decreased glans sensibility and ejaculatory function. We performed a retrospective analysis with long-term followup of anastomotic and substitution onlay urethroplasty in bulbar strictures with an emphasis on postoperative sexual function. MATERIALS AND METHODS A total of 169 patients with bulbar stricture were treated with urethroplasty via the onlay technique (75) or resection followed by end-to-end anastomosis (94) during 1999 to 2009. Mean followup in the transection and onlay groups was 41 and 69 months, respectively (range 12 to 132). All patients were asked verbally about sexual function during followup. Failure was defined as the need for new surgical intervention. RESULTS Erectile dysfunction developed in 1 patient (1%) per group. In the transection group 5 patients (5%), including 4 with longer and more distal strictures, had penile shortening/downward angulation. However, this did not interfere with sexual ability during intercourse. No patient reported impaired glans or ejaculatory function. The success rate in the transection and onlay groups was 91% and 71%, respectively. CONCLUSIONS Transection with resection and end-to-end anastomosis is a good method for bulbar stricture with a low rate of sexual dysfunction and a high success rate postoperatively. To avoid penile angulation/shortening, it might be wise to use the onlay technique for longer and distal strictures.
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Affiliation(s)
- Teresa O Ekerhult
- Department of Urology, Sahlgrenska University Hospital, Gothenburg, Sweden.
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Voelzke BB. Critical review of existing patient reported outcome measures after male anterior urethroplasty. J Urol 2012; 189:182-8. [PMID: 23174257 DOI: 10.1016/j.juro.2012.08.096] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2012] [Indexed: 11/25/2022]
Abstract
PURPOSE Male urethral stricture disease can be recurrent and debilitating. The aim of any intervention is to allow men to return to a normal state of voiding while maintaining a strong quality of life. A systematic review of the literature was conducted to assess for the use of patient reported outcome instruments after male anterior urethroplasty. MATERIALS AND METHODS A review of PubMed® was conducted to identify studies that used a patient reported outcome measure to assess patient outcome after open surgical correction of male strictures. Preference was given to studies that used an instrument in the preoperative and postoperative setting. However, use of an outcome measure solely in the postoperative setting was also accepted. After article selection, the 8 attributes recommended by the Scientific Advisory Committee were used to analyze the measurement properties of each patient reported outcome measure. RESULTS A total of 15 studies were identified that included an instrument to assess patients with anterior urethral strictures. The studies used differing instruments to assess anterior urethral strictures in a nonuniform manner. Four studies used a lower urinary tract symptoms instrument, 8 used a sexual/ejaculatory dysfunction instrument, and 3 used a lower urinary tract symptoms and sexual/ejaculatory function instrument. There was only 1 report that described the development of a urethroplasty specific patient reported outcome instrument. CONCLUSIONS Continued effort is necessary to develop a powerful instrument to assess patient reported outcomes after male urethroplasty. The importance of patient perspective is vital to understanding the success of open urethral reconstruction.
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Affiliation(s)
- Bryan B Voelzke
- Department of Urology, Harborview Medical Center, University of Washington Medical Center, Seattle, Washington 98104, USA.
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Pfalzgraf D, Kluth L, Isbarn H, Reiss P, Riechardt S, Fisch M, Dahlem R. The Barbagli technique: 3-year experience with a modified approach. BJU Int 2012; 111:E132-6. [PMID: 22985312 DOI: 10.1111/j.1464-410x.2012.11399.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
UNLABELLED What's known on the subject? and What does the study add? Urethral strictures can be treated by various methods, e.g. dilatation and endoscopic treatment, as well as with open surgery. However, transurethral treatment shows low long-time success rates, while open urethral reconstruction yields good long-term results. One of the standard procedures to reconstruct the strictured penile urethra is the Barbagli technique, which was introduced in 1996. However, a potential drawback of this technique is the suturing of the urethral margins to the second side of the graft, because the buccal mucosa is already fixed to the corpus cavernosum and the last line is sutured in the back side of the urethra out of sight. The present study aims to assess whether the functional results are compromised by a modified Barbagli technique, which enables a better visualisation of the mucosal margins while making the anastomosis, simplifying the original technique. OBJECTIVE To evaluate stricture recurrence rate as well as the satisfaction with the surgery of patients treated with a modified Barbagli technique published by our study group in 2009. PATIENTS AND METHODS Retrospective analysis by patient's chart review and unvalidated standardised questionnaire of patients treated by the modified Barbagli technique for urethral stricture between May 2008 and September 2010. In all, 22 patients were treated with the modified Barbagli technique for urethral stricture during this time, and 18 patients were available for follow-up. Previous