Name: vessel-sparing excision and primary anastomosis
Uploaded: 2019-01-07T14:00:00
Description: Watch this Scientific Journal Video about Vessel-sparing Excision and Primary Anastomosis at JoVE.com

The authors have no acknowledgments.

All patients provided a signed written informed consent and the approval of the local Ethics Committee (EC/2014/0438) was obtained.
NOTE: The inclusion criteria for the presented protocol were: male; age &#8805;18 years; signed written informed consent; fit for operation; isolated urethral stricture; urethral stricture &#8804;3 cm; urethral stricture only at the bulbar or membranous site. The exclusion criteria were: female; transgender; age &#60;18 years; absence of signed wr...

<ol>
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A., Virasoro, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+Technique+of+Vessel+Sparing+Excision+and+Primary+Anastomosis+for+Proximal+Bulbous+Urethral+Reconstruction.">The Technique of Vessel Sparing Excision and Primary Anastomosis for Proximal Bulbous Urethral Reconstruction.</a> The Journal of Urology. 177 (5), 1799-1802 (2007).</li><li>Gur, U., Jordan, G. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Vessel-sparing+excision+and+primary+anastomosis+(for+proximal+bulbar+urethral+strictures).">Vessel-sparing excision and primary anastomosis (for proximal bulbar urethral strictures).</a> BJU International. 101 (9), 1183-1195 (2008).</li><li>Andrich, D. E., Mundy, A. R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Non-transecting+anastomotic+bulbar+urethroplasty:+a+preliminary+report.">Non-transecting anastomotic bulbar urethroplasty: a preliminary report.</a> BJU International. 109 (7), 1090-1094 (2012).</li><li>Lumen, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Nontransecting+Anastomotic+Repair+in+Urethral+Reconstruction:+Surgical+and+Functional+Outcomes.">Nontransecting Anastomotic Repair in Urethral Reconstruction: Surgical and Functional Outcomes.</a> The Journal of Urology. 196 (6), 1679-1684 (2016).</li><li>Virasoro, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=International+multi-institutional+experience+with+the+vessel-sparing+technique+to+reconstruct+the+proximal+bulbar+urethra:+mid-term+results.">International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results.</a> World Journal of Urology. 33 (12), 2153-2157 (2015).</li><li>Bugeja, S., Andrich, D. 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Urethral stricture repair by vessel-sparing excision and primary anastomosis was initially performed at Ghent University Hospital in 2010. Thereafter, it became a standard of practice in the hospital&#39;s management of patients with isolated short bulbar or posterior urethral strictures. As the bulb remains attached to the perineal body, access to the posterior urethra and the resection of the fibrotic tissue at that site can be compromised. A distortion of the pubic rami due to a pelvic fracture might further impede ac...

Urethroplasty is considered the standard treatment for urethral strictures as it provides excellent long-term success rates1,2. A numerous amount of surgical techniques has been described, challenging the reconstructive urologist to choose the best approach, considering various stricture modalities such as the number of strictures, the stricture length, the stricture location, the etiology, comorbidities, and previous urethral interventions. For isolated short bulbar urethral strictures, the International Consultation on Urologic Diseases (ICUD) recommends urethroplasty by excision and primary anastomosis (EPA) associated with a composite success rate of 93.8%3,4.
Urethroplasty by EPA embodies an approach in which the entire diseased segment of the urethra is removed and replaced by healthy adjacent urethra without the need for grafts or flaps to bridge the gap. Traditionally, this approach included the full thickness transection of the corpus spongiosum at the level of the stricture5. However, as EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full thickness transection of the corpus spongiosum, and the dual urethral blood supply within it, is usually unnecessary. Given this background, Jordan et al. introduced the idea of a vessel-sparing approach in 2007, offering a non-transecting alternative to the classic transecting EPA (tEPA)6,7. This vessel-sparing EPA (vsEPA) has been uprising ever since and several centers have&#8212;though slightly modified&#8212;implemented this technique in their surgical repertoire8,9,10,11,12.
The vessel-sparing technique aims to reduce surgical trauma, especially to the dual arterial blood supply of the urethra embedded in the corpus spongiosum. The preservation of the bulbar arteries potentially reduces the risk of postoperative erectile dysfunction or glans ischemia. Furthermore, it could be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative8,9. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking.
As important as the functional outcome is, vsEPA should at least be able to provide similar surgical outcomes as tEPA. Promising short-term results have been published and are in line with the success rates reported by the ICUD, but a direct comparison between both techniques has, so far, not been performed3,4,8,9,10,11,12.
Pelvic fracture-related urethral injuries are associated with scar tissue formation and a subsequent urethral stricture or complete obliteration of the membranous urethra. Posterior strictures might also develop after surgery or irradiation to the prostate13. For these strictures, urethroplasty with the excision of the scar tissue and bulbo-prostatic anastomosis is recommended as well14. Traditionally, the bulbar arteries were ligated during this procedure if not already obliterated due to the pelvic fracture. To avoid this, a vessel-sparing variant has been introduced and reported as well15,16.
The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main scope is to outline and visualize the surgical technique and to report the representative surgical outcome. An evaluation of the functional outcome parameters is beyond the scope of this paper.

