DVIU is relatively easy procedure to learn, straight forward to perform and can be performed on outpatient basis. These attributes have made DVIU as the procedure of choice among urologists for treating short segment structures, despite poor long-term success rates14. EPA has been the surgical treatment of choice for short segment bulbar urethral strictures, if patients fail to respond to the first-line management by DVIU with long-term success rates of 90 to 98.6% 15 .
The present study demonstrates that nontransecting urethroplasty offers better surgical dividends in primary or failure after DVIU. Transection the urethra and corpus spongiosum for short segment bulbar strictures was challenged at the American Urological Association meeting in 200917. The debate in favour or against transection with EPA and non-transecting techniques is based on stricture aetiology and the success rates and complications. The pathophysiology differs between non-traumatic and traumatic causes. In non-traumatic strictures the corpus spongiosum is well preserved with minimal scarring of around 10% involving the urethral wall, unless there has been any prior interventions18. Whereas, in fall-astride injuries there is usually full-thickness spongiofibrosis with no remaining vascularised spongiosal tissue.
Hence EPA for non-traumatic strictures inevitably transects healthy tissues and is reported to be associated with an 18-22.5% incidence of sexual dysfunction. 19,20
Jordan and colleagues21 were the first to promote the idea of vessel sparing bulbar urethroplasty which gave inception for the Non-transecting bulbar urethroplasty techniques3 with the aim to avoid the potential morbidity associated with transection of spongiosum.
The primary goal in stricture management is restoration of unimpeded flow of urine with minimal sexual side effects22. The most pronounced obstructive symptoms in urethral stricture disease are a weak stream, dribbling, and incomplete emptying. 23
In our study, there is significant improvement of LUTS score and peeling voiding picture score, uroflowmetry (Qmax) in nontransecting urethroplasty group compared to Primary DVIU group. The difference in LUTS score is not statistically significant at six months but worsening in LUTS score and Qmax are noted in DVIU group by the end of 12 months. This suggests that more durable and long-term outcomes can be achieved with Non-transecting Urethroplasty rather than DVIU for short segment bulbar strictures. There is a growing interest in Sexual dysfunction following Surgery for Urethral Strictures, but outcomes in most studies are heterogenous24
We found statistically significant improvement of erectile function scores in Non transecting urethroplasty group at 12 months. Probable explanation for the improvement of Erectile function could be recovery of neuropraxia, decrease in tissue inflammation following surgical manipulation and psychosomatic recovery and the elimination of a supra-pubic catheter after surgery, improvement of body image as well as psychological factors are contributing to possible explanations for the improvement in erectile function25,26. Preservation of healthy spongiosum also is aiding factor to improved sexual function.
Ejaculatory function scores recorvered in both the groups with Non transecting urethroplasty group having statistically better scores at the end of 12 months. The significant improvement of ejaculatory score in the urethroplasty group can be asserted to resection of scarred and non-contractile part of the urethra/spongiosum which improves the rhythmic ejaculatory mechanism by restoring the continuity of the musculature 27 and the improvement of ejaculatory function in DVIU group can be ascertained to resolution of urethral obstruction26. The studies on Ejaculatory function are sparse for both Non-transecting Urethroplasty and DVIU. In addition to Erectile and Ejaculatory function, decreased penile sensitivity and cold glans syndrome after surgery can lead to decreased sexual satisfaction28. No patient in the study had de novo erectile dysfunction or complained of altered glans sensitivity/turgidity. Similar observations have been reported by retrospective studies performed in Non-transecting fashion for short segment bulbar stricture 3,5.
The satisfaction rates in Non transecting urethroplasty group is 96.5% which is similar to existing literature3,5. One patient in the group with past history of multiple endoscopic interventions and underwent ANTABU required an endoscopic dilatation and was not satisfied with the surgical outcome.
2 patients (8%) who underwent ANTABU in the urethroplasty group had postmicturition dribble which was not bothersome. Post micturition dribble could be because of impaired function of perineal nerve branches from the surgical dissection23,24. Similar rates of Post micturition dribble (13.8 %) also noted by Ivaz et al.5
Eleven patients (46%) of the primary DVIU group required reintervention and are unsatisfied with the outcome. It was observed that the patients who were very satisfied and satisfied after surgery had good maximum flow rate, low LUTS score and improved sexual function score. The patients who were not satisfied with the surgery had low flow rate, high LUTS score and modest Sexual function score. Hence assessing the subjective outcomes PROM can help achieve a holistic approach for patient follow-up and for preoperative decision making of the patient.
The success rate of Non transecting urethroplasty is 96.5% in our study. Similar success rates are noted in other studies 3,5. As most strictures recur in the first year post urethroplasty29, we believe that subjective and objective stricture free rate of 96.5% at 12 months augurs well for a satisfactory outcome in the longer term. Most of the studies published on the outcomes of DVIU are conglomerate of variable lengths and aetiologies, hence they may not provide a complete picture of DVIU outcome. The success rate of Primary DVIU in our study is 54% and is of a homogenous group of primary DVIU for short segment bulbar stricture.
Among the nontransecting urethroplasty techniques, H-M, NTABU showed superior outcomes in all the domains and better satisfactory rates. Even though it is hard to comment on superiority of one technique over the other as the sample size is less, we believe when chosen for the right case H-M, NTABU techniques have satisfactory outcomes.
History of previous DVIU/Dilatations increases the complexity of the inevitable urethroplasty30. The patients in the nontransecting urethroplasty group with previous interventions with DVIU/Dilatations had to undergo relatively more complex reconstructions and had inferior LUTS, SEXUAL FUNCTION outcomes when compared to those who had no prior interventions.
During the last three decades urethroplasty has improved in efficacy and safety, while DVIU is increasingly considered ineffective in the long term.31
The fact that DVIU has a low success rate is a strong argument for opting for the more effective and refined urethroplasty techniques with minimal side effects.
The shortcomings of our study include firstly, short duration of follow-up, small number of patients, secondly even though a prospective study, it is non-randomised and lastly, the absence of a descriptive health profile generating system like the EQ-5D.