Erectile & Ejaculatory Dysfunction after Urethroplasty PDF 2021

Current Urology Reports (2021) 22: 19 https://doi.org/10.1007/s11934-021-01039-9 MEN'S HEALTH (R CARRION, SECTION EDITOR) Erectile and Ejaculatory Dysfunction After Urethroplasty Kevin Heinsimer 1 & Lucas Wiegand 1 Accepted: 18 January 2021 / Published online: 8 February 2021 # The...

Current Urology Reports (2021) 22: 19 https://doi.org/10.1007/s11934-021-01039-9 MEN'S HEALTH (R CARRION, SECTION EDITOR) Erectile and Ejaculatory Dysfunction After Urethroplasty Kevin Heinsimer 1 & Lucas Wiegand 1 Accepted: 18 January 2021 / Published online: 8 February 2021 # The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature 2021 Abstract Purpose of the Review The goal of this paper was to evaluate the impact on erectile and ejaculatory function after anterior and posterior urethroplasty. Recent Findings With a rise in the use of urethroplasty, its impact on sexual function has come into question. For anterior urethroplasties, some degree of erectile dysfunction is common, but this tends to be transient, with most patients having a resolution of any de novo dysfunction by 12 months. Patients with posterior urethral strictures have a very high rate of erectile dysfunction prior to surgery and may show improvement after urethroplasty. Ejaculatory function tends to improve in patients due to alleviation of obstruction while some patients notice degradation in force of ejaculation. Summary While urethroplasty has a minimal permanent effect on sexual function for most patients, there are some patients who notice improvement and others worsening. Patients should be counseled on these risks prior to urethroplasty. Keywords Erectile dysfunction. Ejaculatory dysfunction. Anterior urethroplasty. Posterior urethroplasty. Non-transecting urethroplasty. Graft urethroplasty Introduction The etiology of erectile dysfunction (ED) after urethroplasty is felt to be multi-factorial, including Urethral stricture disease accounts for approximately 2% of neurovascular and psychological. The cavernosal nerve fibers urologic pathology and greater than 50% of the urethral dis- traverse the urogenital diaphragm lateral to the membranous eases seen in urologic practice. The “gold standard” treat- urethra [5 , 6]. Dissection of the urethra during urethroplasty ment for urethral stricture disease is urethroplasty. There has may result in the injury of these nerves, either due to blunt been a trend of increased utilization of urethroplasty in recent trauma or electrocautery. Due to this, many surgeons advocate years, driven by the high success rates of urethroplasty to use caution around the anterior lateral proximal bulbar ure- coupled with the poor outcomes of repeated endoscopic pro- thra and minimize cautery in this area [7, 8]. In addition to cedures [2 , 3, 4]. While initial publications of urethral recon- cavernosal nerve trauma, there is concern that injury to the struction focused heavily on stricture recurrence, lower uri- perineal nerve may also result in neurologic ED. Damage to nary tract symptoms, and urethra-related complications, more this nerve during ventral dissection and splitting of the recently, there has been an additional emphasis on addressing bulbospongiosus muscle may negatively impact erectile func- sexual dysfunction after surgery. tion (EF) by damaging supportive erectile neural pathways [9, 10]. Vascular injury may also impact ED after urethroplasty by dividing bulbar, bulbospongiosum, or perforating arteries This article is part of the Topical Collection on Men’s Health that ultimately decrease blood flow (see Fig. 1—to visualize collateral blood supply [4, 3, 11]. Lastly, the psychological * Kevin Heinsimer impact of surgery on the male genitalia may induce ED. [email protected] Coursey et al. compared an age-matched cohort of patients undergoing circumcisions and urethroplasty. De novo erectile Lucas Wiegand dysfunction occurred in 27.3% and 30.9% of the circumcision [email protected] and urethroplasty patients, respectively. While these 1 Department of Urology, University of South Florida, Tampa General numbers are high, the fact that there was no significant differ- Circle, STC Floor 6, Tampa, FL 33606, USA ence between the two surgeries suggests some degree of the 19 Page 2 of 9 Curr Urol Rep (2021) 22: 19 impact the urethroplasty outcomes , they do not seem to impact the rate of ED after urethroplasty. Anterior Urethroplasty Meta-analysis has demonstrated that de novo ED after anterior urethroplasty to be 1%, but reports range from 0–38%. A separate meta-analysis showed no significant difference in ED due to urethroplasty. Fig. 1 Collateral blood supply of