34.1 Introduction

Established believes concerning outcomes in anterior urethral reconstruction are changing, with regard both to the impact on sexual activity and genital cosmetic appearance [1]. Following repair of anterior urethral strictures, successful outcome is generally defined as normal voiding without further invasive procedures. However, the urethra is also involved in sexual and genital functions and most patients undergoing urethroplasty worry about the impact of surgery on sexual life. Therefore, the aim of stricture repair is not only to restore urinary function but also to safeguard sexual activity and guarantee genital cosmesis.

A complete evaluation of anterior urethroplasty should include the sexual point of view, which seems to play an important role in overall postoperative patient satisfaction. Despite the importance of the sexual outcome following penile or bulbar urethroplasty techniques, very few studies have focused on these aspects so far. The most commonly reported sexual problems following anterior urethroplasty include: erectile and ejaculatory dysfunctions, penile curvature or shortening, dissatisfactions with genital cosmetic appearance, sensorial impairment of genitalia and overall dissatisfaction about sexual life. The prevalence of specific postoperative sexual problems may be related to the site of urethral reconstruction (penile or bulbar) and to the technique of urethroplasty employed (graft versus flap and transecting versus non-transecting techniques). In penile urethral reconstruction, the increasing use of buccal mucosa seems to provide better results than the use of skin flaps which easily distorts the cosmesis and elasticity of the penis, thus increasing the risk of complications [1]. In bulbar reconstructions, graft augmentation techniques seem to have less impact on sexual outcome than transecting anastomotic techniques, which has been considered the gold standard for a long time.

Aim of this chapter is to analyse various anterior urethroplasty techniques for penile and bulbar reconstructions and related postoperative sexual complaints, providing also some technical hints on the surgical procedures in order to improve sexual outcomes.

34.1.1 Neuroanatomy

The understanding of the neuroanatomy of the urethra is a prerequisite for prevention or reduction of the neural injuries during the surgical urethral repairs. Two sets of nerves control erectile function. They are designated as autonomic (motor) and somatic (sensory) innervation.

The autonomic system consists of sympathetic (T10-L2) and para-sympathetic fibers (known as pelvic nerves: S2-S4) that make the pelvic plexus (Fig. 34.1). This latter is a 4–5 cm network lying on the posterolateral aspect of the bladder and the prostate. Its caudal fibers form the Cavernous nerves (also named “nervi Erigentes”) which travel posterolateral to the seminal vescicles towards the apex of the prostate. They then accompany laterally the membranous urethra, located at the 3 and 9 o’clock positions external to the striated muscles [2, 3]. Finally they ascend superolaterally in the proximal bulbar urethra; at the penile hilum, the cavernous nerves pierce the corpora cavernosa to innervate the helicine arteries and the erectile tissue: therefore they are located superolaterally (at the 2 and 10 o’clock positions) to the proximal bulbar urethra (Fig. 34.2) [2, 3]. Detailed anatomic studies on the prostatic apex and membranous urethra (relating to radical prostatectomy) have focused the location and importance of the neurovascular bundles, stressing the risk of damage to the erectile function due to urethral repair in the dorsal area of the proximal bulbar tract [3–5]. Hinata et al. described, based on new anatomical findings, a U-shaped mesh of cavernous nerves around the membranous urethra at the level of the rhabdosphincter which fuses at the dorsal side at the level of the penile hilum (Hinata et al.). The presence of cavernous nerve fibers at the dorsal side in the intercrural septum was confirmed by the findings of Blakely et al. These new findings indicate that the cavernous nerves are a complex network with a more extensive location as previously assumed. [6, 7].

The somatic system consists of the paired pudendal nerves which receive contributions from S2-S4 and innervate the pelvis andala perineum. They accompany the internal pudendal vessels through Alcock’s canal to innervate the striated muscle of the pelvic floor (levator ani) and the penis (ischiocavernosus and bulbocavernosus muscles). The pudendal nerves also supply sensory perception to the pelvis and the perineum and terminate as the dorsal nerve of the penis.

The dorsal nerve of the penis is an important branch of the pudendal nerve : it travels underneath the levator ani and continues distally along the dorsolateral surface of the penis lateral to the dorsal artery, gives multiple branches, and terminates in the glans penis. Anterior urethral innervation is by the urethrobulbar nerve, a branch of the perineal nerve : this latter is a branch of the pudendal nerve.

