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Study on clinical outcomes between non-transecting urethroplasty and lingual mucosal urethroplasty for iatrogenic bulbar urethral stricture treatment

Study on clinical outcomes between non-transecting urethroplasty and lingual mucosal... Background This study aimed to compare the clinical outcomes of non-transecting urethroplasty and lingual mucosal urethroplasty in the treatment of iatrogenic bulbar urethral stricture. Results A total of 25 patients with iatrogenic bulbar urethral stricture were enrolled, 12 of whom underwent lingual mucosal urethroplasty, 13 patients who underwent non-transecting urethroplasty. All patients were followed-up and evaluated at 3 postoperative months. Evaluations included urethrography, maximum urine flow rate (Qmax), noc- turnal erectile function testing, International Index of Erectile Function (IIEF-5) assessment, and Anxiety Related Scale (SAS) assessment. In terms of operation time, there was a significant difference between non-transecting urethro - plasty and lingual mucosal urethroplasty. However, there was no significant intergroup difference in intraoperative blood loss. Both techniques were associated with significantly improved Qmax relative to preoperative rates, but there was no significant difference between the groups in this regard over 3 months of postoperative follow-up. Nocturnal penile tumescence and rigidity results showed that there was no significant change in tip hardness after surgery in the non-transecting urethroplasty group. Moreover, IIEF-5 scores indicated that there was no significant intergroup difference in terms of subjective postoperative erectile function. According to the preliminary psychological evalua- tions during postoperative follow-up, the anxiety scores of patients undergoing non-transecting urethroplasty signifi- cantly improved, but there was no significant change in the mean SAS score among patients who underwent lingual mucosal urethroplasty. Conclusion Both surgical methods can achieve the clinical goal of treating iatrogenic bulbar urethral stricture. Non- transecting urethroplasty has the characteristics of short operation time, relative technical simplicity, and retention of the original erectile function of most patients, and the surgical outcomes of non-transecting urethroplasty are not inferior to those of lingual mucosal urethroplasty, and it is a promising technique for widespread use to treat bulbar urethral strictures. Keywords Bulbar urethral stricture, Iatrogenic, Urethral reconstruction, Non-transecting urethroplasty Wei Le and Chengdang Xu contributed equally to this work and are considered co-first authors. *Correspondence: Chao Li chaoli1979@126.com Full list of author information is available at the end of the article © The Author(s) 2023. 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The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Le et al. Basic and Clinical Andrology (2023) 33:12 Page 2 of 9 Résumé Contexte Cette étude visait à comparer les résultats cliniques de l’urétroplastie non transectante et de l’urétroplastie avec greffe de muqueuse linguale dans le traitement de la sténose urétrale bulbaire iatrogène. Un total de 25 patients présentant une sténose urétrale bulbaire iatrogène a été recruté, dont 12 ont subi une urétroplastie avec greffe de muqueuse buccale et 13 une urétroplastie non-transectante. Tous les patients ont été suivis et évalués à 3 mois posto- pératoires. Les évaluations comprenaient une uréthrographie, le débit urinaire maximal (Qmax), un test nocturne de la fonction érectile, l’évaluation de l’index international de la fonction érectile (IIEF5) et une évaluation de l’échelle d’anxiété. Résultats En termes de durée opératoire, il y avait une différence significative entre l’urétroplastie non-transectante et urétroplastie avec greffe de muqueuse buccale. Cependant, il n’y avait pas de différence significative entre les groupes en ce qui concerne la perte de sang peropératoire. Les deux techniques ont été associées à une améliora- tion significative du Qmax par rapport aux taux préopératoires, mais il n’y avait pas de différence significative entre les groupes à cet égard sur 3 mois de suivi postopératoire. Les résultats de la tumescence et de la rigidité nocturnes du pénis ont montré qu’il n’y avait pas de changement significatif de la dureté de l’extrémité du pénis après l’opération dans le groupe d’urétroplastie sans transsection. De plus, les scores IIEF-5 ont indiqué qu’il n’y avait pas de différence significative entre les groupes en termes de fonction érectile subjective postopératoire. Selon les évaluations psy- chologiques préliminaires au cours du suivi postopératoire, les scores d’anxiété des patients ayant subi une urétro- plastie non-transectante se sont améliorés de manière significative, mais il n’y a pas eu de changement significatif du score moyen de l’échelle d’anxiété chez les patients ayant subi une urétroplastie avec greffe de muqueuse buccale. Conclusions Les deux méthodes permettent d’atteindre l’objectif clinique du traitement de la sténose urétrale bulbaire iatrogène. L’urétroplastie sans transsection présente les caractéristiques suivantes: temps d’opération court, simplicité technique relative et maintien de la fonction érectile initiale chez la plupart des patients. Les résultats chi- rurgicaux de l’urétroplastie sans transsection ne sont pas inférieurs à ceux de l’urétroplastie avec greffe de muqueuse buccale et cette technique est prometteuse pour une utilisation généralisée dans le traitement des rétrécissements urétraux bulbaires. Mots‑clés Sténose urétrale bulbaire, Iatrogène, Reconstruction urétrale, Urétroplastie sans transsection Background urethral strictures is to use free oral mucosa to replace The treatment of bulbar urethral strictures is a compli - the urethra. The main surgical techniques include buc - cated clinical problem [1]. In addition to riding injury, cal mucosal or lingual mucosal urethral reconstruction iatrogenic factors (such as intravenous catheterization, [3, 4]. Free lingual mucosa is widely used for major ure- minimally invasive transurethral surgery (such as TURP, thral reconstruction centers in China. When the lingual TURBT, ureteroscopy and lithotripsy) are among the mucosa is extracted by this method, surgical trauma is common causes of bulbar urethral strictures [2]. inflicted on the tongue. This affects postoperative lingual Most bulbar urethral strictures caused by riding inju- sensory and motor activity and (consequently) speech. ries are serious, and sometimes they may even form Many patients will feel apprehensive about these compli- armor scars around narrow urethras. Compared with cations and will find it difficult to consent to undergoing urethral strictures caused by riding injury, iatrogenic ure- such procedures. thral strictures are associated with shorter narrow seg- Although traditional bulbar urethral end-to-end anas- ments and less scarring. tomosis has a high success rate, the corpus spongiosum Endoscopic urethral incision for urethral strictures needs to be completely transected before anastomosis, longer than 1  cm is often unsatisfactory, and open ure- and this extensive surgical trauma may damage the blood throplasty is often required. There are many open surgi - supply and innervation to the patient’s bulbar corpus cal methods available for the treatment of bulbar urethral spongiosum [5], potentially causing a series of complica- strictures. Commonly used surgical methods include free tions and adverse outcomes, including impaired sexual mucous membrane replacement urethroplasty techniques, function [6, 7]. such as those that use mucous membrane from the oral In view of this problem, some scholars have proposed cavity, as well as bulbar urethral end-to-end anastomosis. and applied the surgical method of urethral spongiform In many domestic urethral reconstruction cent- non-transecting anastomosis to treat bulbar urethral ers, the popular surgical approach to treating bulbar strictures, which can achieve better clinical outcomes [8]. Le  et al. Basic and Clinical Andrology (2023) 33:12 Page 3 of 9 To our knowledge, no published studies have com- Preoperative preparation pared the clinical outcomes of non-transecting urethro- The presence of bulbar urethral stricture was confirmed plasty with those of lingual mucosal urethroplasty. We by urethrography and soft cystoscopy, and the length of attempted to treat iatrogenic bulbar urethral strictures the urethral stricture was estimated by urethrography. with non-transecting urethroplasty, and we compared Antibiotic therapy, maximum urine flow rate (Qmax) bulbar urethral