urethra (cp: common penile, da: dorsal Recent prospective trials have shown mixed outcomes artery of the penis, cc: central cavernosal, u: urethral, b: bulbar artery) when evaluating the impact of urethroplasty on EF. Anger et al. found overall IIEF change from 26.9 to 24.8 (P = transient ED related to psychological factors, not 0.13), with only 4% of de novo ED. Erickson et al. re- neurovascular injury alone [13 , 14]. ported 38% of men after urethroplasty experienced ED, but One of the initial reports of erectile function (EF) after over time, 90% of those men had resolution of their ED, with urethroplasty was by Mundy et al. in 1993 showing permanent only 2 patients (4%) having long-term ED. Mondal et al. ED in 5% of men after anastomotic urethroplasty and 0.9% of performed prospective analysis on 35 patients including IIEF men after graft urethroplasty. This initiated multiple ques- and Doppler ultrasonography. This study demonstrated a rate tions in reconstructive urology: Does urethroplasty cause ED? of 50% de novo ED (3 of 6 patients), 28.5% worsening of pre- Does one type of repair hold a higher risk compared to others? operative ED, plus 31% improvement of pre-operative ED Is it the type of repair that matters or is it more related to after urethroplasty. Between pre-operative and 6-month fol- location and length of stricture which will impact EF? low-up, there was no significant difference in IIEF values, Additionally, what is the incidence of ED prior to peak systolic velocity, or resistive index of the cavernosal urethroplasty and is this the major factor for ED after arteries. This study concluded that pre-operative ED urethroplasty? prevalence is the driving force in post-operative ED and that urethroplasty is not the major cause of de novo ED. Urkmez et al. had no statistical change in IIEF pre- and post- urethroplasty. However, this was based on 40% having no Anterior Urethral Strictures change in IIEF, with a balance of 33% of patients having a decrease in IIEF and 27% of patients having an increase in Prior to Urethroplasty IIEF. Similarly, Haines et al. noticed no difference in IIEF before or after urethroplasty, but 21% of patients reported While urethroplasty has become the mainstay for definitive worse EF while 17% had improvement [25 ]. While some urethral reconstruction, urethral dilation and direct vision in- patients are at risk for ED, other patients may have an im- ternal urethrotomy (DVIU) still have a role in urethral stricture provement in EF. Positive gains in IIEF in some patients management. While the latter procedures carry a lower may offset losses by others. A summary of anterior overall success rate and risk of complication compared to urethroplasty findings may be seen in Table 1. urethroplasty, they are not without sexual side effects. A meta-analysis by Jin et al. of endoscopic urethrotomies found Timing After Urethroplasty an overall rate of impotence to be 5%; however, only 3 of the 44 papers addressed ED as a complication. Graversen Timing of EF assessment is a factor in rates of ED as patients et al. found that 10.6% of patients reported ED after DVIU. have a degree of recoverability after their procedure. In 1993, Further workup in one-third of these patients found an abnor- Mundy et al. showed ED rates of 53% after anastomotic mal communication between the corpus cavernosum and cor- urethroplasty and 33% after augmentation urethroplasty at 3 pus spongiosum. Additional factors of ED after months. Long-term, these rates decreased to 5 and 0.9%, re- urethrotomy may also be due to increased scar formation after spectively. Other studies noted a mean time to return to urine extravasates into the periurethral space causing inflam- full EF recovery to be 190 days but ranged from 92–398 days mation and fibrosis [18–20]. Based on this, there is concern. Dogra et al. reported 20% of patients had ED at 3 that increased number of previous dilations or DVIU may months, but by 6 months had a 96% recovery of EF with increase the risk of ED after urethroplasty. Multiples studies minimal improvement after that. Sachin et al. found ED found no impact between pre- and post-urethroplasty EF rates at 3, 6, and 12 months to be 58%, 23%, and 10%, re- based on the number of previous endoscopic interventions spectively [13 ]. Meta-analysis showed that 86% of de novo [9, 19, 21]. While repeated endoscopic procedures may ED resolved after 6–12 months. Curr Urol Rep (2021) 22: 19 Page 3 of 9 19 Table 1 Anterior urethroplasty studies with erectile dysfunction (ED) pre-operative and post-operatively with an evaluation of transecting vs non- transecting procedures. P values between transecting and non-transecting