surgeries, recurrence rate, complications, incontinence, erectile function, satisfaction with the surgery, and oral numbness were assessed. As described in the original technique, also in the modified technique the access to the urethra is achieved through a midline incision. Subsequently, the urethra is completely mobilised. However, it is then rotated 180 ° using stay sutures. Afterwards, the buccal mucosa is sutured into the opened urethra on both sides under vision, giving free access to the margins. Once the buccal mucosa is completely sutured in, the urethra is back-rotated using stay sutures and the margin of the buccal mucosa and the urethra is sutured to the tunica albuginea, stretching and supporting the buccal mucosa. RESULTS Follow-up was available for 18 patients with a mean (range) age of 67.5 (27-74) years. Open previous surgeries had been performed in 27.8% and transurethral surgeries in 72.2%. The mean (range) length of the oral mucosa graft was 7.8 (2.5-13) cm and the mean operative duration was 106 (73-193) min. The success rate was 83.2%; there was no de novo erectile dysfunction and no relevant penile curvature. There was oral numbness in two patients (9%). None of the recurrence-free patients (83.3%) were dissatisfied with the surgery. CONCLUSIONS The technique simplifies the original technique without compromising the functional results. The modification of the technique enables a better visualisation of the mucosal margins while making the anastomosis, simplifying the original technique. The success rate was comparable with the original technique and patient satisfaction with the surgery was high.
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Affiliation(s)
- Daniel Pfalzgraf
- Department of Urology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany.
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Fu Q, Sun X, Tang C, Cui R, Chen L. An Assessment of the Efficacy and Safety of Sildenafil Administered to Patients with Erectile Dysfunction Referred for Posterior Urethroplasty: A Single‐Center Experience. J Sex Med 2012; 9:282-7. [DOI: 10.1111/j.1743-6109.2011.02470.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Nuss GR, Granieri MA, Zhao LC, Thum DJ, Gonzalez CM. Presenting symptoms of anterior urethral stricture disease: a disease specific, patient reported questionnaire to measure outcomes. J Urol 2011; 187:559-62. [PMID: 22177165 DOI: 10.1016/j.juro.2011.10.043] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2011] [Indexed: 11/19/2022]
Abstract
PURPOSE We evaluated the spectrum of symptoms in men with urethral stricture presenting for urethroplasty. MATERIALS AND METHODS We identified 214 men who underwent anterior urethroplasty by a single surgeon (CMG) from March 2001 to June 2010. We retrospectively reviewed the initial patient history. All voiding and sexual dysfunction symptoms were recorded. RESULTS The most common presenting voiding complaints were weak stream in 49% of cases and incomplete emptying in 27%. Overall 21% of men did not present with voiding symptoms specifically addressed by the American Urological Association symptom index. The most common of these symptoms were spraying of urinary stream in 13% of men and dysuria in 10%. No symptoms were reported in 10% of men. Men with lichen sclerosus were more likely to present with obstructive symptoms (76% vs 55%) while men with penile urethral stricture were more likely to present with urinary stream spraying (17% vs 6%, each p <0.05). Sexual dysfunction was reported by 11% of men, most commonly in those with failed hypospadias repair (23% vs 9%) and lichen sclerosus (24% vs 10%, each p <0.05). CONCLUSIONS While the American Urological Association symptom index captures the most common voiding complaints of men with urethral stricture, 21% of those who presented for urethroplasty did not have voiding symptoms assessed by the index. A validated, disease specific instrument is needed to fully capture the presenting voiding symptoms and sexual dysfunction complaints of men with urethral stricture disease.
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Affiliation(s)
- Geoffrey R Nuss
- Department of Urology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Singh UP, Maheshwari R, Kumar V, Srivastava A, Kapoor R. Impact on sexual function after reconstructive surgery for anterior urethral stricture disease. Indian J Urol 2011; 26:188-92. [PMID: 20877594 PMCID: PMC2938540 DOI: 10.4103/0970-1591.65384] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Objective: To evaluate the effect of urethral reconstructive surgery on sexual drive, erectile function and ejaculation. Materials and Methods: The study group consisted of 150 men with a median (range) age of 40 (18–73) years who underwent 168 urethral reconstructive procedures for anterior urethral stricture disease between October 2003 and May 2009. We evaluated sexual functioning using the O’Leary Brief Male Sexual Function Inventory before and after surgery. Results: The median follow-up was 33 months (range 4–72). There were no significant changes in sexual drive and erectile function scores postoperatively for men in the 20-29, 30-39, 40-49, 50-59 and 60-69 years age groups. Overall, there was a significant improvement in ejaculatory function scores after surgery. This improvement was most robust in men in the 20-29, 30-39 and 40-49 years age group. Conclusion: Overall, anterior urethral reconstruction appears no more likely to cause postoperative sexual dysfunction. Different types of urethroplasties, surgical complexity with long stricture excision and the use of buccal graft, preputial flap/tube did not influence outcome.