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			<td height="21" style="height:21px;width:299px;">iso-Betadine Dermicum 125 ml (1)</td>
			<td style="width:183px;">Meda Pharma</td>
			<td style="width:149px;">A-472825</td>
			<td style="width:159px;"></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:299px;">Sterile gown (3)</td>
			<td style="width:183px;">According to surgeon&#39;s preference</td>
			<td style="width:149px;">NA</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:299px;">Sterile gloves (3 pairs)</td>
			<td style="width:183px;">According to surgeon&#39;s preference</td>
			<td style="width:149px;">NA</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Sterile drapes (4)</td>
			<td style="width:183px;">Medline</td>
			<td style="width:149px;">AGBBA073A</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Bard-Parker scalpel number 3 (1)</td>
			<td style="width:183px;">Zepf Medical Instruments</td>
			<td style="width:149px;">06-1003-00</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Bard-Parker scalpel number 4 (1)</td>
			<td style="width:183px;">KLS Martin Group</td>
			<td style="width:149px;">10-100-04</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Scalpel blade number 15 (1)</td>
			<td style="width:183px;">Swann-Morton</td>
			<td style="width:149px;">0205</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Scalpel blade number 24 (1)</td>
			<td style="width:183px;">Swann-Morton</td>
			<td style="width:149px;">0211</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Surgical forceps 14 cm (2)</td>
			<td style="width:183px;">KLS Martin Group</td>
			<td style="width:149px;">12-301-14</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Monopolar electrocauter Valleylab&#160; (1)</td>
			<td style="width:183px;">Medtronic</td>
			<td style="width:149px;">E2100</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Electrocauter blade 15 cm (1)</td>
			<td style="width:183px;">Comepa</td>
			<td style="width:149px;">CO 150i</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Debakey forceps 20 cm (2)</td>
			<td style="width:183px;">D&#252;fner</td>
			<td style="width:149px;">06232-20</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">3-layered compress 30 x 45 cm (5)</td>
			<td style="width:183px;">M&#246;lnlycke Health Care</td>
			<td style="width:149px;">175260</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Surgical compress 10 x 10 cm (10)</td>
			<td style="width:183px;">Hartmann</td>
			<td style="width:149px;">232088</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Mayo-Hegar needle driver 18 cm (1)</td>
			<td style="width:183px;">Zepf Medical Instruments</td>
			<td style="width:149px;">24-1804-18</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Mayo-Hegar needle driver 25 cm (1)</td>
			<td style="width:183px;">Zepf Medical Instruments</td>
			<td style="width:149px;">24-1804-25</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Jones scissor 18 cm (1)</td>
			<td style="width:183px;">D&#252;fner</td>
			<td style="width:149px;">04940-18</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Mayo-Stille scissor 17 cm (1)</td>
			<td style="width:183px;">Zepf Medical Instruments</td>
			<td style="width:149px;">08-1700-17</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;">Lone Star retractor (1)</td>
			<td style="width:183px;">CooperSurgical, Trumbull, CT, USA</td>
			<td style="width:149px;">72403867</td>
			<td></td>
		</tr>
		<tr height="42">
			<td height="42" style="height:42px;width:299px;">Lone Star elastic stays (4)</td>
			<td style="width:183px;">CooperSurgical, Trumbull, CT, USA</td>
			<td style="width:149px;">3311-1G</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Vessel loop 45 cm (1)</td>
			<td style="width:183px;">Braun</td>
			<td style="width:149px;">1095137</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Halsted-Mosquito (6)</td>
			<td style="width:183px;">KLS Martin Group</td>
			<td style="width:149px;">13-317-21</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">20Fr silicone urethral catheter (1)</td>
			<td style="width:183px;">Yushin Medical Co.</td>
			<td style="width:149px;">1037B-20</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">3Fr ureteral catheter (1)</td>
			<td style="width:183px;">Teleflex</td>
			<td style="width:149px;">223602</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">20Fr metal sound (1)</td>
			<td style="width:183px;">Custom made</td>
			<td style="width:149px;">NA</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Vicryl 4-0 wire (6)</td>
			<td style="width:183px;">Ethicon</td>
			<td style="width:149px;">V734D</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Vicryl 3-0 wire (2)</td>
			<td style="width:183px;">Ethicon</td>
			<td style="width:149px;">VCP316H</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Vicryl Rapide 3-0&#160; wire (1)</td>
			<td style="width:183px;">Ethicon</td>
			<td style="width:149px;">VF2260</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">10Fr Drain needle (1)</td>
			<td style="width:183px;">Vygon</td>
			<td style="width:149px;">658.10</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">10Fr Suction drain (1)</td>
			<td style="width:183px;">Oriplast</td>
			<td style="width:149px;">203102</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Vacuum flask 400 ml (1)</td>
			<td style="width:183px;">Oriplast</td>
			<td style="width:149px;">213215AL/QL</td>
			<td></td>
		</tr>
		<tr height="21">
			<td height="21" style="height:21px;width:299px;">Zetuvit 10 x 20 cm (1)</td>
			<td style="width:183px;">Hartmann</td>
			<td style="width:149px;">413771</td>
			<td></td>
		</tr>
	</tbody>
</table>