reconstruction with lingual mucosal ure- testing, and International Index of Erectile Function throplasty. By comparing clinical variables and patient (IIEF-5) assessments were administered before surgery, outcomes associated with the two surgical procedures, and patients with normal urinary function and negative we evaluated whether non-transecting urethroplasty urine culture results were considered suitable for surgery. could be used as a routine treatment option or a benefi - cial supplement for treating iatrogenic bulbar urethral Operative techniques strictures. Overall, we evaluated the technique’s value Lingual mucosal urethroplasty in the clinical treatment of iatrogenic bulbar urethral (1) An inverted “Y” incision was made at the perineum strictures. (2). Then the bulbar corpus spongiosum was separated (3). A urethral dilator was inserted into the anterior urethra to locate the position of the urethral stric- Methods ture and longitudinally open the stenosed segment to All study data were collected from 25 patients with bul- the extent of the normal distal and proximal urethral bar urethral stricture in Tongji Hospital, which is affili - urethral mucosa (4). With the goal of maintaining the ated with Tongji University, from 2010 to 2021. The study corpus spongiosum’s continuity, the rigid scar tissue was conducted in accordance with the Declaration of constituting the urethral stricture was removed, and Helsinki (as revised in 2013). The study was approved by the urethral incision length was measured (5). Then the the Ethics Committee Board of Tongji Hospital Affiliated patient’s oral cavity was cleaned and disinfected. After to Tongji University (NO. K-KYSB-2020-0) and individ- the tongue tip was pulled and marked with a marker, ual consent for this retrospective analysis was waived. an incision, about 2 cm in width, was made. The length of the incision was determined according to the length of urethral incision, and the excised mucosa was used Patient data for ventral onlay reconstruction of the bulbar urethra. In our patients who chose to undergo non-truncating If the stenosis was severe, the length of tongue mucosa urethroplasty, the strictures were all less than 2  cm removed was equivalent to about twice the length of in length, and the distal urethra was separated as it the resected urethra, and the dorsal inlay combined approached the root of the penis to increase ure- with the ventral onlay was used to reconstruct the bul- thral freedom and reduce anastomotic tension. The bar urethra. The excised lingual mucosa was placed in inclusion criteria were as follows: (1) bulbar ure- ice-cooled normal saline to prune the tissue (6). The thral stricture caused by various iatrogenic factors; free lingual mucosal tissue was dissected into the bul- (2) the presence of bulbar urethral stricture indi- bar urethra, and the bulbar urethra was reconstructed cated by preoperative urethrography and soft cys- using the ventral onlay method. If the stenosis was toscopy; (3) the length of the stenosis was < 2  cm; (4) severe, the bulbar urethra was reconstructed using the patients aged 15–50 years; (5) preoperative andro- dorsal inlay method combined with the ventral onlay gen (T), estradiol (E2), and prolactin (PRL) levels method. Finally, (7) an indwelling 18 F silicone catheter within the normal range; and (6) no penile blood flow was inserted (Fig.  1), and (8) the incision was closed reduction diagnosed by preoperative penile Doppler layer by layer. ultrasonography. The exclusion criteria are as follows: (1) congenital Non‑transecting urethroplasty urethral stricture; (2) patients with urethral stricture Steps (1), (2), (3)  and (4)  are the same as those for lin- aged < 15 years or > 60 years; (3) complex urethral stric- gual mucosal urethroplasty [5]. After the proximal and ture—for example, the length of the stricture was ≥ 2  cm distal urethra was sutured intermittently at points 1, 2, or more than two urethral strictures were observed; (4) 4, and 5 in the lithotomy position, an indwelling 18  F patients with a history of two or more procedures involv- silicone catheter was inserted, and then the proximal ing urethral incisions; (5) patients with severe erectile and distal urethra was sutured at points 7, 8, 10, and dysfunction (penile head hardness < 20% detected by 11 [6]. All sutures were tightened to bring the proxi- preoperative nocturnal penile tumescence and rigidity mal and distal urethra close together, and each suture (NPTR) evaluation; and (6) patients with abnormal sex was tied separately to complete urethral anastomosis in hormone levels. Le et al. Basic and Clinical Andrology (2023) 33:12 Page 4 of 9 Fig. 1 Preoperative and postoperative urethrography and surgical procedures of the two surgical methods. Bulbar corpus spongiosum non- transecting urethroplasty: A Preoperative urethrography: bulbar urethral stricture; B Dissociate and split the narrow urethra to expose the distal and distal normal urethra mucosa; C 3 − 0 absorbable suture of proximal urethral mucosa and indwelling catheter; D 3 − 0 suture the proximal end of absorbable line with the distal urethral mucosa; E Tighten and tie the distal and distal urethral mucosal sutures; F Postoperative urethrography: the lumen of the bulbar urethra was unobstructed without stenosis lingual mucosal bulbous urethroplasty: G Preoperative urethrography: bulbar urethral stricture; H Dissociate and split the narrow urethra to expose the distal and distal normal urethral mucosa; I The mucous membrane of the tongue was taken and trimmed; J Urethra was dissected and the lingual mucosa Inlay was used to reconstruct the dorsal urethra; K Urethra was dissected and the lingual mucosa Onlay was used to reconstruct the ventral urethra; L Postoperative urethrography: the lumen of the bulbar urethra was unobstructed without stenosis Evaluation of postoperative sexual function–related the context of a corpus spongiosum that has not been indicators resected [7]. The outer corpus spongiosum of the ure - Three months postoperatively, erectile function–related thral anastomosis was reinforced and sutured again assessments (NPTR and IIEF-5) were conducted, and noc- with 3 − 0 absorbable suture (Fig.  1) [8]. The incision turnal erectile hardness was further analyzed using penile was closed layer by layer. TIP data. The Rigiscan testing instrument usually measures the erectile hardness of the head of the penis (TIP) and the Operative time and intraoperative blood loss root of the penis (BASE) while the patient is sleeping to Surgical data of the two groups were collected, includ- reflect the patient’s true level of erectile function. Accord - ing surgical time and estimated blood loss. Surgical time ing to the current internationally recognized reference was the time from the beginning of the operation (skin ranges, patients with tip hardness below 60% were con- incision) to the end of surgery (skin closure). The amount sidered to have organic erectile dysfunction. At the same of intraoperative blood loss was estimated by measuring time of NPTR measurement, IIEF-5 scale analysis was per- the difference between the amount of blood collected by formed, and the scores obtained were statistically analyzed. an intraoperative negative-pressure suction device and the weight of preoperative and postoperative hemostatic gauze. Statistical analysis PASW Statistics for Windows, version 18.0 (SPSS Inc. Chicago, IL, USA) was used to run independent-sam Postoperative treatment and follow‑up - All patients received prophylactic antibiotics for about ples t-tests and paired t-tests for preoperative and post- 1 week. Catheters were removed after 3 postoperative operative Qmax, IIEF-5 scores, and NPRT data. A P value < 0.05 was considered statistically significant. weeks, and urethrography was performed 1 month later. Follow-up criteria were mainly assessed by preoperative and postoperative differences in NPT, IIEF-5 scores and Results psychological status. The criterion for recurrence of post - Operation and postoperative urinary outcomes operative urethral stricture was a urinary flow rate < 15 There was one patient in each group with progressive ml/s. dysuria after removal of the catheter. The patient who Le  et al. Basic and Clinical Andrology (2023) 33:12 Page 5 of 9 patients, throughout follow-up, urethrography indicated that the original urethral stricture was cured and that the urethra was smooth (Fig. 1). The mean postoperative Qmax indices associated with the two techniques signifi - cantly improved between preoperative and postoperative assessments (lingual mucosal urethroplasty, 17.16 ± 5.11 ml/s vs. 5.58 ± 3.73 ml/s; non-transecting urethroplasty, 