Introduction
Traumatic pelvic fracture is the main cause of posterior urethral stricture [
]. Some patients suffer from erectile dysfunction, which might be related to the damage in the local erectile neurological function, after the occurrence of traumas [
–
]. However, a number of patients still exhibit erectile function after the occurrence of urethral stricture, although the erectile function may be lower than the normal level [
]. Therefore, for patients with posterior urethral stricture, reservation of sexual functions to the greatest extent while the operation effect is guaranteed is worth discussing.
Urethra end-to-end anastomosis after the separation of corpus spongiosum is the most frequently used operation method among the current open operation methods for posterior urethra. Although some research showed that this conventional operation method generally does not affect sexual function after operation [
], it damages the surrounding blood vessels and tissue of the posterior urethra, and thus may also disrupt the erectile function to some extent. In this study, the non-transecting anastomotic urethroplasty was put into preliminary clinical practice, and the related indexes concerning operation condition, urinating condition after operation, and erectile function were evaluated to identify the influence of this method on the urination and sexual function of patients with posterior urethral stricture after operation.
Materials and methods
Patients and establishment of follow-up database
All the data of the clinical study were collected from 23 patients of Tongji Hospital Affiliated to Tongji University in Shanghai from 2012 to 2015.
The selection criteria are as follows: (1) age ranging from 15 years to 45 years with a certain erectile function before operation (international index of erectile function-5 [IIEF-5] score>12); (2) normal androgen (T), estradiol (E2), and prolactin (PRL) levels before the operation; (3) absence of penile blood flow reduction as indicated by Doppler ultrasound diagnosis results before the operation; and (4) the length of posterior urethral stricture was<2.5 cm. This length is based on the estimate of urethrography and flexible ureteroscopy and cystoscopy before operation.
Exclusion criteria are as follows: (1) age is more than 45 years; (2) severe erectile dysfunction (IIEF-5 score≤11) or erectile function failure (nocturnal penile tumescence [NPT] shows negative); (3) complicated urethral stricture, e.g., the length of stricture was≥2.5 cm or more than two urethral stricture sections were observed; (4) abnormal hormonal levels were detected during preoperative examination; (5) lost to follow-up after operation; and (6) administered with medicine for erectile dysfunction treatment. The patients were randomly divided into two groups, which adopted the operation methods of separating and non-transecting posterior urethral anastomosis of corpus spongiosum under the condition that no significant difference existed in the maximum flow rate (Qmax) and IIEF-5 indexes of the two groups ( P<0.05).
Preoperative preparation
Urethrography (Fig. 1), cystoscopy, and ureteroscopy were performed to confirm whether or not posterior urethral stricture existed, and the length of the posterior urethral stricture was estimated to be<2.5 cm through urography. In addition, anti-infection treatment, Qmax test, and IIEF-5 rating were performed on the patients before operation, and the patients with normal results in the urine routine test and negative result in urine cultivation could accept operation.
Separation of corpus spongiosum and urethra end-to-end anastomosis
For this operation, the following are the operation steps: (1) conducting reverse “Y” incision for perineum, (2) dissociating corpus spongiosum, (3) imbedding detection rod at the anterior urethra to locate the urethral stricture part and cutting the urethra at the stricture part, (4) cutting off the scar tissue at the stricture section around the urethra for the exposure of the proximal end urethra, (5) interrupted suturing of the proximal and distal cut ends of urethra, and (6) indwelling catheter.
Non-transecting anastomotic urethroplasty
For this operation, the following are the operation steps: (1) conducting reverse “Y” incision for perineum, (2) dissociating corpus spongiosum, (3) imbedding detection rod at the posterior urethra from bladder stoma to locate the posterior urethra and cutting the corpus spongiosum vertically at the proximal dorsal part of the posterior urethral stricture, (4) imbedding detection rod from the anterior urethra to the distal end of the urethral stricture and vertically cutting the corpus spongiosum at the dorsal part of the corpus spongiosum, (5) cutting off scar tissue around the urethra, (6) conducting anastomosis to the distal and proximal ends of urethra at the lithotomy positions of 1, 3, 5, 6, 7, 9, 11, and 12, and (7) indwelling catheter and suturing the incision (Figs. 2–5).
The detection rod was imbedded to the posterior urethra from the bladder stoma to locate the posterior urethra, and the corpus spongiosum was cut vertically at the proximal dorsal part of the posterior urethral stricture. The urethra-detecting rod exposed at the incision of the proximal end of the stricture was visible.
The urethra-detecting rod was led out from the proximal and distal ends of the stricture section, and the corpus spongiosum was not cut off.
