Role of Transection and Anastomosis in Bulbar Urethral Reconstruction

Abstract

Complete stricture excision and primary end-to-end anastomosis is undoubtedly the most durable and effective reconstructive surgical technique for the treatment of appropriate bulbar urethral strictures. The bulbar urethra is exposed via wide perineal dissection, the diseased urethral segment is precisely identified and completely excised. The proximal and distal urethral ends are sufficiently mobilized to bridge the defect without undue tension. The natural bulbar urethral elasticity is utilized to elongate the urethra. A spatulated spongiosal sparing 2-layer anastomosis with meticulous mucosal apposition is performed. While this procedure is most well suited for bulbar strictures 1–3 cm in length, it can also be performed in select cases of lengthy mid to proximal bulbar strictures up to 5 cm with excellent results. Patient selection is critical; there is limited application for this technique in lengthy distal bulbar urethra strictures and in the penile urethra where urethral tethering may predispose to ventral curvature and shortening with erection. While rare, most complications are transient and minor in nature and include surgical site infection, perineal hematoma, and catheter related complications. Anastomotic urethroplasty failure is most often related to excessive tension at the anastomosis or incomplete resection of the diseased urethral segment. Because complete excision of the diseased urethra and associated spongiofibrosis is essential, the surgeon must be prepared to perform an alternative repair if the defect is too long for reconstruction with a tension-free anastomosis. This technique is well tolerated with a long-term cure rate >90%.