16.92 ± 4.53 ml/s vs. 5.54 ± 3.36 ml/s). In terms of post- operative Qmax, there was no significant difference between the two groups (p > 0.05) (Fig. 2). Surgical indicators The mean operative time associated with lingual mucosal urethroplasty was 135 ± 24.67  min; the mean operation time associated with non-transecting urethroplasty was 100.69 ± 14.48  min, and this difference was statistically significant (Fig. 3 A). Fig. 2 Changes in parameters of maximum postoperative urine flow The mean intraoperative blood loss was 180 ± 47.16 ml rate between the two surgical methods. Qmax of the two surgical in the lingual mucosal urethroplasty group, compared methods was significantly improved after catheter removal, but there with 149.2 ± 25.55 ml associated with non-transecting was no significant statistical difference in Qmax parameters between urethroplasty; this difference was not statistically signifi - the two groups after catheter removal (NS: compared with the lingual mucosal urethral surgery group, P > 0.05) cant (Fig. 3B). Postoperative sexual function evaluation failed lingual mucosal urethroplasty has been regularly At the 3-months follow-up point after surgery, the mean treated with urethral dilation to date, and the patient NPTR rating for the lingual mucosal urethroplasty group from the non-transecting urethroplasty group under- was 42.91 ± 15.33% compared with 56.67 ± 9.42% before went a second open surgery (resection of the lower pubic surgery (p < 0.05). The corresponding outcomes for the margin, resection of urethral stricture, and end-to-end non-transecting urethroplasty group were 51.92 ± 9.91% urethral anastomosis) 6 months after the initial opera- after surgery vs. 56.15 ± 6.25% before surgery (p > 0.05). tion; the catheter was removed 3 weeks after the second There was no significant difference in tip hardness operation, and the urine flow was good. For all other parameters between the groups (p > 0.05) (Fig. 4 A, B). Fig. 3 Comparison of operative time and intraoperative blood loss between the two surgical methods. A Operative time of the two surgical methods. The operative time of lingual mucosa urethroplasty was 135 ± 24.67 min; The operation time of non- transecting urethroplasty was 100.69 ± 14.48 min, and the operation time of non- transecting urethroplasty was shorter, with statistical difference (*: compared with the lingual mucosal urethral surgery group, P < 0.05). B Comparison of intraoperative blood loss between the two surgical methods. Intraoperative blood loss during lingual mucosal urethroplasty was 180 ± 47.16ml, the intraoperative blood loss during non- transecting urethroplasty was 149.2 ± 25.55ml, and there was no statistical difference between the two groups (NS: compared with the lingual mucosal urethral surgery group, P > 0.05) Le et al. Basic and Clinical Andrology (2023) 33:12 Page 6 of 9 Fig. 4 Penile tip hardness values of Post-operative NPTR analysis and IIEF-5 score results between the two surgical methods. A Penile head hardness values of Post-operative NPTR analysis. It showed a downward trend in TIP hardness values of the two different surgical methods, but there was no statistical difference in TIP hardness values of the non- transecting urethra group. There was statistically significant difference in the hardness decrease of the lingual mucosa group, but there was no statistically significant difference in the penile head hardness between the two groups after surgery. B IIEF-5 score results. Follow-up results 3 months after surgery indicated that iIEF-5 value decreased in both the lingual mucosa group and the non- transecting group, and the decrease was statistically significant (P < 0.05). There was no significant difference in IIEF-5 score between the two groups during postoperative follow-up (P > 0.05) In the lingual mucosal urethroplasty group the mean was IIEF-5 score was 19.91 ± 1.89 before surgery vs. 16.67 ± 2.98 after surgery (p < 0.05). The mean scores for the non-transecting urethroplasty group were 20.53 ± 1.59 and 18.53 ± 3.47, respectively (p < 0.05). There was no significant difference in mean IIEF-5 scores betwen the two groups during postoperative fol- low-up (p > 0.05) (Fig . 4 C). Preliminary evaluation results of postoperative psychological state The mean statistics of anxiety score scale (SAS) for patients in the non-transecting urethroplasty group sig- Fig. 5 Postoperative anxiety psychological evaluation results of the nificantly improved 3 months after surgery (62.59 ± 14.18 two surgical methods. According to the follow-up of SAS anxiety before surgery vs. 54.13 ± 12.97 after surgery, p < 0.05). score, the results showed that the postoperative anxiety SAS score of There was no significant change in the mean SAS score the non- transecting surgery group significantly decreased; There was no significant difference in the anxiety score of the lingual mucosa after surgery in the lingual mucosal urethroplasty surgery group (P > 0.05), although the mean value was decreased. group (preoperative 67.18 ± 13.06 vs. postoperative There was no significant difference in SAS score between two groups 63.75 ± 10.05, p > 0.05). There was no significant dif - after operation (P > 0.05) ference in node SAS scores between the two groups 3 months after surgery (p > 0.05) (Fig. 5). strictures, the incidence of iatrogenic bulbar urethral Discussion strictures is increasing with the increasing popularity of Urethral stricture is still a common problem, which can various minimally invasive transurethral operations and arise from various causes. Iatrogenic causes, trauma, and the widespread use of urethral catheters. Most bulbar idiopathic strictures are the main causes in the world urethral injuries caused by riding injuries are serious, today [9]. The bulbar urethra is the most common site and these sometimes may even form armor scars around of anterior urethral stricture formation. Currently, if the the narrow urethra. Compared with urethral strictures length of a stricture exceeds 1.0  cm, intraurethral inci- caused by riding injury, the stenosis distance of patients sion should not be used for treatment, and open surgery with iatrogenic urethral strictures is shorter, and the should be used for bulbar urethral reconstruction, and associated scarring may also be less severe [12]. this may be associated with clinical benefits in improving Traditional end-to-end bulbar urethral anastomosis is postoperative urination status [10, 11]. performed with one-stage anastomosis after the removal In addition to riding injuries, which have been con- of spongy fibrosis and the narrowed urethra. For urethral sidered the most common causes of bulbar urethral Le  et al. Basic and Clinical Andrology (2023) 33:12 Page 7 of 9 strictures caused by riding injury, the urethral stricture for urethral reconstruction and has also been associated segment is long and the fibrosis is severe. Therefore, tra - with favorable clinical outcomes [18]. ditional bulbar urethral end-to-end anastomosis with However, it must be pointed out that due to oral sam- corpus spongiosum transection is an effective method for pling, especially sampling of the lingual mucosa, this the treatment of this kind of stricture. However, a major method can greatly impact psychological well-being and disadvantage of the traditional end-to-end anastomosis postoperative lingual sensation, motor function, and is that the urethra must be completely transected, which speech expression, and inevitably lead to certain negative may impair the penis blood supply and innervation [5]. results for patients’ postoperative rehabilitation. Based Previous reports have shown that corpus spongiosum on these findings, we explored whether non-transecting dissection has no significant negative impact on erectile urethral surgery could be a routine treatment option function [6]. However, surgical cutting of nerve fibers or beneficial supplement for iatrogenic bulbar urethral traveling along the urethra can reduce the sensitivity of strictures. the glans and distal penis and lead to ejaculation dysfunc- At present, few published studies have compared the tion that may affect sexual activity [6]. Preservation of the clinical outcomes of non-transecting urethroplasty with distal urethral blood supply has also been shown to be lingual mucosal urethroplasty. Therefore, in this study, crucial in the treatment of multiple penile urethral stric- patients with bulbar urethral strictures were enrolled to tures [7]. receive either of two surgical procedures, and their prog- Based on the above evidence, some scholars proposed a noses and a series of clinical variables were analyzed. surgical method that does not require