34.1.2 Anatomical and Surgical Considerations

The bulbar urethra is emptied, following micturition, by its closure mechanism created by the elasticity of the spongy tissue, combined with the voluntary contraction of the bulbospongious muscle ; in a similar way, an efficient urethral emptying, during ejaculation, is achieved by the combination of the bulbo-penile urethral closure-pressure with the intermittent reflex contractions of the spongious muscle. In particular, erection of the spongy tissue not only considerably increases the passive urethral closure-pressure but it also increases the bulk of the bulb which, in turn, increases the effect of the reflex ejaculatory contractions of the surrounding bulbo-spongious muscle. Thus, organic emission is a function of the posterior urethra resulting from a simultaneous contraction of the bladder neck, sustained contraction of the seminal vesicles and opening of the distal sphincter. Once the emission has passed the distal sphincter, the continuous flow of the semen is converted into a forceful intermittent ejaculation by the anterior bulbo-penile urethral structure.

The bulbospongious muscles , together with the perineal central tendon, on which they pivot, contribute to the ejaculatory and urinary emission; for this reason, during urethroplasty, it is advisable to attempt to spare the central tendon and to reconstruct the muscles (Figs. 34.3 and 34.4) [8]. Yucel and Baskin supposed that the hypothetical surgical damage to the branches of the perineal nerves, during bulbar urethroplasty, may be responsible for the loss of rhythmic bulbar urethral contractions, causing difficulty in expelling semen (decreased force of semen emission, ejaculation only by manual compression of the perineum at the level of the urethral bulb) and urine [9]. They hypothesised that these sexual complaints could be caused by extensive dissection of the bulbo-spongiosum muscles, or by sectioning the central tendon, or by the neural damage to the perineal nerves during preparation of the bulbar urethra. Therefore it is worthwhile stressing the importance of preserving the central tendon, and of gently handling the bulbospongiosus muscles and reconstructing them at the end of any bulbar urethroplasty.

With the aim to reduce semen sequestration Barbagli described a new muscle- and nerve-sparing bulbar avoiding dissection of the bulbospongiosum muscle from the corpus spongiosum and leaving the central tendon of the perineum intact [10].

However, it must be said that urethral reconstructive procedures inevitably impair the natural emptying mechanism of the spongy tissue, since they interrupt the structural muscle-elastic circularity of the urethral tube which may stop the rhythmic urethral voiding contractions. Furthermore, urethral elasticity is often already impaired, to some extent, by the spongio-fibrotic disease [11].

34.2 Sexual Complaints Following Bulbar Urethroplasty

Bulbar strictures are repaired by means of anastomotic urethroplasties (AU) or by patch graft urethroplasties using Buccal Mucosa (BM) as the graft of choice. Short strictures are traditionally treated by excision and primary anastomotic (EPA) urethroplasty. However, the shortening of the urethra and the vascular injury following urethral transection may lead to increased risk of complications , explaining why in some studies the AUs showed higher incidence of sexual problems such as penile curvature or shortening, impaired erection, decreased penile sensitivity and impaired sexual life, when compared with graft techniques (Table 34.1) [11–18]. Mundy showed that in patients who underwent anastomotic and patch graft urethroplasty the postoperative impotence was temporary in 53% and 33%, and permanent in 5% and 0.9%, respectively [14]. Al-Qudah and Santucci, directly comparing AUs versus BM graft techniques in bulbar repairs, showed a higher incidence of sexual complications (chordee and ED) following AUs [15]. In his series of 153 men undergone EPA urethroplasty, Barbagli reported 23.3% of patients with postoperative ejaculation difficulty and 31.6% with neurovascular disorders (decreased sensitivity) of the glans or penis [16]; he hypothesized that these sensory disorders are related to vascular impairment of the spongiosum distally to the urethral section. In his experience with EPA urethroplasty, Morey reported 18% of complete loss of erection, 44% of chordee, 22% of decreased penile length, 45% of overall dissatisfaction in erection, 33% of erectile worsening noted by partner [12]. Kessler et al. noticed 36% of penile curvature, 38% of penile shortening, 79% of erection deterioration, 57% of impaired sexual life in patient undergone anastomotic techniques [17]. Beysens et al. reported a temporary decline in erectile and ejaculatory function after EPA but not after graft urethroplasty for bulbar strictures [18]. No prospective randomized trials comparing EPA with patch urethroplasty evaluating sexual function are to date available. Therefore, the level of evidence on this issue is low.

Table 34.1

Sexual complaints reported following bulbar urethroplasty [9–15]

	Anastomotic procedures (%)	BM graft (%)
Penile curvature	36	8
Penile shortening	38	11
Impaired erection	79	15
Complete loss of erection	9	0
Overall dissatisfaction in erection	26	19
Temporary impotence	53	33
Impaired sexual life	57	19
Overall satisfaction regarding sexual life	74	97

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