Editing Penis and Urethra Surgery (section)

===== Open reconstruction: excision and reanastamosis =====

====== Technique ======

*The best results are achieved when the following technical points are observed:
** The area of fibrosis is totally excised
** Urethral anastomosis is widely spatulated, creating a large ovoid anastomosis
** Anastomosis is tension free
* '''<span style="color:#ff0000">Position: lithotomy'''
*'''Steps to gain urethral length:'''
*# '''Vigorous mobilization of the corpus spongiosum'''
*# '''Development of the intracrural space and detachment of the bulbospongiosus from the perineal body'''
* '''When the length of stricture precludes total excision of fibrosis with primary anastomosis, tissue transfer in the form of graft or flap is required.'''
** '''Tubularized grafts and skin islands should be avoided, if possible.'''
*** Onlay procedures (graft or flap) are associated with a higher success rate than tubularized grafts or tubularized skin islands.
** '''Excision with primary anastamosis should be avoided in patients with a history of hypospadias repair due to expected altered or absent retrograde blood supply to the urethra through the normal arborization in the glans'''
* It is imperative to evaluate the urethra completely proximal and distal to the stricture with endoscopy and bougienage during surgery to ensure that all the involved urethra is included in the reconstruction.

====== Adverse Events ======
* '''<span style="color:#ff0000">Intraoperative</span>'''
*'''<span style="color:#ff0000">Post-operative</span>'''
**'''<span style="color:#ff0000">Late post-operative</span>'''
***'''<span style="color:#ff0000">Sexual dysfunction</span>'''
***# '''<span style="color:#ff0000">Permanent ejaculatory dysfunction</span>'''
***#* '''May occur in as high as 20% of men following urethroplasty.'''
***#* Complaints are usually related to pooling of semen within the urethra and/or loss of force with ejaculation. The etiology is poorly defined but is presumed to be due to either tortuosity of the neourethra and/or dysfunction of the bulbocavernosal muscle.
***# '''<span style="color:#ff0000">Temporary erectile dysfunction</span>'''
***#* Found in up to 20% of individuals undergoing an anterior urethroplasty.
***#** This incidence is similar between all types of anterior urethroplasties, e.g., excision and primary anastomosis, vascularized or graft urethroplasties.
***#** The erectile dysfunction symptoms classically resolve 6 six months with < 3-4% of patients reporting a permanent alteration in their erectile capabilities.
***#*** Overall, the rate of erectile dysfunction after urethroplasty was ≈equal to the rate after circumcision.
***#** Longer-segment reconstructions were associated with a higher risk of postoperative erectile dysfunction, although the patient’s erectile function improved over time in many cases.
***# '''<span style="color:#ff0000">New onset of penile curvature</span>'''
***#* May occur usually following an overaggressive attempt at excision and primary anastomosis performed in the distal bulbar region.
***# '''<span style="color:#ff0000">Loss of libido and anorgasmia</span>'''
***#* Very rare and are predominately due to a psychological component.