the complete tran- Urethroplasty takes a long time it requires the removal section of the corpus spongiosum [13, 14]. This operation free tissue, but there was no difference in intraoperative can maximize the preservation of blood supply to the blood loss between the two methods. Our results sug- distal corpus spongiosum. Theoretically, it is possible to gested that the time required for non-transecting sur- reduce the risk of postoperative erectile dysfunction or gery is shorter than that required for lingual mucoplasty. glans ischemia by minimizing penile blood supply inter- In terms of the recovery of postoperative urinary func- ruption (due to urethral disconnection) and preserving tion, although one patient in each group had difficulty the bulbar artery, which is conducive to follow-up ure- urinating after removal of the catheter, the rest of the thral intervention; this technique has been performed in patients underwent successful surgery, associated with some clinical centers. satisfactory postoperative urinary function, according to Most patients with iatrogenic bulbar urethral stric- postoperative urethrography. There was no significant tures have relatively short stenotic segments, and associ- difference in mean postoperative Qmax between the two ated scarring may also be less severe; in such cases, only surgical methods, suggesting that the non-transecting the stenotic part of the urethra and surrounding spongy surgical method is also associated with favorable urinary fibrosis need to be removed for treatment. Therefore, outcomes. non-transecting urethroplasty for the treatment of iat- We also conducted a follow-up analysis of sexual well- rogenic bulbar urethral strictures has good theoretical being. Via NPTR testing, we found that tip hardness in feasibility. Our center has also carried out non-tran- patients in the non-transecting urethroplasty group secting urethral surgery for treating urethral strictures showed a decreasing (non-significant) trend postopera - at the bulbar membrane, and the results suggest that, tively. In contrast, in the lingual mucosal urethroplasty compared with traditional end-to-end anastomosis, this group, tip hardness decreased significantly after surgery. method has certain advantages during the perioperative These results suggest that the non-transecting operation period and in terms of postoperative rehabilitation indi- may have a certain protective effect on the postoperative cators [15]. sexual function of patients with bulbar urethral stric- In China, free graft replacement urethroplasty is also tures. However, the results need to be further clarified an option for the treatment of bulbar urethral strictures. with larger-scale studies and clinical trials (e.g., ICI papa- The lingual mucosal epithelium is thick and rich in elas - verine sponge injection with penile Doppler ultrasound). tic fibers, and the lamella propria is thin and tough. The The IIEF-5 scale was also used to observe that there tissue has good elasticity and antimicrobial properties, was a downward trend in postoperative indices in both which makes it suitable for survival in a wet environ- groups, with differences between preoperative and post - ment. Therefore, this procedure is also used in the clini - operative mean scores. A possible explanation is that the cal treatment of long urethral strictures [16, 17]. The pain of the surgical incision, the discomfort of the oral lingual mucosa is relatively convenient for sampling, and cavity, and the psychological effects on patients have a adult tongue mucosa samples can be as large as 6  cm × certain negative impact on erectile function, which will 2 cm on one side. Bilateral sampling can yield more tissue affect sexual health. At the same time, our SAS evaluation Le et al. Basic and Clinical Andrology (2023) 33:12 Page 8 of 9 Funding may also confirm that postoperative anxiety normally This project is supported by Shanghai Science and Technology Commission exists in patients undergoing lingual mucosal urethro- project (No.: 20Y11904400), Shanghai Natural Science Foundation of China plasty, which may be associated with abnormal postop- (No.: 19ZR1448700), and National Natural Science Foundation of China (No.: 82001610). erative mastication and speech function. In contrast, postoperative anxiety improved significantly in patients Availability of data and materials who underwent non-transecting urethroplasty. How- The datasets used and analysed during the current study are available from the corresponding author on reasonable request. ever, conclusions regarding the long-term psychological rehabilitation and mood state of postoperative patients Declarations require long-term follow-up evaluation and multidimen- sional psychological evaluations. Ethics approval and consent to participate In conclusion, urethral anastomotic repair with vascu- The study was approved by the Ethics Committee Board of Tongji Hospital Affiliated to Tongji University (NO. K-KYSB-2020-149). lar preservation has certain functional advantages com- pared with traditional disconnection anastomotic repair Consent for publication for treating iatrogenic bulbar urethral strictures. Lingual Not applicable. mucosal urethroplasty is an invasive procedure, with sur- Competing interests gical trauma having implications on the rehabilitation of The authors declare that they have no competing interests. patients’ psychological health and speech function. We Author details conducted a systematic study on the treatment of iat- Department of Urology, Tongji Hospital, Tongji University School of Medicine, rogenic bulbar urethral strictures via non-transecting 200065 Shanghai, China. urethroplasty and lingual mucosal urethroplasty. To our Received: 29 September 2022 Accepted: 8 January 2023 knowledge, no reports exist of such a comparison, so this study is novel. Our study findings suggest that non- transecting urethral surgery takes less time and can be associated with favorable urinary outcomes. Moreover, References postoperative NPTR findings suggests that a considerable 1. Barratt R, Chan G, La Rocca R, Dimitropoulos K, Martins FE, Campos- number of patients can retain their original sexual func- Juanatey F, et al. Free graft augmentation urethroplasty for Bulbar Urethral Strictures: which technique is best? A systematic review. Eur Urol. tion, suggesting that this surgical method has a protective 2021;80(1):57–68. effect on sexual function. Additionally, the non-transect - 2. Lumen N, Hoebeke P, Willemsen P, De Troyer B, Pieters R, Oosterlinck ing urethroplasty group may have certain advantages in W. Etiology of urethral stricture disease in the 21st century. 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Non-transecting anastomotic bulbar urethro- plasty: a preliminary report. BJU Int. 2012;109(7):1090–4. 6. Barbagli G, De Angelis M, Romano G, Lazzeri M. Long-term followup of Abbreviations bulbar end-to-end anastomosis: a retrospective analysis of 153 patients T Preoperative androgen in a single center experience. J Urol. 2007;178(6):2470–3. E2 Estradiol 7. Lv X, Xu YM, Xie H, Feng C, Zhang J. The selection of procedures in PRL Prolactin one-stage Urethroplasty for treatment of coexisting urethral strictures in NPTR Nocturnal penile tumescence and rigidity anterior and posterior urethra. Urology. 2016;93:197–202. Qmax Maximum urine flow rate 8. Virasoro R, DeLong JM. Non-transecting bulbar urethroplasty is favored IIEF-5 I nternational Index of Erectile Function over transecting techniques. World J Urol. 2020;38(12):3013–8. SAS Anxiet y score scale 9. Wessells H, Angermeier KW, Elliott S, Gonzalez CM, Kodama R, Peterson AC, et al. Male urethral stricture: american Urological Association Guide- Acknowledgements line. J Urol. 2017;197(1):182–90. We sincerely thank Professor Xu YM of Shanghai Sixth People’s Hospital for his 10. Hillary CJ, Osman NI, Chapple CR. Current trends in urethral stricture support and guidance of this study. management. Asian J Urol. 2014;1(1):46–54. 11. Kuo TL, Venugopal S, Inman RD, Chapple CR. Surgical tips and tricks Authors’ contributions during urethroplasty for bulbar urethral strictures focusing on accurate Conception and design: Chao Li, Denglong Wu; administrative support: localisation of the stricture: results from a tertiary centre. Eur Urol. Denglong Wu; provision of study materials or patients: Wei Le, Chengdang Xu; 2015;67(4):764–70. collection and assembly of data: Chengdang Xu, Weidong Zhou; data analysis 12. Zhou SK, Zhang J, Sa YL, Jin SB, Xu YM, Fu Q, et al. Etiology and manage- and interpretation: Wei Le, Chengdang Xu; manuscript writing: all authors; ment of male iatrogenic urethral stricture: retrospective analysis of 172 final approval of manuscript: all authors. cases in a single Medical Center. Urol Int. 2016;97(4):386–91. Le  et al. Basic and Clinical Andrology (2023) 33:12 Page 9 of 9 13. Jordan GH, Eltahawy EA, Virasoro R. The technique of vessel sparing exci- sion and primary anastomosis for proximal bulbous urethral reconstruc- tion. J Urol. 2007;177(5):1799–802. 