Hindawi Publishing Corporation Advances in Urology Volume 2015, Article ID 912438, 7 pages http://dx.doi.org/10.1155/2015/912438
Clinical Study Anastomotic Repair versus Free Graft Urethroplasty for Bulbar Strictures: A Focus on the Impact on Sexual Function Matthias Beysens,1 Enzo Palminteri,2 Willem Oosterlinck,1 Anne-Françoise Spinoit,1 Piet Hoebeke,1 Philippe François,3 Karel Decaestecker,1 and Nicolaas Lumen1 1
Department of Urology, Ghent University Hospital, 9000 Ghent, Belgium Center for Urethral and Genital Surgery, 52100 Arezzo, Italy 3 Department of Urology, CH Mouscron, 7700 Mouscron, Belgium 2
Correspondence should be addressed to Nicolaas Lumen; [email protected] Received 21 April 2015; Revised 1 June 2015; Accepted 9 June 2015 Academic Editor: Francisco E. Martins Copyright © 2015 Matthias Beysens et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. To evaluate alterations in sexual function and genital sensitivity after anastomotic repair (AR) and free graft urethroplasty (FGU) for bulbar urethral strictures. Methods. Patients treated with AR (𝑛 = 31) or FGU (𝑛 = 16) were prospectively evaluated before, 6 weeks and 6 months after urethroplasty. Evaluation included International Prostate Symptom Score (IPSS), 5-Item International Index of Erectile Function (IIEF-5), Ejaculation/Orgasm Score (EOS), and 3 questions on genital sensitivity. Results. At 6 weeks, there was a significant decline of IIEF-5 for AR (−4.8; 𝑝 = 0.005), whereas there was no significant change for FGU (+0.9; 𝑝 = 0.115). After 6 months, differences with baseline were not significant overall and among subgroups. At 6 weeks, there was a significant decline in EOS for AR (−1.4; 𝑝 = 0.022). In the FGU group there was no significant change (+0.6; 𝑝 = 0.12). Overall and among subgroups, EOS normalized at 6 months. After 6 weeks and 6 months, respectively, 62.2 and 52% of patients reported alterations in penile sensitivity with no significant differences among subgroups. Conclusions. AR is associated with a transient decline in erectile and ejaculatory function. This was not observed with FGU. Bulbar AR and FGU are likely to alter genital sensitivity.
1. Introduction
2. Materials and Methods
Although a short bulbar stricture can be treated by dilation or endoscopic urethrotomy, longer or recurrent strictures are best treated by urethroplasty as it provides the best chance of success [1–3]. Anastomotic repair (AR) and free graft urethroplasty (FGU) are established treatments for bulbar strictures with the choice of technique mainly depending on stricture length [1, 3, 4]. The main goal of urethroplasty is to restore urethral patency, and, as a consequence, most papers have focused on this criterion to evaluate success of urethroplasty [1, 3, 5]. In the past decade, there is an upcoming concern that especially bulbar urethroplasty might affect sexual functioning [6–8]. The aim of this paper is to evaluate and compare sexual function after AR and FGU for bulbar strictures in a prospective fashion.
2.1. Patient Recruitment. Out of 258 male patients who underwent urethroplasty between October 2010 and February 2014, 90 patients with a bulbar stricture only were planned to be treated with AR or FGU and eligible to participate in this prospective study. Only native Dutch speaking patients who signed the informed consent (Institutional Review Board Approval EC UZG 2008/234) and who filled in the preoperative questionnaires and at least one postoperative questionnaire (at 6 weeks and/or 6 months) were included in this analysis. Finally, 47 patients were included for further analysis and divided into two groups: AR (𝑛 = 31) versus FGU (𝑛 = 16) (Figure 1). Prepuce and oral mucosa was used as graft in, respectively, 12 and 4 patients. Stricture location and stricture length were evaluated by retrograde
2
Advances in Urology Male urethroplasty, October 2010–February 2014 N = 258
Exclusion on stricture location: Posterior
N = 35
Penile
N = 86
Combined penile-bulbar
N = 32
Exclusion on type of bulbar urethroplasty: Augmented anastomotic repair
N=5
2-stage urethroplasty
N=8
Heineke-Mikulicz repair
N=2
Bulbar urethroplasty with the following: Anastomotic repair
N = 52
Free graft urethroplasty
N = 38
Further exclusion on: No informed consent
N = 13
No native Dutch speaking
N = 20
Being lost to follow-up
N = 10
Final analysis: Anastomotic repair
N = 31
Free graft urethroplasty N = 16
Figure 1: Flowchart of patient inclusion.
