ORIGINAL ARTICLE Vol. 45 (1): 118-126, January - February, 2019 doi: 10.1590/S1677-5538.IBJU.2018.0276 The effect of urethroplasty surgery on erectile and orgasmic functions: a prospective study _______________________________________________ Ahmet Urkmez 1, Ozgur H. Yuksel 2, Emrah Ozsoy 1, Ramazan Topaktas 1, Aytac Sahin 2, Orhan Koca 1, Metin I. Ozturk 1 1 Department of Urology, University of Health Sciences, Haydarpasa Numune Research & Training Hospital, Istanbul, Turkey; 2 Department of Urology, University of Health Sciences, Fatih Sultan Mehmet Research & Training Hospital, Istanbul, Turkey ABSTRACT ARTICLE INFO Objectives: to examine the effects of urethroplasty surgery on sexual functions by tak- Ahmet Urkmez ing into account age, location of stenosis, length of stenosis and surgical technique http://orcid.org/0000-0001-8357-7734 parameters. Materials and Methods: The prospective study was conducted between January 2015 Keywords: and August 2017 with 60 cases. Patients were categorized according to age groups Erectile Dysfunction; Prospective (19-65 / 65-75 years), surgery technique and stricture localization and length. Before Studies; Orgasm the urethroplasty operation and postoperative 6th month follow-up, the international Int Braz J Urol. 2019; 45: 118-26 index of erectile function (IIEF) form (15 questions), was fi lled, the relevant domains of sexual function; erectile function (Q1,2,3,4,5,15), orgasmic function (Q9,10) and overall satisfaction (Q13,14) were assessed. _____________________ Results: The mean age of the cases is 54 ± 13. However, preoperative IIEF, sexual sat- Submitted for publication: isfaction and orgasmic function averages of patients with a stenosis segment length April 14, 2018 of 1-3 cm was found to be signifi cantly higher than that of patients with a stenosis _____________________ segment length of 4-7 cm. Between stenosis segment length groups, there was no Accepted after revision: statistical difference in terms of preoperative and postoperative sexual functions. And June 17, 2018 also, there was no statistically signifi cant change in patients’ preoperative and post- _____________________ Published as Ahead of Print: operative sexual function scores in terms of localization of stricture and surgery tech- October 30, 2018 niques. However, there were statistically signifi cant change in the postoperative IIEF and sexual satisfaction averages according to preoperative averages. Conclusion: Our study suggests that urethroplasty surgery itself does not signifi cantly affect erectile function, orgasmic function, and general sexual satisfaction regardless of the type of surgery, localization and length of stenosis. Besides, there was a signifi - cant decrease in erectile function in senior adults. INTRODUCTION leading to this fi brosis is primarily subepithelial infl ammation and hemorrhage and later stages Urethral stricture refers to the scar forma- are characterized with sclerosis and fi brosis. The tion involving the spongiformis erectile tissue of etiology of urethral stricture disease is multifacto- the corpus spongiosum, resulting in a concomi- rial and mostly consists of iatrogenic reasons (ca- tant narrowing of the urethral lumen. The process theterization / endoscopic procedures) as well as 118 IBJU | URETHROPLASTY ON ERECTILE AND ORGASMIC FUNCTIONS trauma, infections, prostatectomy and other post of the perineal nerve on ejaculation, there is also - prostate cancer treatments, lichen sclerosis and an effect on erectile function. For this reason, the idiopathic reasons. Posterior urethral injuries are perineal nerve is thought to be an extra neural often associated with pelvic fractures. Treatment pathway for erectile function through unrecogni- alternatives include; dilatation, internal urethro- zed reflex mechanisms. To protect erectile func- tomy, laser treatments, and open reconstruction. tions after urethroplasty, it would be beneficial In the past, known as the reconstructive ladder, it to preserve this neural tissue, if possible (12, 13). has always been suggested that the simplest pro- In this study, we examined the effects of urethro- cedure should always be tried in the first stage, plasty surgery on sexual functions by taking into and in case of failure, proceeding to more com- account age, location of stenosis, length of ste- plex approaches is recommended in guidelines. In nosis and surgical technique parameters and we modern urethral reconstruction, this approach is hypothesized that location and length of stricture considered outdated. Even in some studies it has and type of urethroplasty is not affecting sexual been shown that recurrent dilatations and internal functions but older age may affect postoperative urethrotomies reduce the success rate of