vessel-sparing excision and primary anastomosis

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short bulbar or posterior urethral strictures, urethroplasty by excision and primary anastomosis (EPA) is recommended. As EPA only requires the excision of the narrowed segment and the surrounding spongiofibrosis, a full-thickness transection of the corpus spongiosum, as performed in the traditional transecting EPA (tEPA), is usually unnecessary. Jordan et al. introduced the idea of a vessel-sparing approach in 2007, aiming to reduce surgical trauma, especially to the dual arterial blood supply of the urethra, and, thus, potentially reducing the risk of postoperative erectile dysfunction or glans ischemia. This approach could also be beneficial for subsequent urethral interventions such as redo urethroplasty using a free graft, in which a well-vascularized graft bed is imperative. Nevertheless, these potential benefits are only assumptions as prospective studies comparing the functional outcome of both techniques with validated questionnaires are currently lacking. Moreover, vessel-sparing EPA (vsEPA) should at least be able to provide similar surgical outcomes as tEPA. The aim of this paper is to give an elaborate, step-by-step overview of how to manage patients with isolated short bulbar or posterior urethral strictures with vsEPA. The main objective of this manuscript is to outline the surgical technique and to report the representative surgical outcome. A total of 117 patients were managed according to the described protocol. The analysis was performed on the entire patient cohort and on the bulbar (n = 91) and posterior (n = 26) vsEPA group separately. Success rates were 93.4% and 88.5% for the bulbar and posterior vsEPA, respectively. To conclude, vsEPA, as outlined in the protocol, provides excellent success rates with low complication rates for isolated short bulbar and posterior urethral strictures.

Between 2011 and 2017, a total of 117 patients with isolated short bulbar (n = 91) or posterior (n = 26) urethral strictures were treated with vsEPA at Ghent University Hospital. The baseline characteristics are displayed in Table 1. The median follow-up was 35 and 45 months for bulbar and posterior strictures, respectively. The strictures were longer in the patients who underwent posterior vsEPA and, accordingly, the number of patients with a calculated...

Watch this Scientific Journal Video about Vessel-sparing Excision and Primary Anastomosis at JoVE.com

Vessel-sparing Excision and Primary Anastomosis

Here, we present an elaborate and efficient protocol to treat isolated short bulbar or posterior urethral strictures with vessel-sparing excision and primary anastomosis.

Urethroplasty is considered to be the standard treatment for urethral strictures since it provides excellent long-term success rates. For isolated short ...

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