Operation time and bleeding volume during operation
Data were collected from the operations in the two groups of patients, including the operation time and bleeding volume of each patient. Operation time refers to the time from the commencement of the operation (skin incision) to the end of the operation (skin suture). Bleeding volume during operation is obtained by determining the bleeding volume extracted by negative pressure aspirator during operation and the difference between the weights of hemostatic gauze before and after operation.
Postoperative treatment and follow-up
Anti-infection treatments for 3–5 days were performed on all the patients. In addition, the catheters were removed four weeks after operation, and the flow rates were tested one and six months after operation. Urethrography was performed one month after the removal of catheter (Fig. 6).
In addition, IIEF-5 and quality of life (QoL) questionnaire surveys were conducted to follow up the postoperative recovery of the patients 6 months after operation.
Statistical analysis
Two independent samples t-test and paired t-test were performed using SPSS 18.0 for the Qmax, and the IIEF-5 rating scales of the patients before and after operation in the two groups. A Pvalue of<0.05 was considered significant.
Results
Operation time of the two groups of patients
The operation time of the non-transecting corpus spongiosum group was less than that of the separating corpus spongiosum group. However, no significant difference was observed between them (P>0.05) (Table 1).
Bleeding volume during the operation of the two groups of patients
The bleeding volume during operation of the non-transecting corpus spongiosum group was less than that of the separating corpus spongiosum group but no significant difference was observed between them (P>0.05) (Table 2).
Change in Qmax
Separation of corpus spongiosum and posterior urethra end-to-end anastomosis was applied to 12 patients, and the catheters were removed 4 weeks after operation. One patient had difficulty in urination after the removal of the catheter, and reoperation was performed half a year later. The result of urethrography indicated that the urethras of the rest of the patients were smooth after the removal of the catheters, and the Qmax indexes of patients one month and half a year after operation were significantly improved.
The patients who underwent non-transecting anastomotic urethroplasty were able to urinate smoothly after their catheters were removed 4 weeks after the operation. This finding was supported by the result of urethrography. The average Qmax value of the patients was 2.1±2.36 ml/s before operation, then increased to 17.87±2.15 ml/s 1 month after operation, and finally increased to 17.04±1.85 ml/s half a year later (Table 3).
Evaluation of the erectile function of patients after operation
Follow-ups on the erectile function and the IIEF-5 questionnaire survey were conducted six months after operation. All the patients who underwent the separating corpus spongiosum operation suffered from different degrees of erectile dysfunction. Their IIEF-5 scores relatively decreased considerably compared with those of the patients with a certain erectile function before operation. For the non-transecting corpus spongiosum operation, the average IIEF-5 score of the patients was 16.75±2.22 before operation, and it reduced to 15.00±3.86 after operation but no significant difference was observed before and after operation (P = 0.089) (Table 4).
QoL rating of patients
A QoL questionnaire survey was conducted six months after their operation during the sexual function follow- ups. For the separating corpus spongiosum group, the QoL rating at the follow-up time node after the operation decreased significantly, but the result of the non-transecting corpus spongiosum group was quite different (Table 5).
Discussion
As for the posterior urethral stricture caused by traumas, such as pelvic fracture, some literatures showed that a number of patients retained a certain erectile function after the occurrence of posterior urethral stricture. This result might be because the blood supply or erectile nerve in the penis was not damaged completely [
]. For some patients, especially males at reproductive age, sexual life and procreation are required, but the conventional posterior urethra end-to-end anastomosis might greatly affect their sexual function or even cause the loss of sexual function. Therefore, developing an operation plan that can protect a specific patient group with posterior urethral stricture to the maximum extent is significant.
A conventional posterior urethra operation can dissociate posterior corpus spongiosum and cut off the corpus spongiosum and the scar tissue around. If the length of the urethra is inadequate, the horn of the penis must be split and the lower limb of the pubis must be cut off. According to the investigation data collected by Fu
et al. [
] on posterior urethral stricture after pelvic fracture, the occurrence rate of erectile dysfunction (ED) in patients after pelvic fracture was 85%. However, the ED occurrence rate after urethroplasty was 86%, indicating that no considerable difference occurred between ED occurrence rate before operation and that after operation. Thus, urethroplasty is not the main factor of ED caused by posterior urethral stricture [
]. However, the damage from the open corpus spongiosum incision operation to the blood supply of the posterior corpus spongiosum and surrounding neurotomy is inevitable. From the perspectives of anatomy and physiology, the operation method can cause postoperative ED [
,
].