14. Lumen N, Poelaert F, Oosterlinck W, Lambert E, Decaestecker K, Tailly T, et al. Nontransecting Anastomotic Repair in Urethral Reconstruction: Surgical and Functional Outcomes. J Urol. 2016;196(6):1679–84. 15. Le W, Li C, Zhang J, Wu D, Liu B. Preliminary clinical study on non- transecting anastomotic bulbomembranous urethroplasty. Front Med. 2017;11(2):277–83. 16. Sharma AK, Chandrashekar R, Keshavamurthy R, Nelvigi GG, Kamath AJ, Sharma S, et al. Lingual versus buccal mucosa graft urethroplasty for anterior urethral stricture: a prospective comparative analysis. Int J Urol. 2013;20(12):1199–203. 17. Xu YM, Xu QK, Fu Q, Sa YL, Zhang J, Song LJ, et al. Oral complications after lingual mucosal graft harvesting for urethroplasty in 110 cases. BJU Int. 2011;108(1):140–5. 18. Xu YM, Li C, Xie H, Sa YL, Fu Q, Wu DL, et al. Intermediate-Term Outcomes and Complications of Long Segment Urethroplasty with Lingual Mucosa Grafts. J Urol. 2017;198(2):401–6. Publisher’s Note Springer Nature remains neutral with regard to jurisdictional claims in pub- lished maps and institutional affiliations. Re Read ady y to to submit y submit your our re researc search h ? Choose BMC and benefit fr ? 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Study on clinical outcomes between non-transecting urethroplasty and lingual mucosal urethroplasty for iatrogenic bulbar urethral stricture treatment

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Abstract

Background This study aimed to compare the clinical outcomes of non-transecting urethroplasty and lingual mucosal urethroplasty in the treatment of iatrogenic bulbar urethral stricture. Results A total of 25 patients with iatrogenic bulbar urethral stricture were enrolled, 12 of whom underwent lingual mucosal urethroplasty, 13 patients who underwent non-transecting urethroplasty. All patients were followed-up and evaluated at 3 postoperative months. Evaluations included urethrography, maximum urine flow rate (Qmax), noc- turnal erectile function testing, International Index of Erectile Function (IIEF-5) assessment, and Anxiety Related Scale (SAS) assessment. In terms of operation time, there was a significant difference between non-transecting urethro - plasty and lingual mucosal urethroplasty. However, there was no significant intergroup difference in intraoperative blood loss. Both techniques were associated with significantly improved Qmax relative to preoperative rates, but there was no significant difference between the groups in this regard over 3 months of postoperative follow-up. Nocturnal penile tumescence and rigidity results showed that there was no significant change in tip hardness after surgery in the non-transecting urethroplasty group. Moreover, IIEF-5 scores indicated that there was no significant intergroup difference in terms of subjective postoperative erectile function. According to the preliminary psychological evalua- tions during postoperative follow-up, the anxiety scores of patients undergoing non-transecting urethroplasty signifi- cantly improved, but there was no significant change in the mean SAS score among patients who underwent lingual mucosal urethroplasty. Conclusion Both surgical methods can achieve the clinical goal of treating iatrogenic bulbar urethral stricture. Non- transecting urethroplasty has the characteristics of short operation time, relative technical simplicity, and retention of the original erectile function of most patients, and the surgical outcomes of non-transecting urethroplasty are not inferior to those of lingual mucosal urethroplasty, and it is a promising technique for widespread use to treat bulbar urethral strictures. Keywords Bulbar urethral stricture, Iatrogenic, Urethral reconstruction, Non-transecting urethroplasty Wei Le and Chengdang Xu contributed equally to this work and are considered co-first authors. *Correspondence: Chao Li chaoli1979@126.com Full list of author information is available at the end of the article © The Author(s) 2023. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat iveco mmons. org/ licen ses/ by/4. 0/. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons. org/ publi cdoma in/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Le et al. Basic and Clinical Andrology (2023) 33:12 Page 2 of 9 Résumé Contexte Cette étude visait à comparer les résultats cliniques de l’urétroplastie non transectante et de l’urétroplastie avec greffe de muqueuse linguale dans le traitement de la sténose urétrale bulbaire iatrogène. Un total de 25 patients présentant une sténose urétrale bulbaire iatrogène a été recruté, dont 12 ont subi une urétroplastie avec greffe de muqueuse buccale et 13 une urétroplastie non-transectante. Tous les patients ont été suivis et évalués à 3 mois posto- pératoires. Les évaluations comprenaient une uréthrographie, le débit urinaire maximal (Qmax), un test nocturne de la fonction érectile, l’évaluation de l’index international de la fonction érectile (IIEF5) et une évaluation de l’échelle d’anxiété. Résultats En termes de durée opératoire, il y avait une différence significative entre l’urétroplastie non-transectante et urétroplastie avec greffe de muqueuse buccale. Cependant, il n’y avait pas de différence significative entre les groupes en ce qui concerne la perte de sang peropératoire. Les deux techniques ont été associées à une améliora- tion significative du Qmax par rapport aux taux préopératoires, mais il n’y avait pas de différence significative entre les groupes à cet égard sur 3 mois de suivi postopératoire. Les résultats de la tumescence et de la rigidité nocturnes du pénis ont montré qu’il n’y avait pas de changement significatif de la dureté de l’extrémité du pénis après l’opération dans le groupe d’urétroplastie sans transsection. De plus, les scores IIEF-5 ont indiqué qu’il n’y avait pas de différence significative entre les groupes en termes de fonction érectile subjective postopératoire. Selon les évaluations psy- chologiques préliminaires au cours du suivi postopératoire, les scores d’anxiété des patients ayant subi une urétro- plastie non-transectante se sont améliorés de manière significative, mais il n’y a pas eu de changement significatif du score moyen de l’échelle d’anxiété chez les patients ayant subi une urétroplastie avec greffe de muqueuse buccale. Conclusions Les deux méthodes permettent d’atteindre l’objectif clinique du traitement de la sténose urétrale bulbaire iatrogène. L’urétroplastie sans transsection présente les caractéristiques suivantes: temps d’opération court, simplicité technique relative et maintien de la fonction érectile initiale chez la plupart des patients. Les résultats chi- rurgicaux de l’urétroplastie sans transsection ne sont pas inférieurs à ceux de l’urétroplastie avec greffe de muqueuse buccale et cette technique est prometteuse pour une utilisation généralisée dans le traitement des rétrécissements urétraux bulbaires. Mots‑clés Sténose urétrale bulbaire, Iatrogène, Reconstruction urétrale, Urétroplastie sans transsection Background urethral strictures is to use free oral mucosa to replace The treatment of bulbar urethral strictures is a compli - the urethra. The main surgical techniques include buc - cated clinical problem [1]. In addition to riding injury, cal mucosal or lingual mucosal urethral reconstruction iatrogenic factors (such as intravenous catheterization, [3, 4]. Free lingual mucosa is widely used for major ure- minimally invasive transurethral surgery (such as TURP, thral reconstruction centers in China. When the lingual TURBT, ureteroscopy and lithotripsy) are among the mucosa is extracted by this method, surgical trauma is common causes of bulbar urethral strictures [2]. inflicted on the tongue. This affects postoperative lingual Most bulbar urethral strictures caused by riding inju- sensory and motor activity and (consequently) speech. ries are serious, and sometimes they may even form Many patients will feel apprehensive about these compli- armor scars around narrow urethras. Compared with cations and will find it difficult to consent to undergoing urethral strictures caused by riding injury, iatrogenic ure- such procedures. thral strictures are associated with shorter narrow seg- Although traditional bulbar urethral end-to-end anas- ments and less scarring. tomosis has a high success rate, the corpus spongiosum