urethrography. This study included the following evaluations: (i) urinary symptoms: maximum urinary flow (𝑄max ) and the International Prostate Symptom Score (IPSS) questionnaire; the IPSS ranges from 0 (no lower urinary tract symptoms) to 35 (severe lower urinary tract symptoms); (ii) erectile function: the abridged 5-item version of the International Index of Erectile Function (IIEF-5) [9]; this score ranges from 1 (no sexual intercourse) to 25 (no erectile dysfunction); (iii) ejaculation/orgasm: the sum of questions 9 and 10 from IIEF (long version) [10]; this Ejaculation/Orgasm Score (EOS) ranges from 2 (no ejaculation/orgasm) to 10 (normal ejaculation and orgasm);
(iv) postoperative genital sensitivity: a nonvalidated inhouse questionnaire containing 3 dichotomous questions on glans tumescence, alterations in genital sensitivity, and cold feeling in the glans; further analysis of glans tumescence was only done in patients reporting normal erectile function (IIEF-5 ≥ 20) in order to avoid contamination of diminished glans tumescence due to globally diminished penile tumescence. Patients were evaluated preoperatively, after 6 weeks and 6 months. In the first six months, no phosphodiesterase5 inhibitors were prescribed to stimulate sexual rehabilitation. In case of suspicion of stricture recurrence (𝑄max < 15 mL/s and/or IPSS > 19), retrograde urethrography and urethroscopy were done. A functional definition of failure
Advances in Urology
3
Table 1: Patients’ characteristics (SD = standard deviation; FGU = free graft urethroplasty; AR = anastomotic repair; DVIU = direct vision internal urethrotomy; 𝑄max = maximum urinary flow; IPSS = International Prostate Symptom Score; IIEF = International Index of Erectile Function; EOS = Ejaculation/Orgasm Score).
Age (years) Follow-up (months) Stricture length (cm) Stricture etiology Traumatic Inflammatory Iatrogenic Idiopathic Previous interventions None DVIU/dilation(s) Urethroplasty(ies) Preop 𝑄max (mL/s) Preop IPSS (. . ./35) Preop IIEF-5 (. . ./25) Preop EOS (. . ./10) Suprapubic catheter Yes No
All (𝑛 = 47)
FGU (𝑛 = 16)
AR (𝑛 = 31)
𝑝 value
Mean (SD) Mean (SD) Mean (SD)
40 (16) 23.3 (10.9) 3 (2.4)
48 (18) 25.2 (12.5) 5.4 (2.6)
37 (13) 22.2 (10) 1.8 (0.8)
0.018 0.376
Clinical Study Anastomotic Repair versus Free Graft Urethroplasty for Bulbar Strictures: A Focus on the Impact on Sexual Function Matthias Beysens,1 Enzo Palminteri,2 Willem Oosterlinck,1 Anne-Françoise Spinoit,1 Piet Hoebeke,1 Philippe François,3 Karel Decaestecker,1 and Nicolaas Lumen1 1
Department of Urology, Ghent University Hospital, 9000 Ghent, Belgium Center for Urethral and Genital Surgery, 52100 Arezzo, Italy 3 Department of Urology, CH Mouscron, 7700 Mouscron, Belgium 2
Correspondence should be addressed to Nicolaas Lumen; [email protected] Received 21 April 2015; Revised 1 June 2015; Accepted 9 June 2015 Academic Editor: Francisco E. Martins Copyright © 2015 Matthias Beysens et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objectives. To evaluate alterations in sexual function and genital sensitivity after anastomotic repair (AR) and free graft urethroplasty (FGU) for bulbar urethral strictures. Methods. Patients treated with AR (𝑛 = 31) or FGU (𝑛 = 16) were prospectively evaluated before, 6 weeks and 6 months after urethroplasty. Evaluation included International Prostate Symptom Score (IPSS), 5-Item International Index of Erectile Function (IIEF-5), Ejaculation/Orgasm Score (EOS), and 3 questions on genital sensitivity. Results. At 6 weeks, there was a significant decline of IIEF-5 for AR (−4.8; 𝑝 = 0.005), whereas there was no significant change for FGU (+0.9; 𝑝 = 0.115). After 6 months, differences with baseline were not significant overall and among subgroups. At 6 weeks, there was a significant decline in EOS for AR (−1.4; 𝑝 = 0.022). In the FGU group there was no significant change (+0.6; 𝑝 = 0.12). Overall and among subgroups, EOS normalized at 6 months. After 6 weeks and 6 months, respectively, 62.2 and 52% of patients reported alterations in penile sensitivity with no significant differences among subgroups. Conclusions. AR is associated with a transient decline in erectile and ejaculatory function. This was not observed with FGU. Bulbar AR and FGU are likely to alter genital sensitivity.