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Affiliation(s)
- Uday P Singh
- Department of Urology and Renal Transplant, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, Uttar Pradesh, India
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Dogra PN, Saini AK, Seth A. Erectile dysfunction after anterior urethroplasty: a prospective analysis of incidence and probability of recovery--single-center experience. Urology 2011; 78:78-81. [PMID: 21550645 DOI: 10.1016/j.urology.2011.01.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Revised: 01/03/2011] [Accepted: 01/11/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the incidence and probability of recovery of erectile dysfunction after different types of one-stage urethroplasties for anterior urethral stricture disease. METHODS Seventy-eight men undergoing single-stage anterior urethroplasty from January 1, 2008 to March 31, 2010 were followed prospectively. Patients were divided into 3 groups: group 1 (n=25)-penile substitution urethroplasty; group 2 (n=32)--primary excision anastomotic bulbar urethroplasty; and group 3 (n=21)--bulbar substitution urethroplasty. Patients willing to participate completed the International Index of Erectile Function (IIEF) preoperatively and then on subsequent follow-up visits at 3, 6, 9, 12, and 15 months after urethroplasty. Pre- and post-urethroplasty erectile functions were compared. RESULTS Our mean follow-up period was 15.50+2.389 months. The mean age (years) was similar among groups. The mean stricture length (cm) was 4.78±0.747, 2.95±0.658, and 6.13±0.981 in-groups 1, 2, and 3, respectively (P=.001). Mean preoperative IIEF score was 24.60±2.365 (similar among groups). Erectile dysfunction (ED) was found in 15 (20%) patients: 4/25 (16%), 9/32 (28%), and 2/21 (10%) in groups 1, 2, and 3, respectively. Mean postoperative decline (3 months) in IIEF score was 22.54±4.823. Overall, the decline was not significant among groups (P=.502.) Recovery of erectile function was seen in 75/78 (96%) men at a mean follow-up time of 5.63±2.59 months. CONCLUSIONS Anterior urethroplasty has a probability of causing ED in as much as 20% of patients. The type of urethroplasty has no significant effect on ED. Recovery of erectile function occurs within 6 months of urethroplasty.
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Affiliation(s)
- Prem N Dogra
- Department of Urology, All India Institute of Medical Sciences, New Delhi, India.
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Johnson EK, Latini JM. The impact of urethroplasty on voiding symptoms and sexual function. Urology 2011; 78:198-201. [PMID: 21458033 DOI: 10.1016/j.urology.2011.01.045] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2010] [Revised: 01/18/2011] [Accepted: 01/21/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To determine the effect of urethroplasty for urethral stricture disease on both voiding symptoms and sexual function through the use of validated patient questionnaires. METHODS Pre- and post-operative scores for the American Urological Association Symptom Index (AUASI), Incontinence Symptom Index (ISI), and Sexual Health Inventory for Men (SHIM) were obtained and compared for adult male patients undergoing urethroplasty. Score differences were then stratified by age. Relevant clinical and demographic characteristics were also examined. RESULTS Over the 15-year study period, 183 patients underwent 222 urethroplasties. Median age at the time of surgery was 45 years. Urethroplasties were performed for 207 anterior and 15 posterior urethral strictures. The most common approaches were primary anastomotic (36.5%), staged (23.9%), and buccal graft augmented (21.6%). Overall, 63% of men had a clinically meaningful (≥4 point) improvement in AUASI total score and 69% had improvement in their quality of life (QOL) score after urethroplasty. In aggregate, AUASI total scores improved by 7 points (P<.001), and QOL scores improved by 2 points (P<.001). There was no significant difference in ISI or SHIM scores before and after urethroplasty. AUASI total scores improved more dramatically in younger patients. Half of patients with improved AUASI QOL scores did not have a corollary improvement in their total score. CONCLUSIONS As measured by validated questionnaires, patients of all ages can expect a meaningful improvement in bothersome voiding symptoms after urethroplasty for urethral stricture disease, with minimal impact on continence or erectile function.