populations if stated Study Patients Rate of Rate of post-op ED Author’s conclusion pre-op ED De novo ED Transecting Non-transecting P value urethroplasty urethroplasty Anger et al. 25 28% 4% Bulbar urethroplasty has minimal (2007) effect on ED but age and pre-existing ED are the most important factors. Erickson 52 44% 38% 50% transient 26% transient P = 0.16 40% risk of ED after urethroplasty et al. but most resolve after 6 months. (2010) Dogra et al. 78 60% 3.8% 28% transient, 9% 13% transient, 0 Most ED is transient and there is no (2011) permanent permanent difference between repair types. Bugeja et al. 67 6.7% 2.4% Non-transection provides a (2015) lower risk of ED. Mondal 35 82% 37% (new or Urethroplasty causes no significant et al. worse ED) change in EF before and after surgery. (2016) Sachin et al. 40 Excluded 10% 61% transient, 55% transient, “Similar Significant transient ED with most (2017) 11.1% 9% permanent out- patients recovering function permanent comes” Haines et al. 87 16% 21% 32% 17% P = 0.22 Decline in EF is noticeable in (2017) some patients but overall, the change is minimal. Chapman 352 9.6% 14.3% 4.3% P = 0.008 Non-transecting anastomotic et al. urethroplasty seems to decrease (2019) the risk of ED after anterior urethroplasty compared to transecting EPA. Technique short and extended EPAs with 13% having permanent ED. Barbagli et al. reported no patients with impotence after anasto- Anterior urethroplasty may be done with variable techniques motic urethroplasty. However, there were 13% of patients with based on stricture length, location, and surgeon preference. changes in glans fullness and 18% with decreased glans sensi- Excision and primary anastomosis (EPA) involve urethral mo- tivity. More recently, there has been a shift to perform non- bilization, excision of the stricture, and a circumferential anas- transecting anastomotic urethroplasties. The spongiofibrosis is tomosis of healthy urethra proximally to distally [27–29]. excised without full-thickness transection of the corpus Augmentation urethroplasty (AU) requires either a graft (usu- spongiosum, allowing preservation of blood flow through the ally oral mucosa) or skin flap for repair on either side of the corpus spongiosum and avoiding unnecessary surgical trauma urethra placed ventrally, dorsally, or both. A combination of the [4, 30 ]. While there are no randomized controlled trials com- two techniques may be required for an augmented anastomotic paring the two, a prospective multi-institutional study showed the repair. Based on the concerns of higher rates of ED with EPA, rate of ED after non-transecting anastomosis was 4.3% compared many studies have assessed the impact of the type of to 14.3% of those with a standard EPA [30 ]. Other studies have urethroplasty on EF. found similarly low rates (2%) of ED after non-transecting anas- tomotic urethroplasties without a negative impact on urethral stricture recurrence. Some authors argue that a two-layer Excision and Primary Anastomosis closure of the corpus spongiosum during a standard EPA pre- serves the vascular plexus of the urethra and avoids loss of bidi- While EPA is the primary urethroplasty for most reconstructive rectional blood flow, thereby minimizing the risk of ED [29, 32]. urologists for short urethral strictures, there are concerns that there is an increased risk of ED compared to non-transecting urethroplasties [14, 29, 30 ]. The proposed increased risk of Augmentation Urethroplasty ED is due to urethral mobilization for a tension-free anastomosis, along with complete transection of the corpus spongiosum, By using a graft or flap tissue for urethroplasty, urethral tran- resulting in decreased vascular antegrade blood flow. section may be avoided (excluding augmented anastomotic Morey et al. noted a 30% rate of ED in a series including both urethroplasties), allowing spongiosum blood flow to be 19 Page 4 of 9 Curr Urol Rep (2021) 22: 19 preserved. Depending on the technique, less urethral mobili- 25 , 26]. One study showed no difference overall based on zation may be required further preserving perforating arteries location. However, in the sub-analysis of men with normal branching between the corpora cavernosa and corpus pre-operative EF, bulbar urethroplasty posed a greater risk of spongiosum and minimizing neural trauma. Palminteri et al. developing post-urethroplasty ED compared to men undergo- had no patients develop ED after ventral onlay graft ing penile urethroplasty (76% vs 38%, P = 0.05). This urethroplasties. In fact, 35% of their patients had improvement increased risk may be due to the proximity of bulbar in EF. The author argues without urethral transection and