Introduction: The classic transecting excision and primary anastomosis (EPA) for reconstruction of posterior urethra stenosis (PUS) entails division of the bulbar arteries. Consequently, irrigation of the spongiosum will depend on the dorsal penile arteries and retrograde flow from the glans. However, if the penile arterial blood supply is compromised, transection may result in ischemia of the bulb and failure of the reconstruction. To decrease this risk, we modified the EPA technique avoiding urethral transection to preserve the bulbar arteries. We report our long-term results with this vessel-sparing posterior EPA approach (vspEPA). Methods: Surgical Technique. The bulbar urethra is mobilized in a non-transecting fashion by division of the triangular ligament without detachment of the bulb from the perineal body. Distal release and lateral retraction of the bulbar urethra to one side with two vessel loops provides sufficient room for scar removal and anastomosis as with the classic transecting technique. In most cases both bulbar arteries can be spared, but in front of severe local fibrosis, division of one artery may be necessary to remove the scar, preserving the contralateral artery. Results: Since April 2008, 115 patients with PUS received a vspEPA at our institution. The patients had a bulbo-membranous stenosis (n=91, 79%), prostate-membranous stenosis (n=11, 10%), or bulbo-vesical stenosis (n=13, 11%). Median age was 60 years (range 15-83) and median stenosis length was 2.5 cm (range 1-6), Sixty-two patients (54%) had a complete urethral obliteration. Bulbar artery preservation was unilateral in 57 and bilateral in 58. Median operative time was 170 min (range 70-265) and median estimated blood loss was 300 cc (range 50-2,000). A bulbo-membranous anastomosis was performed in 48 patients (42%), bulbo-prostatic in 54 (47%) and bulbo- vesical in 13 (11%). With 47 months of median follow up (range 5-146), vspEPA was successful in 109 patients (95%). Complications occurred in 34 (30%) patients but only 6 (5%) of them were Clavien grade =III. Conclusions: This vspEPA technique is feasible and safe and since 2008 it is our standard approach for anastomotic urethroplasty at the posterior urethra. We believe that vascular preservation may improve the outcome of reconstruction and our results are meaningful and highly encouraging. SOURCE OF Funding: None
