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Excision and Primary Anastomosis (EPA)

Excision and primary anastomosis (EPA) removes a short stricture and joins healthy urethral ends without tension. Selection depends on stricture site, length, fibrosis and the risk of penile shortening. Current EAU guidance favors transecting EPA for short, nearly obliterative post-traumatic bulbar strictures with full-thickness fibrosis, and non-transecting EPA or a free graft for short bulbar strictures without straddle injury. [16]

For graft-based alternatives in longer strictures, see Buccal Mucosa Graft. For the vessel-sparing modification, see Jordan Vessel-Sparing EPA and Non-Transecting Bulbar Urethroplasty. For pelvic-fracture posterior urethral injury, see Pelvic Fracture Urethral Injury (PFUI). The clinical condition is at Urethral Stricture.

Indications​

  • Short, isolated bulbar urethral strictures — generally ≤2 cm, though high-volume centers have extended this to strictures up to 4–5 cm in the proximal bulbar urethra.[1][5]
  • The SIU/ICUD consultation recommends EPA for short isolated bulbar strictures when the expected success of alternative endoscopic procedures is <50%.[2]
  • The AUA Urethral Stricture Disease Guideline (2023) recommends urethroplasty as initial treatment for bulbar strictures ≥2 cm, given the low success of endoscopic approaches for longer strictures.[6]
  • EPA can also be applied to focal pendulous (penile) urethral strictures, particularly those of traumatic etiology (e.g., penile fracture), with success rates of approximately 93%.[7]
  • Appropriate for both primary and recurrent strictures, including repeat EPA after prior failed EPA, with comparable success rates (~94–95%).[8]

Relative contraindications​

  • Any defect that cannot be closed without tension or unacceptable shortening; usually this limits standard EPA to approximately 2 cm, with selected longer proximal repairs requiring individualized assessment [16]
  • Penile urethral strictures (risk of chordee), though short focal traumatic penile strictures may be amenable[7]
  • Strictures associated with lichen sclerosus (typically require substitution urethroplasty)
  • Panurethral strictures

Surgical Technique​

The procedure is performed via a perineal approach with the patient in lithotomy position:

  1. Exposure — midline perineal incision; bulbospongiosus muscle divided to expose the bulbar urethra.
  2. Identification — strictured segment identified, aided by preoperative retrograde urethrography and intraoperative assessment (calibration, cystoscopy).
  3. Excision — fibrotic segment excised back to healthy, well-vascularized urethral tissue on both ends.
  4. Spatulation — both urethral ends spatulated on opposite sides (typically dorsal and ventral) to widen the anastomotic lumen and prevent circumferential scar contracture.
  5. Mobilization — urethra mobilized to permit a tension-free anastomosis. Avoid excessive mobilization or forced approximation. Elaborated perineal maneuvers such as inferior pubectomy or supracrural rerouting belong to selected complex posterior/PFUI reconstructions, not routine anterior bulbar EPA.
  6. Anastomosis — tension-free, mucosa-to-mucosa anastomosis using absorbable sutures (typically 4-0 or 5-0 polyglycolic acid), interrupted or running.
  7. Catheter — urethral catheter (16–18 Fr) left in place, with duration tailored to the repair. Assess extravasation by urethrography before removal; selected uncomplicated short repairs can have earlier removal. [17]

Transecting vs. Non-Transecting (Vessel-Sparing) EPA​

A major evolution in technique has been the introduction of vessel-sparing (non-transecting) EPA (VS-EPA), first described in 2007.[9] Non-transecting EPA preserves the bulbar arteries and the dorsal vascular supply of the corpus spongiosum, theoretically reducing the risk of erectile dysfunction and glans ischemia.

FeatureTransecting EPANon-Transecting (VS-EPA)References
Corpus spongiosumFully transectedPreserved in continuity; approach varies[1][2]
Bulbar artery blood supplyDisruptedPreserved[1]
Success rate90–99%90–98%[1][2][3]
Erectile dysfunction risk2–19%Potentially lower[1][4]
Failure rate (short-term)3–12%~7%[2]

A single-center comparison of 200 patients found that ntEPA did not negatively affect failure rates, complication rates, or operative time compared to tEPA. Diabetes and prior urethroplasty — but not the non-transecting technique itself — were significant predictors of failure.[10]

Outcomes​

EPA has high reported patency in selected cohorts. These series do not establish superiority over grafts in comparable patients:

