Excision and Primary Anastomosis for Short Bulbar Strictures: Is It Safe to Change from the Transecting towards the Nontransecting Technique?

Abstract

Objective To explore whether it is safe to change from transecting excision and primary anastomosis (tEPA) towards nontransecting excision and primary anastomosis (ntEPA) in the treatment of short bulbar urethral strictures and to evaluate whether surgical outcomes are not negatively affected after introduction of ntEPA. Materials and Methods Two-hundred patients with short bulbar strictures were treated by tEPA (n=112) or ntEPA (n=88) between 2001 and 2017 in a single institution. Failure rate and other surgical outcomes (complications, operation time, hospital stay, catheterization time, and extravasation at first cystography) were calculated for both groups. Potentially predictive factors for failure (including ntEPA) were analyzed using Cox regression analysis. Results Median follow-up for the entire cohort was 76 months, 118 months, and 32 months for, respectively, tEPA and ntEPA (p<0.001). Nineteen (9.5%) patients suffered a failure, 13 (11.6%) with tEPA and 6 (6.8%) with ntEPA (p=0.333). High-grade (grade ≥3) complication rate was low (1%) and not higher with ntEPA. Median operation time, hospital stay, and catheterization time with tEPA and ntEPA were, respectively, 98 and 87 minutes, 3 and 2 days, and 14 and 9 days. None of these outcomes were negatively affected by the use of ntEPA. Diabetes and previous urethroplasty were significant predictors for failure (Hazard ratio resp. 0.165 and 0.355), whereas ntEPA was not. Conclusions Introduction of ntEPA did not negatively affect short-term failure rate, high-grade complication rate, operation time, catheterization time, and hospital stay in the treatment of short bulbar strictures. Diabetes and previous urethroplasty are predictive factors for failure.

Update on managing anterior urethral strictures

“…introduced the vessel-sparing or nontransecting EPA,[ 55 ] which was modified by Andrich and Mundy[ 56 57 ] and has been incorporated into clinical practice. [ 58 59 60 61 ] To date, however, there is no clear evidence of a superiority of the nontransecting approach over conservative transecting EPA regarding postoperative sexual and erectile functions,[ 61 ] but both approaches appear to be equally effective regarding stricture recurrence-free survival and perioperative safety. [ 59 60 61 ]…”

VeSpAR trial: a randomized controlled trial comparing vessel-sparing anastomotic repair and transecting anastomotic repair in isolated short bulbar urethral strictures

“…Promising short-term results have been described in single-arm observational studies and are in line with the reported composite success rate of the ICUD [ 3 , 6 – 10 ]. However, direct comparisons between vsAR and tAR have only been done in retrospective studies which are strongly biased by the fact that patients who underwent vsAR had shorter follow-up than patients who underwent tAR [ 11 , 12 ]. Moreover, since vsAR is a more novel technique, one could hypothesize that the performing surgeon is better trained and more experienced in the era of vsAR compared to the earlier in their surgical career, when tAR was the only AR technique.…”