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Affiliation(s)
- Emilie K Johnson
- University of Michigan, Department of Urology, Ann Arbor, Michigan 48109-0330, USA.
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Palminteri E, Berdondini E, Shokeir AA, Iannotta L, Gentile V, Sciarra A. Two-sided bulbar urethroplasty using dorsal plus ventral oral graft: urinary and sexual outcomes of a new technique. J Urol 2011; 185:1766-71. [PMID: 21420128 DOI: 10.1016/j.juro.2010.12.103] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE Repair of bulbar strictures using anastomotic techniques may cause sexual complications, while 1-side graft urethroplasties may not be sufficient to provide an adequate lumen in narrow strictures. We evaluated the urinary and sexual results of a 2-sided dorsal plus ventral graft urethroplasty by preserving the narrow urethral plate in tight strictures. MATERIALS AND METHODS Between 2002 and 2010, 105 men with bulbar strictures underwent dorsal plus ventral graft urethroplasty. The results are reported in a homogeneous group of 73 of 105 cases in which buccal mucosa was used as a graft with findings after 1 year or more of followup. The urethra was opened ventrally, and the exposed dorsal urethra was incised in the midline to create a raw area over the tunica albuginea where the first graft was placed dorsal-inlay. Thereafter the urethra was augmented by the ventral-onlay second graft and the spongiosum was closed over itself. Successful urethral reconstruction was defined as normal voiding without the need for any postoperative procedure. Postoperative sexual dysfunction was investigated using a validated questionnaire. RESULTS Mean followup was 48.9 months and mean stricture length was 3.3 cm. Of these 73 cases 64 (88%) were successful and 9 (12%) were treatment failures with re-stricture. Furthermore, of 49 of 73 cases who were preoperatively sexually active, none reported postoperative erectile impairment and all were satisfied with their sexual life. CONCLUSIONS In cases of tight bulbar stricture the dorsal plus ventral buccal mucosa graft provides adequate urethral augmentation by preserving the urethral plate and avoiding postoperative sexual complications.
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Affiliation(s)
- Enzo Palminteri
- Center for Urethral and Genitalia Reconstructive Surgery, Arezzo, Italy.
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Abstract
There is no technique which can be used in all types and localizations of urethral strictures. Urethral strictures occur in the majority of cases in the bulbar urethra. The success rate of urethroplasty is above 80% and results are much better compared to DVIU. Dorsal onlay shows a significantly better success rate than ventral onlay. If the graft bed has poor vascularization a flap should be used or a staged approach should be considered.
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Affiliation(s)
- S Hauser
- Klinik und Poliklinik für Urologie, Universitätsklinikum Bonn, Sigmund-Freud-Strasse 25, 53105, Bonn, Germany.
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Erickson BA, Granieri MA, Meeks JJ, McVary KT, Gonzalez CM. Prospective analysis of ejaculatory function after anterior urethral reconstruction. J Urol 2010; 184:238-42. [PMID: 20483147 DOI: 10.1016/j.juro.2010.03.038] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2009] [Indexed: 11/24/2022]
Abstract
PURPOSE Urethral reconstruction may improve ejaculatory function by relieving urethral obstruction but could worsen it by disrupting the bulbocavernosus muscle. We prospectively evaluated the effects of urethral reconstruction on ejaculatory function. MATERIALS AND METHODS All men who underwent anterior urethroplasty from September 2006 to June 2009 were asked to complete the ejaculatory function component of the Male Sexual Health Questionnaire (7 questions with a total of 35 points) preoperatively and postoperatively after resuming sexual activity. Postoperatively decreased and improved ejaculation was defined as an increase and a decrease of 5 or more points, respectively. RESULTS A total of 43 men were included in the study. The overall ejaculatory score did not change postoperatively (25.54 vs 26.94 points, p = 0.17) at a mean +/- SD followup of 8.1 +/- 6.0 months but men with poor preoperative function had significant improvement (15.27 vs 21.22 points, p = 0.01). Overall ejaculatory vigor (3.19 vs 3.56 points, p = 0.25) and volume (3.49 vs 3.88, p = 0.19) did not change significantly. Postoperative function was stable in 30 men (70%), improved in 8 (19%), including 7 with bulbar and 1 with penile urethroplasty, and worse in 5 (11%), including 4 with bulbar and 1 with penile urethroplasty. CONCLUSIONS Urethral reconstruction appears to have a minimal effect on ejaculatory function when evaluated by the Male Sexual Health Questionnaire. More objective testing may be necessary to fully assess the effect of urethroplasty on ejaculatory function.