1. Introduction
2. Materials and Methods
Although a short bulbar stricture can be treated by dilation or endoscopic urethrotomy, longer or recurrent strictures are best treated by urethroplasty as it provides the best chance of success [1–3]. Anastomotic repair (AR) and free graft urethroplasty (FGU) are established treatments for bulbar strictures with the choice of technique mainly depending on stricture length [1, 3, 4]. The main goal of urethroplasty is to restore urethral patency, and, as a consequence, most papers have focused on this criterion to evaluate success of urethroplasty [1, 3, 5]. In the past decade, there is an upcoming concern that especially bulbar urethroplasty might affect sexual functioning [6–8]. The aim of this paper is to evaluate and compare sexual function after AR and FGU for bulbar strictures in a prospective fashion.
2.1. Patient Recruitment. Out of 258 male patients who underwent urethroplasty between October 2010 and February 2014, 90 patients with a bulbar stricture only were planned to be treated with AR or FGU and eligible to participate in this prospective study. Only native Dutch speaking patients who signed the informed consent (Institutional Review Board Approval EC UZG 2008/234) and who filled in the preoperative questionnaires and at least one postoperative questionnaire (at 6 weeks and/or 6 months) were included in this analysis. Finally, 47 patients were included for further analysis and divided into two groups: AR (𝑛 = 31) versus FGU (𝑛 = 16) (Figure 1). Prepuce and oral mucosa was used as graft in, respectively, 12 and 4 patients. Stricture location and stricture length were evaluated by retrograde
2
Advances in Urology Male urethroplasty, October 2010–February 2014 N = 258
Exclusion on stricture location: Posterior
N = 35
Penile
N = 86
Combined penile-bulbar
N = 32
Exclusion on type of bulbar urethroplasty: Augmented anastomotic repair
N=5
2-stage urethroplasty
N=8
Heineke-Mikulicz repair
N=2
Bulbar urethroplasty with the following: Anastomotic repair
N = 52
Free graft urethroplasty
N = 38
Further exclusion on: No informed consent
N = 13
No native Dutch speaking
N = 20
Being lost to follow-up
N = 10
Final analysis: Anastomotic repair
N = 31
Free graft urethroplasty N = 16
Figure 1: Flowchart of patient inclusion.
urethrography. This study included the following evaluations: (i) urinary symptoms: maximum urinary flow (𝑄max ) and the International Prostate Symptom Score (IPSS) questionnaire; the IPSS ranges from 0 (no lower urinary tract symptoms) to 35 (severe lower urinary tract symptoms); (ii) erectile function: the abridged 5-item version of the International Index of Erectile Function (IIEF-5) [9]; this score ranges from 1 (no sexual intercourse) to 25 (no erectile dysfunction); (iii) ejaculation/orgasm: the sum of questions 9 and 10 from IIEF (long version) [10]; this Ejaculation/Orgasm Score (EOS) ranges from 2 (no ejaculation/orgasm) to 10 (normal ejaculation and orgasm);
(iv) postoperative genital sensitivity: a nonvalidated inhouse questionnaire containing 3 dichotomous questions on glans tumescence, alterations in genital sensitivity, and cold feeling in the glans; further analysis of glans tumescence was only done in patients reporting normal erectile function (IIEF-5 ≥ 20) in order to avoid contamination of diminished glans tumescence due to globally diminished penile tumescence. Patients were evaluated preoperatively, after 6 weeks and 6 months. In the first six months, no phosphodiesterase5 inhibitors were prescribed to stimulate sexual rehabilitation. In case of suspicion of stricture recurrence (𝑄max < 15 mL/s and/or IPSS > 19), retrograde urethrography and urethroscopy were done. A functional definition of failure
Advances in Urology
3
Table 1: Patients’ characteristics (SD = standard deviation; FGU = free graft urethroplasty; AR = anastomotic repair; DVIU = direct vision internal urethrotomy; 𝑄max = maximum urinary flow; IPSS = International Prostate Symptom Score; IIEF = International Index of Erectile Function; EOS = Ejaculation/Orgasm Score).
Age (years) Follow-up (months) Stricture length (cm) Stricture etiology Traumatic Inflammatory Iatrogenic Idiopathic Previous interventions None DVIU/dilation(s) Urethroplasty(ies) Preop 𝑄max (mL/s) Preop IPSS (. . ./35) Preop IIEF-5 (. . ./25) Preop EOS (. . ./10) Suprapubic catheter Yes No
All (𝑛 = 47)
FGU (𝑛 = 16)
AR (𝑛 = 31)
𝑝 value
Mean (SD) Mean (SD) Mean (SD)
40 (16) 23.3 (10.9) 3 (2.4)
48 (18) 25.2 (12.5) 5.4 (2.6)
37 (13) 22.2 (10) 1.8 (0.8)
0.018 0.376