dor- urethroplasty dissection to cavernosal nerves compared to pe- sal mobilization, ventral onlay should pose the lowest risk of nile urethral surgery. In two separate meta-analyses, there ED. Of note, 4% in this study reported cold glans with was no difference in the rate of ED between penile and bulbar erections but no patient had decreased glans fullness. urethroplasties [8, 19]. EPA vs AU Stricture Length Numerous studies have since compared EPA to AU in reference Length of stricture may be a marker of the extent of disease to sexual dysfunction. In contrast with Mundy et al., many stud- including spongiofibrosis and damage to surrounding ies have shown no difference in the rate of ED after urethroplasty neurovascular tissue. Stricture length also impacts surgi- when comparing EPA to UA [9, 13 , 21, 24, 25 , 26, 34]. cal decision-making, what technique will be used, and the Ericksen et al. showed a trend toward increased rates of post- length of the urethra that must be dissected. Because of operative ED in men undergoing EPA (50%) compared to men this, it may be hypothesized that there is an increased risk of undergoing graft urethroplasty (26%, P = 0.16). Interestingly, ED with longer repairs. Coursey et al. found patients who both arms had complete urethral transection and excision of the reported worsening of their ED had a longer average stricture scar; however, those with graft urethroplasty showed lower rates (6.8 cm) versus those who reported no change or improve- of post-operative ED. The author suggests the increased length of ment in their EF (4.4 cm). Urkmez et al. found higher urethra excised and increased urethral mobilization required to rates of pre-operative ED based in patients with longer stric- complete an EPA may be the reason for the increased risk of ED tures (1–3 cm versus 4–7cm); however, post-operatively, associated with EPA. Dogra et al. compared urethroplasties, there was no difference in overall change increased risk of including penile flap/graft, EPA, and bulbar AU. They found no ED the two arms. Other studies, including meta-analysis, difference in post-op IIEF at 12 months. However, they noticed a have found no association with stricture length and increased greater statistical change in IIEF at 3 months between EPA com- risk of post-operative ED [19, 21, 26, 30 ]. pared to bulbar AU (− 3.2 vs − 0.2). This difference resolved over the next 9 months. After 12 months, they noted only 3 Age patients of 72 had ED after urethroplasty, all within the EPA group; however, this was not statistically significant. As a patient’s age increases, so does the rate of ED, along with In a meta-analysis, the data is conflicted. Feng et al. found a the rate of comorbidities (diabetes mellitus, hypertension, cor- lower incidence of ED after bulbar graft urethroplasty (16%) onary artery disease, etc.) [37, 38]. Many studies have identi- compared to EPA (36%) (P = 0.04). This sub-analysis only fied increased rates of ED after urethroplasty associated with included 2 studies and 52 patients of a total of 1729 patients increased age. Haines et al. found age > 50 was associated. A separate meta-analysis by Blaschko et al. found no with decreased EF after anterior urethroplasty [25 ]. Urkmez difference in EF after urethroplasty based on technique. et al. found that pre-operatively, IIEF was worse in patients > This article did not delineate which studies or patients were 65 years old (17.9) compared to those < 65 years old (21.6), used in this sub-analysis. and the decrease in IIEF was higher in those > 65 years old (− 4.3) versus those < 65 years old (− 0.1). Erickson et al. Perineal Urethrostomy found a significant decline in EF for men 50–59 years old and a trend for those > 60 years old (due to limited numbers) while There is limited data available on post-operative sexual func- those < 50 years old had no significant change in EF. tion after perineal urethrostomy. Murphy et al. showed Dogra et al. found no difference in age and the rate of ED reviewed 92 patients after perineal urethrostomy and found after anterior urethroplasty but noted patients > 55 years old no significant change in EF [35 ]. had a lower pre-operative IIEF and greater decline after urethroplasty. However, these results were not statistically Location (Penile vs Bulbar) significant. Chapman et al. reported no increased changes in sexual function associated with age [30 ]. One meta- Most studies have found no difference in the rates of ED after analysis suggested a trend toward increased rates of de novo urethroplasty between penile and bulbar reconstruction [9, ED for each year increased in age, but this was not statistically Curr Urol Rep (2021) 22: 19 Page 5 of 9 19 significant (OR 1.12, CI 0.97–1.31). Age may be a direct decompress neurovascular structures allowing regain of func- factor for post-urethroplasty ED related to poor tissue elastic- tion. Additionally, removal of suprapubic catheters and ity and ability to heal or merely a surrogate for underlying voiding per urethra may resolve psychologic impacts affecting comorbidities. EF. However, the resolution of ED after urethroplasty may be multi-factorial, including timing, as EF may continue to Posterior Urethral Strictures recover up to 24 months after the trauma without intervention. This long recovery may be related to the recovery of While rare, posterior urethral stricture disease is commonly neuropraxia and the development of accessory blood flow. associated with pelvic fracture injuries, in patients with pelvic fractures, only 2–10% will have concomitant pelvic fracture Penile Revascularization urethral injuries (PFUI) [6, 13 ]. ED in all patients with a pelvic fracture is estimated to be 5–20%, whereas, for those PFUI may result in traumatic transection of the bulbar arteries with PFUI, the rate of ED ranges from 18–72% [6, 39, 40]. supplying the urethra. The urethra is then dependent upon The severity of the pelvic trauma increases the risk of ED, retrograde flow through the dorsal penile artery. ED after with the most severe pelvic fractures having 100% ED [6, 39]. pelvic fracture may be an indicator of loss of penile blood flow Pubic diastasis and lateral prostatic displacement are both due to an injury between the internal pudendal and dorsal found to be risk factors for ED. Koraitim et al. showed penile artery. Without retrograde flow, with loss of both bul- diastasis of the pubic bone shows 16 times increased risk of bar arteries, posterior urethroplasty may fail due to ischemia if ED compared to those without it. Additionally, increased the bulbar arteries are also occluded. Penile revasculari- length of stenosis or gap length has been found to be a risk zation allows for a bypass of the occluded vessel feeding the factor. Comparing patients with gap length < 2 cm to > 2 cm, penile artery to restore arterial perfusion, treat arteriogenic the rate of preprocedural ED was 20% vs 64%, respectively ED, and decrease the risk of ischemia at the time of posterior. The etiology of ED is attributed to increased force of urethroplasty [44–46]. If patients have ED due to arterial in- trauma resulting in direct neurovascular injury and entrapment sufficiency after pelvic fracture, revascularization may be per- of the nerves during healing with dense scar formation in the formed prior to urethroplasty or after reconstruction if ED pelvis. Using penile duplex ultrasonography, the causes of persists [45, 46]. The technique typically involves anastomos- ED in patients after pelvic fracture with PFUI are shown to be ing the inferior epigastric artery to penile vasculature. arteriogenic (76%), arteriovenogenic (8%), and pure neuro- Outcomes have shown > 80% subjective improvement in EF genic (16%). There may also be concomitant nerve and vas- [45, 46]. Zuckerman et al. reported no recurrent stenosis if cular damage in 40% of patients. posterior urethroplasty was completed 6 months after penile revascularization. However, penile revascularization has Posterior Urethroplasty had limited implementation due to its stringent patient selec- tion criteria, complex workup that is invasive and operator Posterior urethroplasty involves urethral mobilization and dependent, as well as the technically challenging nature of anastomosis after excision of fibrotic tissue. El-Assmy the procedure compared to penile implantation. This tech- et al. reported no de novo ED after posterior urethroplasty, nique may be considered in select patients but will likely be but only 18% of their patients were potent prior to surgery reserved for specialized centers.. Seven of those 52 patients with pre-operative erectile dysfunction had recovery of their erections after urethroplasty Treatment of ED After Urethroplasty at a median of 12 months. These patients were more likely to have iatrogenic induced urethral strictures or less severe pelvic First-line therapy for ED after urethroplasty is phosphodies- injuries. Dhabuwala et al. also had no patients with de terase type 5 inhibitor (PDE5i) [20, 26]. Al-Qudah et al. re- novo ED after posterior urethroplasty and 22% of patients ported that of their patients after urethroplasty with ED, 100% with pre-operatively ED reported improved EF their repair were sildenafil responsive. Fu et al. described the use of. Sachin et al. showed 8 patients with normal pre- sildenafil 100 mg/day, three