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Affiliation(s)
- Bradley A Erickson
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
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Erickson BA, Granieri MA, Meeks JJ, Cashy JP, Gonzalez CM. Prospective analysis of erectile dysfunction after anterior urethroplasty: incidence and recovery of function. J Urol 2009; 183:657-61. [PMID: 20018319 DOI: 10.1016/j.juro.2009.10.017] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2009] [Indexed: 11/27/2022]
Abstract
PURPOSE Anterior urethroplasty has been shown to negatively impact erectile function. Recovery of function is common but the likelihood and extent of recovery have not been fully elucidated. MATERIALS AND METHODS Between October 2006 and May 2008 men undergoing anterior urethroplasty were enrolled in a prospective study to evaluate the effects of urethroplasty on erectile function. The International Index of Erectile Function was completed preoperatively and on all subsequent postoperative visits. Preoperative and postoperative erectile function was compared. RESULTS A total of 52 patients who underwent anterior urethroplasty were included in the study. Repair locations were bulbar (35) and penile (17). Of the patients undergoing bulbar urethroplasty 20 had excision and primary anastomosis, and 15 had augmented anastomotic repair. All penile repairs were ventral onlay repair (11) or inlay repair in 2 stages (6). Postoperative erectile dysfunction was noted in 20 (38%) men, of whom 18 recovered fully at a mean postoperative period of 190 days (range 92 to 398). In patients with normal preoperative erectile function bulbar urethroplasty was more likely than penile urethroplasty to cause erectile dysfunction (76% vs 38%, p = 0.05). Within the bulbar urethra excision and primary anastomosis repairs led to slightly higher erectile dysfunction rates than augmented anastomotic repairs (50% vs 26%, p = 0.16). CONCLUSIONS Anterior urethroplasty caused erectile dysfunction in approximately 40% of patients, although recovery was seen in most by 6 months. Bulbar urethroplasty appears to affect erectile function to a greater extent than penile urethroplasty, which may be explained by the proximity of the bulbar urethra to the nerves responsible for erection.
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Affiliation(s)
- Bradley A Erickson
- Department of Urology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois 60611, USA
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Dalpiaz O, Mitterberger M, Kerschbaumer A, Pinggera GM, Bartsch G, Strasser H. Anatomical approach for surgery of the male posterior urethra. BJU Int 2008; 102:1448-51. [PMID: 18540937 DOI: 10.1111/j.1464-410x.2008.07772.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To investigate, in a morphological study, the anatomy of the male rhabdosphincter and the relation between the membranous urethra, the rhabdosphincter and the neurovascular bundles (NVBs) to provide the anatomical basis for surgical approach of the posterior urethra as successful outcomes in urethral reconstructive surgery still remain a challenging issue. MATERIALS AND METHODS In all, 11 complete pelves and four tissue blocks of prostate, rectum, membranous urethra and the rhabdosphincter were studied. Besides anatomical preparations, the posterior urethra and their relationship were studied by means of serial histological sections. RESULTS In the histological cross-sections, the rhabdosphincter forms an omega-shaped loop around the anterior and lateral aspects of the membranous urethra. Ventrally and laterally, it is separated from the membranous urethra by a delicate sheath of connective tissue. Through a midline approach displacing the nerves and vessels laterally, injuries to the NVBs can be avoided. With meticulous dissection of the delicate ventral connective tissue sheath between the ventral wall of the membranous urethra and the rhabdosphincter, the two structures can be separated without damage to either of them. This anatomical approach can be used for dissection of the anterior urethral wall in urethral surgery. CONCLUSIONS Based on precise anatomical knowledge, the ventral wall of the posterior urethra can be dissected and exposed without injuring the rhabdosphincter and the NVBs. This approach provides the basis for sparing of the rhabdosphincter and for successful outcomes in urethral surgery for the treatment of bulbo-membranous urethral strictures.
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Affiliation(s)
- Orietta Dalpiaz
- Department of Urology, Medical University Innsbruck, Innsbruck, Austria.
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Abstract
Advances in urogenital plastic surgical tissue transfer techniques have enabled urethral reconstruction surgery to become the new gold-standard for treatment of refractory urethral stricture disease. Questions remain, however, regarding the long-term implications on sexual function after major genital reconstructive surgery. In this article, we review the pathologic features of urethral stricture disease and urologic trauma that may affect erectile function (EF) and assess the impact of various specific contemporary urethroplasty surgical techniques on male sexual function.
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Affiliation(s)
- Joshua Carlton
- Department of Urology, UT Southwestern Medical Center, Dallas, Texas 75390-9110, USA
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