SeriesnSuccessFollow-up
Eltahawy / Jordan 2007[1]26098.8%mean 50.2 mo
SIU/ICUD pooled[2]1,23493.8%—
Horiguchi 2021[3]30897.1%median 37 mo
Siegel 2015 (initial / repeat / secondary)[8]—94% / 95% / 94%—
Jasionowska 2022 SR[11]—89.7% (median)shortest strictures, median 2.1 cm

Patient-reported outcomes show significant improvement: mean Qmax improves from ~7.7 to ~24.1 mL/s, and 98.6% of patients report being satisfied or very satisfied.[3]

Complications​

Older series reported low perioperative complication rates, but these figures do not capture all patient-reported penile and sexual symptoms.[1][2]

ComplicationRateReference
Erectile dysfunction2.3–19%[1][3][4][12]
Urinary tract infection~5%[1]
Position-related neuropraxia~3.4%[1]
Scrotalgia~1.5%[1]
Wound complications~1.5%[1]
Chordee / penile tethering~23% (mild, no curvature)[12]
Postvoid dribbling~8% (vs ~28% with dorsal onlay)[12]
IncontinenceRare (<1%)[13]

In the Jordan series, ED occurred in 2.3% (6/260), with 4 of 6 having a history of significant straddle trauma. A larger series found 19.1% had ≥5-point SHIM deterioration. Anastomotic urethroplasty may carry higher ED rates than augmentation techniques, though this remains debated.[1][3][4][12]

EPA vs. Other Urethroplasty Techniques​

The 151-patient Scandinavian randomized trial compared transecting EPA with BMG for bulbar strictures ≤2 cm. EPA caused more penile complaints, particularly shortening and reduced glans filling. IIEF-5 scores did not differ significantly. Recurrence was 12.9% in each arm at 12 months, but the trial was not powered to establish equal recurrence risk. [18] The 2026 long-term report retains the signal of more penile complications after transecting EPA with similar recurrence; its abstract does not provide new event counts. [19]

Terlecki’s retrospective series compared predominantly proximal EPA with predominantly distal graft repairs. The intermediate-length recurrence comparison (1/33 versus 6/16) therefore cannot separate the effect of location and selection from technique; it is not evidence to routinely extend EPA to every 5 cm stricture.[5]

Redmond’s adjusted recurrence association for transecting augmented anastomotic repair versus dorsal onlay concerns longer graft-requiring strictures, not standard EPA or every non-transecting variant.[14]

Extended Primary Anastomosis with Penile Plication (EPAPP)​

EPAPP is a novel technique designed to extend the applicability of anastomotic urethroplasty to longer bulbar strictures that would traditionally require grafting or flap reconstruction. Described by VanDyke, Baumgarten, and Ortiz in 2021, the key innovation is the addition of ventral corporal body plication, which shortens the distance between the two healthy urethral ends and enables a tension-free primary anastomosis without graft material.[15]

Concept and rationale​

After excision of the strictured segment, plication sutures are placed on the ventral surface of the corpora cavernosa to reduce the gap between the proximal and distal urethral stumps. This effectively "telescopes" the corporal bodies, allowing direct mucosa-to-mucosa reanastomosis even when the gap would otherwise be too large for standard EPA. EPAPP is positioned as an alternative to perineal urethrostomy for patients with long or complex bulbar strictures who may not be ideal candidates for grafting.[15]

Operative technique​

The technique builds on standard EPA exposure, with ventral corporal plication as the additive step that reduces the urethral gap:[15]

  1. Exposure. Midline perineal or midline penoscrotal incision with a self-retaining retractor. The urethra is dissected circumferentially and the obstruction confirmed by flexible cystoscopy.
  2. Excision and calibration. The corpus spongiosum and urethra are divided at the stricture; the diseased segment is systematically resected in both directions to grossly normal urethra. Proximal and distal ends are calibrated to a minimum luminal diameter of 26 Fr.
  3. Distal mobilization and inspection. Extensive distal mobilization is carried to the penoscrotal junction. Retrograde flexible cystoscopy is performed to rule out additional stricture, bladder stones, or tumors.
  4. Spatulation. The distal urethra is spatulated dorsally and the proximal urethra ventrally (opposite-side spatulation widens the anastomosis).
  5. Tension assessment. The defect between urethral ends is measured with the penis not on stretch — stretch falsely exaggerates the defect length and would lead to unnecessary plication.
  6. Ventral corporal plication — the EPAPP step. If the urethral ends cannot be approximated without tension, ventral plication of the proximal corporal bodies is performed symmetrically using non-absorbable braided 2-0 Ethibond polyester suture:
    • Sutures are placed in an inverted mattress fashion (the geometry described previously for Peyronie's-deformity correction).
    • Each suture spans 15–20 mm.
    • Sutures are placed in paired fashion — one on each corporal body — with subsequent paired sutures placed in tandem until the urethral ends approximate without tension.
    • Additional unilateral sutures can be placed as needed to ensure uniform circumferential reduction of the defect (correcting any asymmetric shortening).
  7. Anastomosis. Standard mucosa-to-mucosa anastomosis with 10–12 absorbable sutures over a 16 Fr Foley catheter.
  8. Length documentation. Stretched penile length is measured (ruler at the base of the penis) before the initial incision and after skin closure to document the plication-related shortening.