times a week in patients without operative IIEF, scores changed from 24 pre-operatively to comorbidities (HTN, DM, heart disease) with ED. Sildenafil 22 after urethroplasty (P = 0.47) [13 ]. A meta-analysis of had an 80% success rate with more success in those with less PFUI suggested an overall 3% risk of de novo ED to be related severe ED and those with arterial and non-vascular etiologies to posterior urethroplasty, in addition to a 34% risk of ED on Doppler compared to those with venous etiologies. related to pelvic fracture trauma. Summary of posterior Tang et al. described using tadalafil 5 mg daily after PFUI urethroplasty findings may be seen in Table 2. and showed 83% of those treated responded well. They also Ability to regain EF after posterior urethroplasty is felt to noted better IIEF improvement in those treated closer to the be due to removal of fibrotic stenosis, which may release and time of PFUI. This may support the early use of PDE5i in 19 Page 6 of 9 Curr Urol Rep (2021) 22: 19 Table 2 Posterior urethroplasty studies with erectile dysfunction (ED) pre-operative compared to the rate of de novo ED and rate of improvement in EF after urethroplasty Study Patients Pre-op ED De novo ED Rate of improved EF Author’s conclusion Dhabuwala 26 73% 0% 15% Posterior urethroplasty et al. (1990) does not seem to cause ED. Feng et al. 379 (meta-analysis) 43% 19% There is a decrease in the incidence of (2013) ED after posterior urethroplasty. Blaschko et al. (2014) 1534 (meta-analysis) 34% 3% Posterior urethroplasty poses a small risk of de novo ED. El-Assmy et al. (2015) 81 81% 0% 13.5% ED after PFUI is due to initial trauma, not posterior urethroplasty. Sachin et al. 8 68% transient, ED after posterior urethroplasty (2017) 25% permanent improves with times, similar to anterior urethroplasty. Baradaran et al. (2019) 15 0% 0% There seems to be no de novo ED in pediatric patients after posterior urethroplasty. patients with ED after urethroplasty or be confounded by the urethroplasty, and 20% in their penile skin flap group. No fact that patients farther out from surgery have improved EF. patients in the oral graft group reported chordee. Morey Second-line and third-line therapy if PDE5i fails is et al. noticed chordee or penile shortening in 27% of patients intracavernosal injections and penile prosthesis, respectively. undergoing EPA. Some of these patients underwent ex- A rare case to note is described by Kardar et al. where the tended EPA (> 2.5 cm) which may explain the curvature. placement of malleable prosthesis following posterior Baradaran et al. reported a rate of chordee of 20% after urethroplasty requires urethral rerouting. The patient developed urethroplasty in patients < 19 years old. All patients had penile a complete urethral obliteration and implant infection 18 curvature < 30 degrees that did not interfere with intercourse months after the implantation. It was felt that due to the or require treatment. No patient in the study had > 30 degrees rerouting and rigid nature of the implant, ischemia caused ero- curvature [55 ]. sion and infection [6, 50]. There are also case reports of con- comitant IPP revisions and urethroplasties to treat urethral stric- Ejaculatory Dysfunction tures related to previous prosthetic placement [51, 52]. While both were successful, this is unlikely to become standard prac- Expulsion of semen from the urethra is aided by coordinated tice due to the increased risk on prosthetic infection. contractions of the ischiocavernosus and bulbospongiosum mus- cles. Damage to the muscle or the perineal nerve branches Penile Length and Curvature After Urethroplasty innervating it may result in decreased ejaculatory forces after urethroplasty. Erickson et al. (2007) found that on average, An additional sexual concern during urethroplasties is devel- men’s ejaculatory function (EjacF) improved after urethroplasty. oping chordee and penile shortening due to the shortening of Additionally, the authors showed no difference in EjacF based on the urethra during reconstruction. Typically, anastomotic pro- timing after surgery, which, unlike EF, does not appear to require cedures have been limited to the bulbar and posterior urethra time to recover after urethroplasty. Like EF, EjacF seemed slight- due to concern that EPA in the penile urethra would result in ly dependent upon age. Those > 60 years old did not report an chordee and penile shortening [3, 36]. This has been chal- improvement in EjacF after urethroplasty was compared to those lenged recently with good results of penile EPA in select pa- < 60 years old. Erikson et al. (2010) found that prior to tients. For bulbar urethroplasties, distal