In 2007 Dr. Gerald H. Jordan introduced a novel technique for short bulbar urethral strictures, the vessel sparing excision and primary anastomosis (VS-EPA). ¹ The goal for the vessel sparing technique in the bulbar urethra was to obtain equivalent and durable outcomes to traditional transecting excision and primary anastomosis (T-EPA) while preserving the proximal vasculature of the corpus spongiosum (figs. 1 and 2). The initial idea was to potentially benefit patients with bulbar urethral stricture after radical prostatectomy. In preserving the proximal blood supply to the bulb he could potentially prevent the feared cuff erosion in those patients who would require an artificial urinary sphincter to treat stress urinary incontinence. With time he proved that the technique was feasible and the indication expanded to all strictures of the bulbar urethra. The potential for benefit was also recognized in patients with a history of hypospadias and/or synchronous strictures.

Modifications to his initial technique followed as others found the principle of preserving the proximal blood supply of the bulb to be feasible while not compromising the excellent results of the T-EPA. ^2-5

The group from London reported 100% success in their initial small series of patients undergoing complete excision or Heineke–Mikulicz stricturoplasty without ventral spongiosal transection. ² They later validated their results with 97% radiological stricture free rate at a mean follow-up of 13 months. ³

Figure 1. The main steps for traditional transecting stricture excision and primary anastomosis.

The VS-EPA technique was validated in many centers across the globe, and initial reports by Jordan et al were updated with time showing that outcomes are similar to T-EPA. In one such report 68 patients underwent urethral reconstruction with this technique and 95% had successful outcomes after a mean follow-up of 17 months. ⁶ Advanced age, extended length of stay and previous endoscopic treatments were predictors of failure. Although nonvalidated questionnaires were used, de novo erectile dysfunction only occurred in 6% of the patients.

With proven success in anatomical patency, the next step was to evaluate if the nontransecting techniques would have potential benefits for sexual function. A publication from the group in Alberta, Canada, compared T-EPA vs VS-EPA for bulbar urethral strictures and found similar outcomes between groups (94% vs 98% success) after a mean followup of 64 months. ⁷ In their large retrospective multi-institutional series, patients reported more adverse sexual effects with the T-EPA vs VS-EPA (14% vs 4%), suggesting that the vessel-sparing approach may have a positive impact on sexual function.

Figure 2. Steps for the vessel sparing (nontransecting) stricture excision and primary anastomosis.

The group in Ghent, Belgium, is conducting a prospective, single blinded, controlled, randomized clinical trial to directly compare VS-EPA and T-EPA for surgical and functional outcomes, the VeSpAR trial (fig. 3). ⁸ Failure is defined as the inability to pass a 16Fr flexible cystoscope. Postoperative worsened erectile function is defined as a decrease of 5 points or greater on the International Index of Erectile Function (IIEF-5) questionnaire. They recently presented early analysis at the European Urological Association Meeting. Since October 2018 a total of 52 patients have been enrolled, of whom 39 have been analyzed and have a median followup of 93 (IQR 10–107) days. Of these 39, 21 were randomized in the VS-EPA group and 18 were randomized in the T-EPA group. They report a conversion rate of 14% from the VS-EPA to T-EPA. The 3-month failure free survival rate was 93% (SD 6.4) in the vessel sparing group and 100% in the transecting group (p=0.4). A total of 11 patients in the VS-EPA and 8 in the T-EPA groups reached 3-month followup with completed preopeartive and postoperative IIEF-5 questionnaires. They found so far that 0/11 (0%) of the patients undergoing VS-EPA and 4/8 (50%) patients had worsened erectile function at 3-month followup (p=0.02). ⁹ The trial plans to enroll 100 patients before closing in January 2021.

Figure 3. VeSpAR trial timeline.

In conclusion, the goal for the vessel sparing technique in the bulbar urethra is to obtain equivalent and durable outcomes to traditional EPA while preserving the proximal vasculature of the corpus spongiosum. The approach is logical and advantageous in theory, and series from many centers around the world have confirmed safety and equivalent efficacy. Mid-term and long-term followup from the original series as well as contemporary studies support durable results equivalent to traditional techniques. The surgeon should convert to a traditional EPA without hesitation if there is any concern about inadequate excision of the stricture or the creation of a tension free, wide anastomosis.

Recent publications propose that preserving the proximal spongiosal blood supply may have potential benefits for sexual function.

A well designed prospective randomized clinical trial comparing traditional EPA and VS-EPA with comprehensive and validated data regarding erectile function, quality of life and urethral patency outcomes is currently being conducted and will determine if preserving the proximal bulbar blood supply is a valuable step forward in preserving sexual function.