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- Review -

Erectile function after urethral reconstruction

Joshua Carlton, Maharshi Patel, Allen F. Morey

Department of Urology, UT Southwestern Medical Center, Dallas, Texas 75390-9110, USA

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. (Asian J Androl 2008 January; 10: 75_78)

Keywords: urethral reconstruction; urethral stricture; erectile function; sexual function

Correspondence to: Dr Allen F. Morey, Department of Urology, UT Southwestern Medical Center, J8.112, 5323 Harry Hines Blvd, Dallas, Texas 75390-9110, USA.
Tel: +1-214-648-6598 Fax: +1-214-648-6310
E-mail: allen.morey@utsouthwestern.edu

DOI:

1 Introduction

Surgical reconstruction of urethral stricture disease has now become a mainstay for treatment in refractory cases. Reconstructive techniques have advanced markedly in the past two decades and their success rates are now well documented throughout the urological community. At the same time, as effective medical treatments have emerged for erectile dysfunction (ED), increasing attention has been directed toward preservation of sexual function for all male urologic patients. Surprisingly, despite the magnitude of genital dissection required for many complex urethroplasty procedures, little has been reported regarding the effect of urethral reconstruction surgery on erectile function (EF). The present article discusses the anterior and posterior effects of various urethral reconstructive techniques on EF.

2 General considerations

2.1 Age

Age and condition of the patient are important to consider when determining which form of reconstruction to perform and how the procedure might affect EF. Erickson et al. [1] note the greatest impact on EF after urethroplasty surgery in men in the age group of 50_59 years. A similar, but not as dramatic decrement in EF was noted for the 60_69-year age group. In contrast, men under 50 years showed practically no change in EF postoperatively [1]. Similarly, Anger et al. [2] report that older men, as well as men with peripheral vascular disease, are at higher risk of developing ED postoperatively. Clearly, men at advanced age and with greater numbers of comorbidities might also have compromised sexual function prior to urethroplasty, and it behooves the reconstructive urologist to carefully question these patients in this area before surgery [2].

2.2 Stricture length

Stricture length often correlates to both the severity and magnitude of fibrosis within the urethra and surrounding tissues. It is this parameter that governs which reconstructive procedures are selected, with more elaborate tissue transfer techniques being required for strictures of greater length. Long strictures are often associated with inflammatory disease, repeated urethral dilations and instrumentations, a history of prolonged urethral catheterization, and/or traumatic urethral distraction. Coursey et al. [3] report that men undergoing repair of longer strictures report ED more often, with most in their series requiring extensive penile flap procedures for longer strictures.

2.3 Stricture location

Recent reports suggest that stricture location has an insignificant effect on EF in men undergoing urethral reconstruction for anterior strictures. Anger et al. [2] evaluated 25 men who underwent four different types of bulbar urethroplasty, to assess whether injury to the neurovascular supply to erectile tissue might occur. They found bulbar urethroplasty to have an insignificant effect on EF [2]. One drawback of the study by Anger et al. [2] was a small population size and a mostly young and healthy group. However, Shenfeld et al. [4, 5] also found that membranous urethral stricture repair showed minimal effect on EF. Of 13 patients, only one complained of decreased EF postoperatively, whereas nine obtained ED before surgery [4, 5]. Kesseler et al. [6, 7] report on the long-term results of urethral stricture repair via primary anastomosis: membranous, membranobulbar and bulbar strictures constituted 33%, 10% and 58% of stricture location sites, respectively. Only two of the 40 who underwent anastomotic repair in these locations reported ED postoperatively [6, 7]. These series argue that location of urethral stricture plays an insignificant role in EF after urethral reconstruction.

2.4 Time between injury and surgery

Another consideration in assessing EF after urethral reconstruction is the time elapsed from the injury to the date of surgery. A report by Berger et al. [8] found a difference in nocturnal penile tumescence testing for patients who underwent urethroplasty surgery within 6 months of a urethral disrupting injury, with a 20% improvement noted in those who were operated on after 6 months [8]. It was postulated that nerve function, given ample time after injury, can reconstitute and, therefore, might influence patient reports of EF.

Yu et al. [9] compare simple urethral cystoscopic realignment and immediate end-to-end anastomosis as immediate treatments for posterior urethral disruption, and find that EF after early anastomotic urethroplasty (within 24 h after injury) results in significantly worse erectile function. Yu et al. [9] suggest that early aggressive anastomotic surgery worsens vascular and pelvic nerve involvement with posterior urethral injury.

2.5 Time after surgery

As time progresses from the date of surgery, considerable psychological and physical healing takes place. As a result, any compromise of sexual function after anterior urethroplasty tends to be transient in nature. Several authors have noted a tendency of returning EF with elapsing time. According to Mundy [10], 53% of patients who underwent end-to-end anastomosis and 33% of patients who underwent urethral augmentation reported ED within 3 months after surgery, while as time progressed, the rates of reported ED dropped remarkably to 5% and 9%, respectively [1, 10]. In a large multi-institutional study, Coursey et al. [3] also demonstrate major improvements in EF after time elapsing, including improvements in erectile length and angle. Andrich et al. [11] report that ED appeared in the weeks after surgery more often in the anastomotic group than the augmented group, and that improved EF was noted in the majority within 2_3  months. Patients should be counseled on the tendency of ED to occur within a few months of surgery, if at all, and the trend toward steady recovery thereafter. Case series that do not mention the time in which patients report their EF are of limited value.

