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Excision and Primary Anastomosis (EPA)

Excision and primary anastomosis (EPA) is the gold-standard urethroplasty technique for short bulbar urethral strictures, with reported success rates of 93–99% across large series and long-term follow-up.[1][2][3] EPA involves complete excision of the fibrotic segment and spatulated, tension-free, end-to-end reanastomosis of the healthy urethral ends — the goal is to remove all diseased tissue and restore urethral continuity without grafts or flaps.[2][4]

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 Posterior Urethroplasty for 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​

  • Long strictures (>4–5 cm) where tension-free anastomosis cannot be achieved
  • 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. Tension-relieving maneuvers include urethral mobilization, separation of the crura, inferior pubectomy (rarely needed), and supracrural rerouting.
  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, typically for 2–3 weeks before pericatheter retrograde urethrogram and removal.

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 (dorsal urethrotomy only)[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]
Operation time~98 min~87 min[2]
Catheterization time~14 days~9 days[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 consistently demonstrates the highest success rates among urethroplasty techniques:

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​

Overall complication rates are <15%, with most events self-limited and resolving in the early postoperative period.[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​

For longer strictures requiring buccal mucosal grafts, a non-transecting dorsal onlay technique appears superior to augmented anastomotic urethroplasty. In a 507-patient series with mean stricture length 4.4 cm, augmented anastomotic urethroplasty was independently associated with stricture recurrence (HR 4.8, p=0.002) compared to pure dorsal onlay.[14] For longer strictures, a non-transecting dorsal onlay approach is preferred over transecting augmented anastomosis.

For proximal bulbar strictures up to 5 cm, EPA alone (without grafts) has been shown superior to graft procedures, with recurrence rates of 3% vs. 38% for intermediate-length strictures.[5]

Predictors of Failure​

  • Diabetes mellitus (HR 0.165)[10]
  • Prior urethroplasty (HR 0.355)[10]
  • Increasing stricture length[14]
  • Iatrogenic etiology[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]

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.