Key technical principles:

  • EPAPP uses ventral corporal plication to reduce the urethral gap. Peyronie plication also shortens tunica; its location depends on curvature, so ventral placement is not its opposite.
  • Symmetry first (paired sutures across both corporal bodies), with unilateral sutures only as needed to correct any residual asymmetry.
  • Suture span does not give a validated one-to-one estimate of final penile or urethral-gap shortening; reassess tension and geometry after plication.
  • Inverted mattress geometry distributes tension and reduces the risk of suture pull-through on the relatively thin tunical surface.

Indications​

  • Long bulbar strictures (mean length 3.75 ± 1.4 cm in the original series — substantially longer than typical EPA candidates ≤2 cm)[15]
  • Patients in whom graft harvest is to be avoided (depleted oral mucosa donor sites, limited operative time, comorbidities precluding graft urethroplasty)
  • The initial cohort was predominantly older and sexually inactive; this describes selection, not a reason to presume shortening or curvature will be acceptable[15]
  • An alternative to perineal urethrostomy in patients who prefer to retain antegrade voiding through a reconstructed orthotopic urethra

Distinction from Peyronie's plication​

The corporal plication used in EPAPP is mechanically similar to but conceptually distinct from the tunical plication performed for Peyronie's disease. In Peyronie's surgery, plication is applied to the convex side of the tunica albuginea to shorten it and correct curvature. In EPAPP, plication is ventral and serves to reduce corporal length to bridge a urethral gap, not to correct curvature. The mechanical principle of shortening tissue through plication sutures is shared. See Peyronie's Correction for the Peyronie's-specific application.

Outcomes — VanDyke 2021​

ParameterResult
Number of patients10 (2.9% of 346 urethroplasties at the originating institution)
Mean stricture length3.75 ± 1.4 cm
Mean age66.6 yr (vs 55.6 yr for the general urethroplasty cohort)
Sexually active preoperativelyminority
Postop VCUGurethral patency without extravasation in all 10
Median follow-up9.7 months
Asymptomatic at follow-up8/10 (80%)
Recurrence2/10 — both managed with a single balloon dilation

The small EPAPP cohort was older and largely sexually inactive. It cannot establish the sexual or cosmetic acceptability of plication for other patients; obtain individual counseling about shortening and curvature.[15]

Patient counseling​

  • Penile shortening is an expected consequence of ventral corporal plication; the amount should be measured, not assumed from the gap alone.
  • Penile curvature (ventral) may develop and should be discussed preoperatively.
  • Erectile function — the technique can be considered when erectile function is already impaired or sexual activity is not a priority.
  • Single-stage non-graft reconstruction is the principal advantage — avoids buccal mucosa harvest. Comparative operative-time, sexual-function and long-term advantages have not been established.

EPAPP remains a niche technique with limited long-term data; it is not a replacement for Dorsal Onlay OMG Urethroplasty or Augmented Anastomotic Urethroplasty in younger sexually active patients but offers a meaningful single-stage option for selected older / non-sexually-active patients with long bulbar strictures who would otherwise be steered toward perineal urethrostomy.

Predictors of Failure​

  • Diabetes mellitus (association in a retrospective cohort)[10]

  • Prior urethroplasty (association in the same cohort)[10]

  • Increasing length may make a tension-free EPA unsuitable; the Redmond risk estimate arose from graft-requiring AAU/onlay repairs, not a standard EPA cohort.[14]

  • Lichen sclerosus (generally excluded from EPA candidacy)

Follow-Up​

Standard postoperative follow-up includes uroflowmetry and cystoscopy (typically at 4–6 months), with ongoing symptom monitoring. Late recurrences are uncommon but can occur years after surgery.[1]

Videos​

Excision and Primary Anastomosis
Operative technique
Excision and Primary Anastomosis
Operative technique
Excision and Primary Anastomosis
Operative technique

References​

  1. Eltahawy EA, Virasoro R, Schlossberg SM, McCammon KA, Jordan GH. Long-term followup for excision and primary anastomosis for anterior urethral strictures. J Urol. 2007;177(5):1803-6. doi:10.1016/j.juro.2007.01.033.