mobilization is urethroplasty, 25% of men with anterior urethral strictures report- typically limited to the penoscrotal junction to avoid releasing ed poor ejaculatory function. While there was no overall change the urethra from the penile corpora cavernosum to decrease in EjacF for all comers, those with poor pre-operative scores the risk of chordee. Barbagli noted no patients reported significant improvement after urethroplasty. This was complaining of chordee after anastomotic urethroplasty, but mostly driven by improvement in pain, volume, and vigor with limited this technique to stricture < 3 cm, avoiding extensive ejaculation. They did have 11% of men show a decrease in EjacF mobilization of the urethra distally. Al-Qudah et al. re- and most of these were in patients undergoing bulbar ported chordee in 4% of their EPA, 11% of their posterior urethroplasties. Palminteri et al. found 65% of patients Curr Urol Rep (2021) 22: 19 Page 7 of 9 19 noticed an improvement in ejaculation due to improved force, Compliance with Ethical Standards volume, and lack of obstruction. Patients who noticed worse ejaculatory function after urethroplasty (19%) reported post- Conflict of Interest Kevin Heinsimer and Lucas Wiegand each declare no potential conflicts of interest. ejaculation dribbling and reduced stream. Barbagli also re- ported 23% of patients reported decreased ejaculation force after Human and Animal Rights and Informed Consent This article does not anastomotic urethroplasty. This is felt to be related to injury to the contain any studies with human or animal subjects performed by any of perineal nerve innervation to the bulbospongiosus or trauma to the authors. the muscle itself. Ejaculation is routinely better after urethroplasty due to alleviation of obstruction if the bulbospongiosus muscle is reapproximated during incision clo- References sure [4, 33]. To avoid ejaculatory dysfunction, certain techniques have Papers of particular interest, published recently, have been been proposed. Avoiding division of the central tendon may also highlighted as: help preserve EjacF due to its support of the muscles involved Of importance [25 ]. Additionally, muscle-sparing urethroplasties have been in- Of major importance vestigated with an aim to preserve EjacF by avoiding damage to the bulbospongiosum muscles and perineal nerve. This was first 1. Xambre L. Sexual (Dys) function after urethroplasty. Adv Urol. described by Barbagli et al. who showed no ejaculatory dysfunc- 2016;2016:9671297. https://doi.org/10.1155/2016/9671297. tion in any of the six patients. More recently, Fredrick et al. 2. Cotter KJ, Hahn AE, Voelzke BB, Myers JB, Smith TG 3rd, Elliott SP, et al. Trends in urethral stricture disease etiology and compared their outcomes of bulbospongiosus muscle-sparing urethroplasty technique from a multi-institutional surgical out- patients to a control arm of matched patients who underwent comes research group. Urology. 2019;130:167–74. https://doi.org/ standard urethroplasties. They found no difference between the 10.1016/j.urology.2019.01.046 Ten surgeons combine data over two arms when looking at ejaculatory outcomes suggesting no 8 years to show trends in technique and preferences in urethroplasties. There is an increase in utilization of dorsal benefit of this technique for ejaculatory outcomes [58 ]. graft urethroplasty and non-transecting anastomic urethroplasy. 3. Horiguchi A. Substitution urethroplasty using oral mucosa graft for Conclusion male anterior urethral stricture disease: current topics and reviews. Int J Urol. 2017;24(7):493–503. https://doi.org/10.1111/iju.13356. 4. Verla W, Oosterlinck W, Spinoit AF, Waterloos M. A Comprehensive The effect of urethroplasty on sexual function is rare but pres- review emphasizing anatomy, etiology, diagnosis, and treatment of ent. While most authors find the limited permanent impact on male urethral stricture disease. Biomed Res Int. 2019;2019:9046430. erectile dysfunction after anterior urethroplasty, it is clear that https://doi.org/10.1155/2019/9046430. some patients are at risk post-operatively, but this seems to be 5. Baradaran N, Hampson LA, Edwards TC, Voelzke BB, Breyer BN. Patient-reported outcome measures in urethral reconstruction. Curr transient for most. Patients undergoing posterior urethroplasties Urol Rep. 2018;19(7):48. https://doi.org/10.1007/s11934-018- may notice gains in erectile function more commonly than new- 0797-9 Review of patient outcomes after urethroplasty. Article onset ED, but many of these patients will already have ED prior addresses need and direction for urethral stricture PROMs. to surgery. 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