Endoscopic urethral incision for urethral strictures needs to be completely transected before anastomosis, longer than 1  cm is often unsatisfactory, and open ure- and this extensive surgical trauma may damage the blood throplasty is often required. There are many open surgi - supply and innervation to the patient’s bulbar corpus cal methods available for the treatment of bulbar urethral spongiosum [5], potentially causing a series of complica- strictures. Commonly used surgical methods include free tions and adverse outcomes, including impaired sexual mucous membrane replacement urethroplasty techniques, function [6, 7]. such as those that use mucous membrane from the oral In view of this problem, some scholars have proposed cavity, as well as bulbar urethral end-to-end anastomosis. and applied the surgical method of urethral spongiform In many domestic urethral reconstruction cent- non-transecting anastomosis to treat bulbar urethral ers, the popular surgical approach to treating bulbar strictures, which can achieve better clinical outcomes [8]. Le  et al. Basic and Clinical Andrology (2023) 33:12 Page 3 of 9 To our knowledge, no published studies have com- Preoperative preparation pared the clinical outcomes of non-transecting urethro- The presence of bulbar urethral stricture was confirmed plasty with those of lingual mucosal urethroplasty. We by urethrography and soft cystoscopy, and the length of attempted to treat iatrogenic bulbar urethral strictures the urethral stricture was estimated by urethrography. with non-transecting urethroplasty, and we compared Antibiotic therapy, maximum urine flow rate (Qmax) bulbar urethral reconstruction with lingual mucosal ure- testing, and International Index of Erectile Function throplasty. By comparing clinical variables and patient (IIEF-5) assessments were administered before surgery, outcomes associated with the two surgical procedures, and patients with normal urinary function and negative we evaluated whether non-transecting urethroplasty urine culture results were considered suitable for surgery. could be used as a routine treatment option or a benefi - cial supplement for treating iatrogenic bulbar urethral Operative techniques strictures. Overall, we evaluated the technique’s value Lingual mucosal urethroplasty in the clinical treatment of iatrogenic bulbar urethral (1) An inverted “Y” incision was made at the perineum strictures. (2). Then the bulbar corpus spongiosum was separated (3). A urethral dilator was inserted into the anterior urethra to locate the position of the urethral stric- Methods ture and longitudinally open the stenosed segment to All study data were collected from 25 patients with bul- the extent of the normal distal and proximal urethral bar urethral stricture in Tongji Hospital, which is affili - urethral mucosa (4). With the goal of maintaining the ated with Tongji University, from 2010 to 2021. The study corpus spongiosum’s continuity, the rigid scar tissue was conducted in accordance with the Declaration of constituting the urethral stricture was removed, and Helsinki (as revised in 2013). The study was approved by the urethral incision length was measured (5). Then the the Ethics Committee Board of Tongji Hospital Affiliated patient’s oral cavity was cleaned and disinfected. After to Tongji University (NO. K-KYSB-2020-0) and individ- the tongue tip was pulled and marked with a marker, ual consent for this retrospective analysis was waived. an incision, about 2 cm in width, was made. The length of the incision was determined according to the length of urethral incision, and the excised mucosa was used Patient data for ventral onlay reconstruction of the bulbar urethra. In our patients who chose to undergo non-truncating If the stenosis was severe, the length of tongue mucosa urethroplasty, the strictures were all less than 2  cm removed was equivalent to about twice the length of in length, and the distal urethra was separated as it the resected urethra, and the dorsal inlay combined approached the root of the penis to increase ure- with the ventral onlay was used to reconstruct the bul- thral freedom and reduce anastomotic tension. The bar urethra. The excised lingual mucosa was placed in inclusion criteria were as follows: (1) bulbar ure- ice-cooled normal saline to prune the tissue (6). The thral stricture caused by various iatrogenic factors; free lingual mucosal tissue was dissected into the bul- (2) the presence of bulbar urethral stricture indi- bar urethra, and the bulbar urethra was reconstructed cated by preoperative urethrography and soft cys- using the ventral onlay method. If the stenosis was toscopy; (3) the length of the stenosis was < 2  cm; (4) severe, the bulbar urethra was reconstructed using the patients aged 15–50 years; (5) preoperative andro- dorsal inlay method combined with the ventral onlay gen (T), estradiol (E2), and prolactin (PRL) levels method. Finally, (7) an indwelling 18 F silicone catheter within the normal range; and (6) no penile blood flow was inserted (Fig.  1), and (8) the incision was closed reduction diagnosed by preoperative penile Doppler layer by layer. ultrasonography. The exclusion criteria are as follows: (1) congenital Non‑transecting urethroplasty urethral stricture; (2) patients with urethral stricture Steps (1), (2), (3)  and (4)  are the same as those for lin- aged < 15 years or > 60 years; (3) complex urethral stric- gual mucosal urethroplasty [5]. After the proximal and ture—for example, the length of the stricture was ≥ 2  cm distal urethra was sutured intermittently at points 1, 2, or more than two urethral strictures were observed; (4) 4, and 5 in the lithotomy position, an indwelling 18  F patients with a history of two or more procedures involv- silicone catheter was inserted, and then the proximal ing urethral incisions; (5) patients with severe erectile and distal urethra was sutured at points 7, 8, 10, and dysfunction (penile head hardness < 20% detected by 11 [6]. All sutures were tightened to bring the proxi- preoperative nocturnal penile tumescence and rigidity mal and distal urethra close together, and each suture (NPTR) evaluation; and (6) patients with abnormal sex was tied separately to complete urethral anastomosis in hormone levels. Le et al. Basic and Clinical Andrology (2023) 33:12 Page 4 of 9 Fig. 1 Preoperative and postoperative urethrography and surgical procedures of the two surgical methods. Bulbar corpus spongiosum non- transecting urethroplasty: A Preoperative urethrography: bulbar urethral stricture; B Dissociate and split the narrow urethra to expose the distal and distal normal urethra mucosa; C 3 − 0 absorbable suture of proximal urethral mucosa and indwelling catheter; D 3 − 0 suture the proximal end of absorbable line with the distal urethral mucosa; E Tighten and tie the distal and distal urethral mucosal sutures; F Postoperative urethrography: the lumen of the bulbar urethra was unobstructed without stenosis lingual mucosal bulbous urethroplasty: G Preoperative urethrography: bulbar urethral stricture; H Dissociate and split the narrow urethra to expose the distal and distal normal urethral mucosa; I The mucous membrane of the tongue was taken and trimmed; J Urethra was dissected and the lingual mucosa Inlay was used to reconstruct the dorsal urethra; K Urethra was dissected and the lingual mucosa Onlay was used to reconstruct the ventral urethra; L Postoperative urethrography: the lumen of the bulbar urethra was unobstructed without stenosis Evaluation of postoperative sexual function–related the context of a corpus spongiosum that has not been indicators resected [7]. The outer corpus spongiosum of the ure - Three months postoperatively, erectile function–related thral anastomosis was reinforced and sutured again assessments (NPTR and IIEF-5) were conducted, and noc- with 3 − 0 absorbable suture (Fig.  1) [8]. The incision turnal erectile hardness was further analyzed using penile was closed layer by layer. TIP data. The Rigiscan testing instrument usually measures the erectile hardness of the head of the penis (TIP) and the Operative time and intraoperative blood loss root of the penis (BASE) while the patient is sleeping to Surgical data of the two groups were collected, includ- reflect the patient’s true level of erectile function. Accord - ing surgical time and estimated blood loss. Surgical time ing to the current internationally recognized reference was the time from the beginning of the operation (skin ranges, patients with tip hardness below 60% were con- incision) to the end of surgery (skin closure). The amount sidered to have organic erectile dysfunction. At the same of intraoperative blood loss was estimated