3 Anterior urethroplasty reconstruction

3.1 Anastomotic urethroplasty

Primary end-to-end anastomosis is the gold-standard reconstructive technique for short bulbar urethral strictures (< 2 cm), with free grafts and pedicled flaps best reserved for longer strictures. Eltahawy et al. [12] find new onset ED to be negligible following anterior anastomotic urethroplasty (2.3%) [12]. Similarly, Santucci et al. [13] report that new onset of ED occurred in less than 1% of 168 men having bulbar urethroplasty via primary anastomosis [13]. Others have reported a range of 5%_26% of men with anastomotic reconstruction for anterior strictures complaining of ED [3, 6, 14]. These figures, taken together, justify the continued aggressive use of primary anastomosis for short-length urethral strictures.

3.2 Augmentation urethroplasty

As stricture length increases, the likelihood of requiring a graft or skin flap to complete urethral reconstruction also increases. Penduluous urethral strictures are especially appropriate for urethral substitution procedures because resection with primary anastomosis in this area is contraindicated because of the risk of contributing to excessive tension and/or chordee.

3.2.1 Buccal mucosa grafts

Buccal mucosa is now the preferred donor site for urethral grafts. Although buccal grafts are utilized mainly in the bulbar urethra, their use in distal areas during complex or reoperative cases appears to be well justified, and any adverse effects on sexual function after buccal mucosa graft urethroplasty appears to be negligible [3, 14]. Nelson et al. [15] also find that sexual function after reoperative hypospadias repair using buccal mucosa is excellent postoperatively. Partial resection with anastomosis during dorsal or ventral graft onlay has not been shown to increase the risk of ED [16]. Graft position, either ventral or dorsal, has not been shown conclusively to adversely impact sexual outcomes [8].

3.2.2 Penile skin flap

Penile skin flap urethroplasty has now virtually replaced scrotal flap procedures for urethral reconstruction because it is hairless, versatile, and highly reliable. Penile flap techniques, however, should be reserved for long distal strictures and those in which the stricture is too fibrotic to support a graft. Transfer of a long penile skin flap to the deep perineum is associated with tethering of the penis during erections, with the results often including pain and disruption of the anastomosis. For this reason, skin flap urethroplasty is most appropriate for pendulous strictures.

Coursey et al. [3] found that, compared to other techniques, such as primary anastomosis and buccal mucosal grafting, patients reported the highest incidence of postoperative sexual dysfunction after penile skin flap urethroplasty. Mean stricture length was 6.7 cm for patients undergoing penile flap procedures in that series, much longer than in men having other urethroplasty techniques, which likely indicates both more fibrosis in the periurethral tissues and a more complex genital dissection in the surgical correction [3]. Kessler et al. [6, 7] also reported the highest incidence of ED resulting from flap urethroplasty, with 32% of men noting a negative change in EF, often moderate to severe in magnitude. Al-Qudah et al. [14] report that performing fasciocutaneous skin flap resulted in major complications in 40% of patients, including chordee and temporary fistula.

3.2.3 Two-stage mesh graft

When stricture length and severity is extreme, as in cases of lichen sclerosis, a two-stage procedure involving stricture excision with implantation of a meshed skin graft might be appropriate. The second stage of the mesh graft urethroplasty involves tubularizing the graft and interposing healthy dartos tissue.

Erickson et al. [1] report a mean stricture length of 7.8 cm for patients undergoing two-stage urethroplasty involving mesh graft substitution. Kessler et al. [6] found that significant ED developed after two-stage procedures in nearly half of their patients. Similarly, Coursey et al. [3] found that, among 26 men having two-stage procedures, 23.1% and 11.5% reported major changes in erectile length and angle, respectively. Clearly, stricture length and complexity of repair warrant additional counseling regarding the possibility of altered sexual function. It is also likely that extensive two-stage repairs will produce ejaculatory and sensory disturbances of some degree (Figure 1).

4 Posterior urethral reconstruction

Traumatic injury to the pelvis is associated with both urethral disruption and ED. Shenfeld et al. [4] investigate nocturnal penile tumescence after posterior urethral disruption before reconstruction and find that both vascular and neurogenic disturbances are often prevalent. Pelvic fractures and significant straddle injuries commonly cause injury to the cavernous nerves and pudendal artery branches, which are proximal to the pelvic bones and membranous urethra [3, 11, 12].

Men with shorter urethral defects (< 3 cm) are expected to sustain less neurological damage. In those with longer defects, during posterior urethral reconstruction, it might be necessary for the surgeon to develop the intracorporal space, thus placing the delicate neurovascular structures at additional risk. Additional challenging maneuvers, such as inferior or complete pubectomy, might be required for complex deformities, thus further increasing the likelihood of impaired EF (Figure 2).

The initial injury, not the reconstructive surgery, is responsible for most of the long-term problems with sexual function. Delayed anastomotic repairs in experienced hands are the gold standard for treatment of pelvic fracture-related urethral disruptions. Asci et al. [17] report that the EF of patients having initial suprapubic cystostomy with delayed urethroplasty after pelvic fracture urethral injuries is similar to those having immediate primary urethral realignment. Berger et al.[8] report similar pre- and postoperative ED rates after urethral reconstruction for post-traumatic urethral stricture: roughly 17%. Morey and McAninch [18] recorded the long-term outcome of 82 men who underwent posterior urethroplasty after traumatic strictures. With follow-up longer than 1 year, they observed that impotence rates dropped from 54% before surgery to 38% after surgery, thus indicating that young men often demonstrate a delayed return to sexual function, which might occur several years after posterior urethral injury [18].

5 Conclusion

Many factors influence the sexual outcomes of men having urethral reconstruction surgery. Age of the patient, sexual function prior to surgery, elapsed time following surgery, stricture length and severity, and the magnitude of pelvic trauma are likely to have a direct influence on long-term sexual function after treatment.

References

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