  2. Morey AF, Watkin N, Shenfeld O, Eltahawy E, Giudice C. SIU/ICUD consultation on urethral strictures: anterior urethra — primary anastomosis. Urology. 2014;83(3 Suppl):S23-6. doi:10.1016/j.urology.2013.11.007.

  3. Horiguchi A, Ojima K, Shinchi M, et al. Single-surgeon experience of excision and primary anastomosis for bulbar urethral stricture: analysis of surgical and patient-reported outcomes. World J Urol. 2021;39(8):3063-3069. doi:10.1007/s00345-020-03539-8.

  4. Gallegos MA, Santucci RA. Advances in urethral stricture management. F1000Res. 2016;5:2913. doi:10.12688/f1000research.9741.1.

  5. Terlecki RP, Steele MC, Valadez C, Morey AF. Grafts are unnecessary for proximal bulbar reconstruction. J Urol. 2010;184(6):2395-9. doi:10.1016/j.juro.2010.08.034.

  6. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. Urethral stricture disease guideline amendment (2023). J Urol. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482.

  7. Shakir NA, Fuchs JS, Haney N, et al. Excision and primary anastomosis reconstruction for traumatic strictures of the pendulous urethra. Urology. 2019;125:234-238. doi:10.1016/j.urology.2018.05.043.

  8. Siegel JA, Panda A, Tausch TJ, et al. Repeat excision and primary anastomotic urethroplasty for salvage of recurrent bulbar urethral stricture. J Urol. 2015;194(5):1316-22. doi:10.1016/j.juro.2015.05.079.

  9. Virasoro R, DeLong JM. Non-transecting bulbar urethroplasty is favored over transecting techniques. World J Urol. 2020;38(12):3013-3018. doi:10.1007/s00345-019-02867-8.

  10. Waterloos M, Verla W, Oosterlinck W, François P, Lumen N. Excision and primary anastomosis for short bulbar strictures: is it safe to change from the transecting towards the nontransecting technique? Biomed Res Int. 2018;2018:3050537. doi:10.1155/2018/3050537.

  11. Jasionowska S, Bochinski A, Shiatis V, et al. Anterior urethroplasty for the management of urethral strictures in males: a systematic review. Urology. 2022;159:222-234. doi:10.1016/j.urology.2021.09.003.

  12. Furr JR, Wisenbaugh ES, Gelman J. Urinary and sexual outcomes following bulbar urethroplasty — an analysis of 2 common approaches. Urology. 2019;130:162-166. doi:10.1016/j.urology.2019.02.042.

  13. Martínez-Piñeiro JA, Cárcamo P, García Matres MJ, et al. Excision and anastomotic repair for urethral stricture disease: experience with 150 cases. Eur Urol. 1997;32(4):433-41.

  14. Redmond EJ, Hoare DT, Rourke KF. Augmented anastomotic urethroplasty is independently associated with failure after reconstruction for long bulbar urethral strictures. J Urol. 2020;204(5):989-995. doi:10.1097/JU.0000000000001177.

  15. VanDyke ME, Baumgarten AS, Ortiz NM, et al. Extended primary anastomosis with penile plication (EPAPP): a promising new alternative to perineal urethrostomy for reconstruction of long urethral strictures. Urology. 2021;149:245-250. doi:10.1016/j.urology.2020.11.048.

  16. European Association of Urology. EAU Guidelines on Urethral Strictures: disease management in males. 2026. Current guideline.

  17. European Association of Urology. EAU Guidelines on Urethral Strictures: perioperative care of urethral surgery. 2026. Current guideline.

  18. Nilsen OJ, Holm HV, Ekerhult TO, et al. To transect or not transect: results from the Scandinavian Urethroplasty Study, a multicentre randomised study of bulbar urethroplasty comparing excision and primary anastomosis versus buccal mucosal grafting. Eur Urol. 2022;81(4):375–382. doi:10.1016/j.eururo.2021.12.017.

  19. Holm HV, Ohnesorge SS, Nilsen OJ. Long-term outcomes of transecting versus nontransecting bulbar urethroplasty: results from the Scandinavian Urethroplasty Study. Eur Urol Focus. 2026;12(3):316–318. doi:10.1016/j.euf.2026.05.007.