by measuring time of NPTR measurement, IIEF-5 scale analysis was per- the difference between the amount of blood collected by formed, and the scores obtained were statistically analyzed. an intraoperative negative-pressure suction device and the weight of preoperative and postoperative hemostatic gauze. Statistical analysis PASW Statistics for Windows, version 18.0 (SPSS Inc. Chicago, IL, USA) was used to run independent-sam Postoperative treatment and follow‑up - All patients received prophylactic antibiotics for about ples t-tests and paired t-tests for preoperative and post- 1 week. Catheters were removed after 3 postoperative operative Qmax, IIEF-5 scores, and NPRT data. A P value < 0.05 was considered statistically significant. weeks, and urethrography was performed 1 month later. Follow-up criteria were mainly assessed by preoperative and postoperative differences in NPT, IIEF-5 scores and Results psychological status. The criterion for recurrence of post - Operation and postoperative urinary outcomes operative urethral stricture was a urinary flow rate < 15 There was one patient in each group with progressive ml/s. dysuria after removal of the catheter. The patient who Le  et al. Basic and Clinical Andrology (2023) 33:12 Page 5 of 9 patients, throughout follow-up, urethrography indicated that the original urethral stricture was cured and that the urethra was smooth (Fig. 1). The mean postoperative Qmax indices associated with the two techniques signifi - cantly improved between preoperative and postoperative assessments (lingual mucosal urethroplasty, 17.16 ± 5.11 ml/s vs. 5.58 ± 3.73 ml/s; non-transecting urethroplasty, 16.92 ± 4.53 ml/s vs. 5.54 ± 3.36 ml/s). In terms of post- operative Qmax, there was no significant difference between the two groups (p > 0.05) (Fig. 2). Surgical indicators The mean operative time associated with lingual mucosal urethroplasty was 135 ± 24.67  min; the mean operation time associated with non-transecting urethroplasty was 100.69 ± 14.48  min, and this difference was statistically significant (Fig. 3 A). Fig. 2 Changes in parameters of maximum postoperative urine flow The mean intraoperative blood loss was 180 ± 47.16 ml rate between the two surgical methods. Qmax of the two surgical in the lingual mucosal urethroplasty group, compared methods was significantly improved after catheter removal, but there with 149.2 ± 25.55 ml associated with non-transecting was no significant statistical difference in Qmax parameters between urethroplasty; this difference was not statistically signifi - the two groups after catheter removal (NS: compared with the lingual mucosal urethral surgery group, P > 0.05) cant (Fig. 3B). Postoperative sexual function evaluation failed lingual mucosal urethroplasty has been regularly At the 3-months follow-up point after surgery, the mean treated with urethral dilation to date, and the patient NPTR rating for the lingual mucosal urethroplasty group from the non-transecting urethroplasty group under- was 42.91 ± 15.33% compared with 56.67 ± 9.42% before went a second open surgery (resection of the lower pubic surgery (p < 0.05). The corresponding outcomes for the margin, resection of urethral stricture, and end-to-end non-transecting urethroplasty group were 51.92 ± 9.91% urethral anastomosis) 6 months after the initial opera- after surgery vs. 56.15 ± 6.25% before surgery (p > 0.05). tion; the catheter was removed 3 weeks after the second There was no significant difference in tip hardness operation, and the urine flow was good. For all other parameters between the groups (p > 0.05) (Fig. 4 A, B). Fig. 3 Comparison of operative time and intraoperative blood loss between the two surgical methods. A Operative time of the two surgical methods. The operative time of lingual mucosa urethroplasty was 135 ± 24.67 min; The operation time of non- transecting urethroplasty was 100.69 ± 14.48 min, and the operation time of non- transecting urethroplasty was shorter, with statistical difference (*: compared with the lingual mucosal urethral surgery group, P < 0.05). B Comparison of intraoperative blood loss between the two surgical methods. Intraoperative blood loss during lingual mucosal urethroplasty was 180 ± 47.16ml, the intraoperative blood loss during non- transecting urethroplasty was 149.2 ± 25.55ml, and there was no statistical difference between the two groups (NS: compared with the lingual mucosal urethral surgery group, P > 0.05) Le et al. Basic and Clinical Andrology (2023) 33:12 Page 6 of 9 Fig. 4 Penile tip hardness values of Post-operative NPTR analysis and IIEF-5 score results between the two surgical methods. A Penile head hardness values of Post-operative NPTR analysis. It showed a downward trend in TIP hardness values of the two different surgical methods, but there was no statistical difference in TIP hardness values of the non- transecting urethra group. There was statistically significant difference in the hardness decrease of the lingual mucosa group, but there was no statistically significant difference in the penile head hardness between the two groups after surgery. B IIEF-5 score results. Follow-up results 3 months after surgery indicated that iIEF-5 value decreased in both the lingual mucosa group and the non- transecting group, and the decrease was statistically significant (P < 0.05). There was no significant difference in IIEF-5 score between the two groups during postoperative follow-up (P > 0.05) In the lingual mucosal urethroplasty group the mean was IIEF-5 score was 19.91 ± 1.89 before surgery vs. 16.67 ± 2.98 after surgery (p < 0.05). The mean scores for the non-transecting urethroplasty group were 20.53 ± 1.59 and 18.53 ± 3.47, respectively (p < 0.05). There was no significant difference in mean IIEF-5 scores betwen the two groups during postoperative fol- low-up (p > 0.05) (Fig . 4 C). Preliminary evaluation results of postoperative psychological state The mean statistics of anxiety score scale (SAS) for patients in the non-transecting urethroplasty group sig- Fig. 5 Postoperative anxiety psychological evaluation results of the nificantly improved 3 months after surgery (62.59 ± 14.18 two surgical methods. According to the follow-up of SAS anxiety before surgery vs. 54.13 ± 12.97 after surgery, p < 0.05). score, the results showed that the postoperative anxiety SAS score of There was no significant change in the mean SAS score the non- transecting surgery group significantly decreased; There was no significant difference in the anxiety score of the lingual mucosa after surgery in the lingual mucosal urethroplasty surgery group (P > 0.05), although the mean value was decreased. group (preoperative 67.18 ± 13.06 vs. postoperative There was no significant difference in SAS score between two groups 63.75 ± 10.05, p > 0.05). There was no significant dif - after operation (P > 0.05) ference in node SAS scores between the two groups 3 months after surgery (p > 0.05) (Fig. 5). strictures, the incidence of iatrogenic bulbar urethral Discussion strictures is increasing with the increasing popularity of Urethral stricture is still a common problem, which can various minimally invasive transurethral operations and arise from various causes. Iatrogenic causes, trauma, and the widespread use of urethral catheters. Most bulbar idiopathic strictures are the main causes in the world urethral injuries caused by riding injuries are serious, today [9]. The bulbar urethra is the most common site and these sometimes may even form armor scars around of anterior urethral stricture formation. Currently, if the the narrow urethra. Compared with urethral strictures length of a stricture exceeds 1.0  cm, intraurethral inci- caused by riding injury, the stenosis distance of patients sion should not be used for treatment, and open surgery with iatrogenic urethral strictures is shorter, and the should be used for bulbar urethral reconstruction, and associated scarring may also be less severe [12]. this may be associated with clinical benefits in improving Traditional end-to-end bulbar urethral anastomosis is postoperative urination status [10, 11]. performed with one-stage anastomosis after the removal In addition to riding injuries, which have been con- of spongy fibrosis and the narrowed urethra. For urethral sidered the most common causes of bulbar urethral Le  et al. Basic and Clinical Andrology (2023) 33:12 Page 7 of 9 strictures caused by riding injury, the urethral stricture for urethral reconstruction and has also been associated segment is long and the fibrosis is severe. Therefore, tra - with favorable clinical outcomes [18]. ditional bulbar urethral end-to-end anastomosis with However, it must be pointed out that due