The Technique Of Vessel Sparing Excision And Primary Anastomosis For Proximal Bulbous Urethral Reconstruction

August 7, 2007 – 11:24 pm | posted in Urology / Nephrology

UroToday.com- In a recent paper by Gerald Jordan and colleagues from Eastern Virginia Medical School in Norfolk, Virginia a technique of vessel sparing during end-to-end primary anastomosis for proximal bulbar urethral strictures is described. To complete an EPA successfully an absence of tension on the repair is of utmost importance. To achieve this tension-free anastomosis the proximal urethral segment can be mobilized distally with a sacrifice of the bulbar arteries. Together with mobilization of the distal urethral segment to the penoscrotal junction, a segment of 2 5 cm can be excised. In patients with proximal bulbar strictures who may be a candidate for the future placement of an artificial urinary sphincter it may be advantageous to spare these vessels to allow for a robustly vascularized urethra that may be more resistant to ischemic erosion. Dr. Jordan describes the technique to spare these vessels in this paper which is published in the May 2007 issue of the Journal of Urology.

The technique was employed in 10 patients over a three-year period. Six men had suffered straddle injuries, 3 had strictures after radical prostatectomies, and one potentially had a congenital stricture. The patients were placed in the exaggerated lithotomy position. Standard distal urethral mobilization was performed. The proximal segment was meticulously exposed to the level of the bulb and the urethra was dissected dorsally off the corpora cavernous while the bulbar arteries were dissected off the urethra ventrally and kept out of harms way by retracting with a vessel loop. The strictured area was excised and the anastomosis was completed in the usual fashion using 10 to 12 circumferential 4-zero absorbable sutures. The corpus spongiosum is reconstructed over the anastomosis. The paper has both intraoperative photos and drawings that help describe this modification in technique.

Mean patient age was 47 years, the patient with a congenital stricture was 2 years old. Mean stricture length was 1.5 cm. After a mean follow-up of 12.5 months, all patients were found to have a patent, stricture-free urethra by urethrocystoscopy at 6 months. Two of the patients who underwent stricture repair after radical prostatectomy were incontinent, one underwent placement of an artificial urinary sphincter via a transcorporal technique and 10 months later is dry and empties without difficulty. The other incontinent patient is awaiting AUS placement which is placed only after 6 months has passed after urethroplasty.

Dr. Jordan admits that his results with the technique may not be better than the already outstanding results with an EPA (95%). He believes this technique might be useful to preserve a robust proximal blood supply to diminish the potential for ischemic erosion in patients that may require an artificial urinary sphincter for the treatment of incontinence.

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