According to the result of this study, the IIEF-5 scores of patients who received conventional posterior urethra end-to-end anastomosis was lower than their IIEF-5 scores before operation. The difference between the values was significant. This result indicated that the conventional posterior urethra end-to-end anastomosis has a negative effect on the sexual function of patients with posterior urethral stricture.
Non-transecting anastomotic urethroplasty was first proposed by Professor Andrich [
]. The main feature of this method is that urethra end-to-end anastomosis is performed by cutting the distal and proximal ends of the urethral stricture/locked section after the dissociation of the posterior urethra. The original urethral stricture/locked section must be put aside to retain the integrity of the spongiosum for the protection of the blood supply of penis spongiosum and corpus spongiosum.
When the non-transecting technique was used in patients with traumatic posterior urethral strictures caused by pelvic fracture, the indications were very strict as follows: (1) mild scarring or fibrosis of corpus spongiosum; (2) stricture or urethratresia less than 2.0 cm; and (3) posterior urethral strictures or urethratresia with preserved sexual function before surgery. If patients met two of the above-mentioned criteria, this non-transecting technique can be adopted.
The patients undergoing multiple transurethral incision or urinary dilatation and patients with complex posterior urethral strictures were unable to undergo non-transecting anastomotic bulbo-membranous urethroplasty. Complex posterior urethral stricture includes: (1) urethral stricture more than 3.0 cm with or without complications; and (2) urethral stricture with calculus, diverticulum, urinary fistula, false passage, sphincter impairment, severe deformity of pelvis, and high stricture near the neck of the bladder.
This study showed that non-transecting anastomotic urethroplasty has some advantages with regard to operation time and bleeding volume over conventional separating urethra operation. While their operation times had no significant difference, the average operation time of non-transecting operation was shorter than that of conventional separating urethra operation. This result was confirmed by the obtained data from the patients. As for the bleeding volume, although the arteries of corpus spongiosum and penis spongiosum were not cut off in the non-transecting anastomotic urethroplasty, a significant difference was observed between the non-transecting anastomotic urethroplasty and separating spongiosum operation, and the advantages of the former were more significant than that of the latter.
No significant difference was observed between the Qmax of non-transecting anastomotic urethroplasty and that of conventional corpus spongiosum separating urethra end-to-end anastomosis, indicating that the former can achieve the effect of conventional posterior urethra end-to-end anastomosis.
Six months after operation was selected as the time node for the follow-up of the sexual function condition of the patients in this study. Based on the research data by Feng
et al. [
,
], erectile function of quite a number of patients was improved to a certain extent six months after operation. This improvement is attributed to the disappearance of tissue edema and infection after half a year, and alleviation of the pressure in the incision of scar on the local nerve. In addition, the elimination of obstruction factors greatly benefited the erectile mentality of the patients. Therefore, IIEF-5 and QoL questionnaire surveys on sexual function were performed for patients six months after operation.
Significant differences were observed between the IIEF-5 and QoL scores of the two groups of patients, indicating that the ED severity of the patients who underwent non-transecting anastomotic urethroplasty was much lower than that of the patients receiving corpus spongiosum separating operation. Moreover, these scores indicated that non-transecting anastomotic urethroplasty can, to a certain extent, protect the residual erectile function of patients.
Certainly, strict limitations were established on the selection of patients for non-transecting anastomotic urethroplasty. First, the length of stricture/locked section of urethra must be less than 2.5 cm. A stricture/locked section longer than this length might result in excessive anastomotic tension that may affect the operation effect. In addition, non-transecting corpus spongiosum operation was not applicable to patients who underwent internal urethra incision or urethral dilatation multiple times, because these operations can increase the scars around the urethra, consequently rendering the dissociation and retention of completed corpus spongiosum difficult.
However, the samples of this study were limited. More patients who suffered from posterior urethral stricture and received the non-transecting anastomotic urethroplasty operation should be investigated in the future, while the number of patients in the current research is 12. Meanwhile, determining whether or not curing postoperative ED with medicines (e.g., Viagra and Tadalafil) is effective is our next step in our future studies. In addition, penile blood flow Doppler ultrasound can facilitate inspection and follow-up. Despite these limitations, the current research data indicated that non-transecting anastomotic urethroplasty can reduce the disruption to the blood supply of penis spongiosum and surrounding nerve and damage to the vascular tissue to a certain extent. Therefore, non-transecting anastomotic urethroplasty is an alternative operation method for treating a specific patient group with posterior urethral stricture.
Non-transecting anastomotic urethroplasty is an effective operation method for posterior urethra reconstruction, and it can reduce the occurrence rate of erectile dysfunction after operation.
Higher Education Press and Springer-Verlag Berlin Heidelberg
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