ESSM Newsletter # 38

14 ESSM Today Urethroplasty and erectile dysfunction by Salvatore Sansalone and Guido Barbagli Urethral stricture disease affects the quality of life of the patient and his partner. Treatment of urethral stricture is always a great challenge for urologists, although a paradigm shift in manag- ing this disease has occurred within the past decades. In addition to attaining meaningful im- provement in voiding efficiency and alleviating symptoms, satisfaction with remaining erectile function after surgery is also an important crite- rion of ideal postoperative outcome for urethro- plasty because no one technique is appropriate for all stricture diseases. The urologist must be familiar with various open surgical techniques. Some urologists accept that erectile dysfunction (ED) usually occurs after open urethral surgery and that ED rate is dramatically different due to the variety of procedures. The outcomes of urethral reconstructive surgery have traditionally focused on parameters such as urinary flow rate, lower urinary tract symp- tom (LUTS) score, or recurrent urethral stricture requiring further treatment. Mundy [1] was the first urologist to report the incidence of ED after urethroplasty in 1993 reporting a permanent ED rate of 5% after anastomotic repairs and a rate of 0.9% after graft urethroplasty. In stud- ies assessing postoperative erectile function at more than one time point, ED was found to be transient, resolving between 6 to 12 months in 86% of cases. Up to date, there has been a scar- city of systematic studies specifically evaluating the effect of different types of urethroplasty on erectile function. The difficulty of evaluating the specific incidence of ED after open reconstruc- tive surgery may lead to further misguidance in providing treatment for these patients. The incidence of de novo ED after urethroplasty is largely underreported. Erectile dysfunction can be caused by altered blood flow through arteries, defective venous engorgement or absent neural transmission. As described by Lue et al. [2] cav- ernosal nerves mostly traverse about 3mm out- side cavernosa and only few traverse through it. So anatomically, there seems to be minimal risk to erectile neural mechanism after urethroplasty. Various literatures have shown varying results of ED following urethroplasty depending on site, size and operative techniques. During PPU for PFUI (pelvic fracture urethral injury), dissection is carried out more posteriorly to excise scar tis- sue and to gain adequate length for tension-free anastomosis. To achieve tension free anastomo- sis, corporeal separation or inferior pubectomy may be needed, increasing the chances of injury to neurovascular structures and thereby increas- ing the likelihood that ED will develop. Surgical treatment of urethral strictures includes numerous open techniques, such as graft ure- throplasty, urethral anastomosis, urethral realign- ment, and so on. Although these procedures have become increasingly popular and effective, the relationship between open urethroplasty and ED is still controversial. So far, only few comparative studies have carefully assessed patient erectile function after various kinds of open urethroplasty. Therefore, a metaanalysis of this problem is nec- essary so that the morbidity of ED after different open urethroplasty can be evaluated objectively. Based on these results, urologists can choose the best strategy for treating these patients in order to avoid the occurrence of ED as much as possible. We have conducted according to the PRISMA Statement a meta-analysis review [3]. A total of 790 studies were identified in our da- tabase and bibliographic probe. Seventy of these studies (8.86%) were identified as relevant, but 47 of these (67.14%) were excluded because they did not meet the inclusion criteria or be- cause they contained data that were undeducible for statistical analyses. In conclusion, 23 studies (2.91%) were germane to the predetermined inclusion criteria. In aggregate, these 23 studies included 1,729 patients, and ED was reported in 560 (32.39%) cases. Comparison I Before urethroplasty vs. after urethro- plasty – overall assessment Five studies eligible for the meta-analysis re- ported patient erectile function before and after various anterior open urethroplasty. No statisti- cal difference was found in the incidence of ED pre- and postoperation (OR = 0.85; 95% CI: 0.52–1.40; P = 0.53). Meanwhile, erectile status before and after various posterior open urethroplasty were evaluated in six studies. The analysis revealed that the incidence of ED be- fore the operation was significantly higher than that after the operation (40.96% vs. 25.63%; OR = 2.21; 95% CI: 1.23–3.27; P < 0.001) but with unacceptable statistical heterogeneity (I2 = 61%). Comparison II Comparison of a different anterior urethro- plasty site According to the location of the urethral stricture, we further classified the anterior urethroplasty into penile and bulbar urethroplasty. The single study eligible for comparing ED before and after penile graft urethroplasty was from Erickson et al. [4] The rate of ED before urethroplasty was similar to that after urethroplasty (23.53% vs. 35.29%). There was no statistically significant difference between the two groups (P = 0.45). Furthermore, we compared the ED incidence be- Prof. Salvatore Sansalone Department of Experimental Medicine and Surgery University Tor Vergata Rome, Italy salvatore.sansalone@yahoo.it Guido Barbagli, M. D. Head of the Center for Reconstructive Urethral Surgery Via dei Lecci, 22 52100 Arezzo, Italy info@urethralcenter.it