ultimate sexual functions. open urethral reconstruction (1, 2). In the treat- ment of urethral strictures, urethroplasty, excision MATERIAL AND METHODS and primary anastomosis are accepted as the “gold standard” treatment method due to low morbidi- Following ethical board approval, the ty and cost effectiveness besides long - term high prospective study was conducted between Janu- success rates. Certainly there are also strictures ary 2015 and August 2017 with 60 cases aged that require tissue transfer; grafts and flaps are between 19 and 75 years. Patients under 18 years successfully deployed here (3, 4). of age and patients with very poor erectile func- In addition to psychogenic factors, erectile tion (IIEF score ≤ 5) or with no erectile function dysfunction (ED) after urethroplasty may be due were excluded. And also, patients with a history to damage to the cavernous nerve, damage to the of coronary artery bypass graft surgery, unregu- perineal nerve, and deterioration of the flow of lated hypertension and diabetes were excluded the bulbar artery. In order to reduce this damage, from the study. Patients were categorized accor- it is suggested to protect bulbospongiosus mus- ding to age groups (19-65 / 65-75 years) and cle and peroneal nerves, not to cut central ten- stricture localization and length. Only six pa- don, not to damage the bulbar artery, use buccal tients with 2 cm stricture at bulbar urethra, had mucosal graft without cutting corpus spongiosum undergone endoscopic intervention once before (5-7). The neurovascular structures responsible for and failed. All urethroplasty operations were per- the erectile function pass from a distance of ap- formed by the same surgeon experienced in re- proximately 3 mm from clockwise 1 and 11 right constructive urology. All patients were evaluated outside the corpus spongiosum and some bran- with anamnesis, history, physical examination, ches from the cavernous nerves enter the corpus urine analysis and culture, uroflowmetry, retro- spongiosum across the entire penis. The intercra- grade urethrography before surgery. Before the nial area shows that this vessel and nerve bundle open urethroplasty operation and postoperative is unprotected and vulnerable to trauma. For this 6th month follow-up, the international index of reason, the bulb can be very easily damaged du- erectile function (IIEF) form (15 questions) was ring the dissection of the urethra (8-10). Another filled, the relevant domains of sexual function; important point for this region is the damage of erectile function (Q1-5, 15), orgasmic function the perineal nerve during the separation of the (Q9, 10) and overall satisfaction (Q13, 14) were bulbospongiosus muscle on the corpus spongio- assessed. The technique of the surgery, localiza- sum. It provides semen expulsion and sense of pe- tion of the stricture and the length of the narrow nile ventral surface (11). In addition to the effect segment were also noted. 119 IBJU | URETHROPLASTY ON ERECTILE AND ORGASMIC FUNCTIONS Surgical Approach age, 20% were over 65 years of age. While 75% of Urethroplasty was applied for bulbar and the strictures were located at bulbar area, 25% of penile urethral strictures. This series includes them were at penile urethra 76.7% had undergone excision and end - to - end anastomoses (using buccal mucosal graft operation, 16.7% had penile both transecting and non - transecting techni- skin flap and 6.7% had excision and end - to - end que), dorsal onlay buccal mucosal graft, ventral anastomosis operation. In 63.3% of patients, stric- inlay buccal mucosal graft and penile skin flap ture segment length was 3 cm and below; 36.7% cases. During operation, surgeon prone to keep of patients had 3 cm and more (Table-1). the dissection area as small as possible at the bul- Preoperative IIEF values of the patients bar urethral level and did not used cautery during ranged from 8 to 29, with a mean of 19.93 ± 5.76. the dissection. And also, surgeon tried to protect Postoperative IIEF values ranged from 6 to 30, bulbospongiosus muscle and peroneal nerves, not with a mean of 20 ± 7.99. There was no statisti- to cut central tendon, not to damage the bulbar cally significant difference between preoperative artery, and used buccal mucosal graft without cut- and postoperative in terms of IIEF, sexual satis- ting corpus spongiosum. faction and orgasmic function averages (p > 0.05). When the preoperative and postoperative IIEF sco- Statistical analysis res of the patients are evaluated individually, 27% showed an increase of 4 points or more in the IIEF While the findings of the study were eva- score, 33% showed a decrease of 4 points or more luated, IBM SPSS Statistics 22 program was used in the IIEF score, and 40% had no change in the for statistical