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Erectile Function After Bulbar Urethroplasty: Does surgical approach matter?
Kristian Stensland, MD1, Bryan Voelzke, MD2, Sean Elliott, MD3, Bradley Erickson, MD4, Jeremy Myers, MD5, Christopher McClung, MD6, Benjamin Breyer, MD7, Alex Vanni, MD1.
1Lahey Hospital and Medical Center, Burlington, MA, USA, 2University of Washington, Seattle, WA, USA, 3University of Minnesota, Minneapolis, MN, USA, 4University of Iowa, Iowa City, IA, USA, 5University of Utah, Salt Lake City, UT, USA, 6Ohio State University, Columbus, OH, USA, 7University of California San Francisco, San Francisco, CA, USA.

BACKGROUND: While urethroplasty has proven to be a durable solution to urethral strictures, the effect on sexual function following excision and primary anastomosis (EPA) for bulbar urethral strictures remains controversial. Some reports suggest that sexual function following EPA is diminished compared to buccal mucosa graft (BMG) onlay urethroplasty, and some have advocated avoiding EPA to prevent postoperative sexual dysfunction. The objective of our study is to explore the effect of stricture location and urethroplasty type on postoperative erectile function.
METHODS: Bulbar urethroplasties were retrospectively reviewed from 12 institutions that collaborate in a prospective, multi-institutional reconstructive urology database. Sexual function was measured via pre- and post-operative SHIM (Sexual Health Inventory for Men) questionnaire, with max score 25. Patients filled post-operative questionnaires at follow-up visits and the most recent post-op SHIM was used in this study. Patients with bulbar or bulbomembranous urethral strictures who underwent BMG urethroplasty via dorsal, lateral or ventral onlay or EPA were included. Patients were excluded if they had previously undergone urethroplasty, had a pelvic fracture urethral injury, had a radiation-related stricture, or were missing a pre- or post-operative SHIM score. The Kruskal-Wallis or t-tests were used for ranked and non-ranked comparisons as appropriate with significance set at the p=0.05 level.
RESULTS: In total, 211 patients were included (EPA 141, onlay 70). Median stricture length was 2 cm vs. 4 cm in the EPA vs. BMG group respectively (P<0.001). Men in each group were of similar age (42 vs. 44 years, p = 0.41), and had similar prevalence of coronary artery disease, diabetes, smoking history, peripheral vascular disease, and hyperlipidemia. At a median follow-up of 8 months, there was no statistical difference in change from pre- to post-operative SHIM score comparing EPA to onlay procedures (0.03 vs. 0.27, p=0.82). There were also no significant differences in change in SHIM score for EPA patients based on proximal location of stricture (Table 1, p=0.43).
CONCLUSIONS: This multi-institutional study demonstrates that men undergoing EPA or onlay BMG urethroplasty do not have different postoperative erectile function compared to preoperative SHIM scores. Men undergoing EPA did not demonstrate a change in erectile function compared to onlay BMG urethroplasty. Both EPA and onlay urethroplasty appear to be viable options for urethroplasty with no difference in expected postoperative erectile function regardless of stricture location.
Change in SHIM scores from pre- to post-operative by stricture location in EPA patients (p=0.43)
Most Proximal Stricture LocationMedian Change in SHIMMean Change in SHIM
Bulbomembranous Urethra11.5
Proximal Bulbar Urethra0-0.2
Mid-bulbar Urethra0-0.3
Distal Bulbar Urethra0-0.5


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