to oral sam- corpus spongiosum transection is an effective method for pling, especially sampling of the lingual mucosa, this the treatment of this kind of stricture. However, a major method can greatly impact psychological well-being and disadvantage of the traditional end-to-end anastomosis postoperative lingual sensation, motor function, and is that the urethra must be completely transected, which speech expression, and inevitably lead to certain negative may impair the penis blood supply and innervation [5]. results for patients’ postoperative rehabilitation. Based Previous reports have shown that corpus spongiosum on these findings, we explored whether non-transecting dissection has no significant negative impact on erectile urethral surgery could be a routine treatment option function [6]. However, surgical cutting of nerve fibers or beneficial supplement for iatrogenic bulbar urethral traveling along the urethra can reduce the sensitivity of strictures. the glans and distal penis and lead to ejaculation dysfunc- At present, few published studies have compared the tion that may affect sexual activity [6]. Preservation of the clinical outcomes of non-transecting urethroplasty with distal urethral blood supply has also been shown to be lingual mucosal urethroplasty. Therefore, in this study, crucial in the treatment of multiple penile urethral stric- patients with bulbar urethral strictures were enrolled to tures [7]. receive either of two surgical procedures, and their prog- Based on the above evidence, some scholars proposed a noses and a series of clinical variables were analyzed. surgical method that does not require the complete tran- Urethroplasty takes a long time it requires the removal section of the corpus spongiosum [13, 14]. This operation free tissue, but there was no difference in intraoperative can maximize the preservation of blood supply to the blood loss between the two methods. Our results sug- distal corpus spongiosum. Theoretically, it is possible to gested that the time required for non-transecting sur- reduce the risk of postoperative erectile dysfunction or gery is shorter than that required for lingual mucoplasty. glans ischemia by minimizing penile blood supply inter- In terms of the recovery of postoperative urinary func- ruption (due to urethral disconnection) and preserving tion, although one patient in each group had difficulty the bulbar artery, which is conducive to follow-up ure- urinating after removal of the catheter, the rest of the thral intervention; this technique has been performed in patients underwent successful surgery, associated with some clinical centers. satisfactory postoperative urinary function, according to Most patients with iatrogenic bulbar urethral stric- postoperative urethrography. There was no significant tures have relatively short stenotic segments, and associ- difference in mean postoperative Qmax between the two ated scarring may also be less severe; in such cases, only surgical methods, suggesting that the non-transecting the stenotic part of the urethra and surrounding spongy surgical method is also associated with favorable urinary fibrosis need to be removed for treatment. Therefore, outcomes. non-transecting urethroplasty for the treatment of iat- We also conducted a follow-up analysis of sexual well- rogenic bulbar urethral strictures has good theoretical being. Via NPTR testing, we found that tip hardness in feasibility. Our center has also carried out non-tran- patients in the non-transecting urethroplasty group secting urethral surgery for treating urethral strictures showed a decreasing (non-significant) trend postopera - at the bulbar membrane, and the results suggest that, tively. In contrast, in the lingual mucosal urethroplasty compared with traditional end-to-end anastomosis, this group, tip hardness decreased significantly after surgery. method has certain advantages during the perioperative These results suggest that the non-transecting operation period and in terms of postoperative rehabilitation indi- may have a certain protective effect on the postoperative cators [15]. sexual function of patients with bulbar urethral stric- In China, free graft replacement urethroplasty is also tures. However, the results need to be further clarified an option for the treatment of bulbar urethral strictures. with larger-scale studies and clinical trials (e.g., ICI papa- The lingual mucosal epithelium is thick and rich in elas - verine sponge injection with penile Doppler ultrasound). tic fibers, and the lamella propria is thin and tough. The The IIEF-5 scale was also used to observe that there tissue has good elasticity and antimicrobial properties, was a downward trend in postoperative indices in both which makes it suitable for survival in a wet environ- groups, with differences between preoperative and post - ment. Therefore, this procedure is also used in the clini - operative mean scores. A possible explanation is that the cal treatment of long urethral strictures [16, 17]. The pain of the surgical incision, the discomfort of the oral lingual mucosa is relatively convenient for sampling, and cavity, and the psychological effects on patients have a adult tongue mucosa samples can be as large as 6  cm × certain negative impact on erectile function, which will 2 cm on one side. Bilateral sampling can yield more tissue affect sexual health. At the same time, our SAS evaluation Le et al. Basic and Clinical Andrology (2023) 33:12 Page 8 of 9 Funding may also confirm that postoperative anxiety normally This project is supported by Shanghai Science and Technology Commission exists in patients undergoing lingual mucosal urethro- project (No.: 20Y11904400), Shanghai Natural Science Foundation of China plasty, which may be associated with abnormal postop- (No.: 19ZR1448700), and National Natural Science Foundation of China (No.: 82001610). erative mastication and speech function. In contrast, postoperative anxiety improved significantly in patients Availability of data and materials who underwent non-transecting urethroplasty. How- The datasets used and analysed during the current study are available from the corresponding author on reasonable request. ever, conclusions regarding the long-term psychological rehabilitation and mood state of postoperative patients Declarations require long-term follow-up evaluation and multidimen- sional psychological evaluations. Ethics approval and consent to participate In conclusion, urethral anastomotic repair with vascu- The study was approved by the Ethics Committee Board of Tongji Hospital Affiliated to Tongji University (NO. K-KYSB-2020-149). lar preservation has certain functional advantages com- pared with traditional disconnection anastomotic repair Consent for publication for treating iatrogenic bulbar urethral strictures. Lingual Not applicable. mucosal urethroplasty is an invasive procedure, with sur- Competing interests gical trauma having implications on the rehabilitation of The authors declare that they have no competing interests. patients’ psychological health and speech function. We Author details conducted a systematic study on the treatment of iat- Department of Urology, Tongji Hospital, Tongji University School of Medicine, rogenic bulbar urethral strictures via non-transecting 200065 Shanghai, China. urethroplasty and lingual mucosal urethroplasty. To our Received: 29 September 2022 Accepted: 8 January 2023 knowledge, no reports exist of such a comparison, so this study is novel. Our study findings suggest that non- transecting urethral surgery takes less time and can be associated with favorable urinary outcomes. Moreover, References postoperative NPTR findings suggests that a considerable 1. Barratt R, Chan G, La Rocca R, Dimitropoulos K, Martins FE, Campos- number of patients can retain their original sexual func- Juanatey F, et al. Free graft augmentation urethroplasty for Bulbar Urethral Strictures: which technique is best? A systematic review. Eur Urol. tion, suggesting that this surgical method has a protective 2021;80(1):57–68. effect on sexual function. Additionally, the non-transect - 2. Lumen N, Hoebeke P, Willemsen P, De Troyer B, Pieters R, Oosterlinck ing urethroplasty group may have certain advantages in W. Etiology of urethral stricture disease in the 21st century. 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Journal

Basic and Clinical Andrology – Springer Journals

Published: May 4, 2023

Keywords: Bulbar urethral stricture; Iatrogenic; Urethral reconstruction; Non-transecting urethroplasty; Sténose urétrale bulbaire; Iatrogène; Reconstruction urétrale; Urétroplastie sans transsection

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