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Jordan Vessel-Sparing Excision and Primary Anastomosis

The Jordan vessel-sparing excision and primary anastomosis (VS-EPA) was first described by Gerald H. Jordan, Eltahawy, and Virasoro in 2007 as a modification of transecting EPA.[1] By preserving the corpus spongiosum and its dual arterial blood supply while excising only the diseased mucosal segment, VS-EPA has high reported patency in selected cohorts. Preserving vascularity is its rationale; Jordan-specific reductions in erectile dysfunction, glans ischemia or future AUS erosion have not been established in a randomized comparison.[2][3]

Anatomical Rationale​

The Jordan technique aims to preserve arterial inflow when adequate viable tissue remains. The arterial supply to the bulbar urethra and glans derives from the internal pudendal artery, which gives rise to the bulbar arteries and the urethral artery supplying the corpus spongiosum.[4] In standard EPA, full-thickness transection of the corpus spongiosum severs this dual supply. Jordan described separating the urethra from the proximal bulbar blood supply to permit urethral division without dividing the feeding arteries or the preserved spongy tissue. Complete transection may still be appropriate for a short traumatic obliteration with full-thickness fibrosis.[1][5]

Key vascular structures preserved by the Jordan technique:

  • Bulbar arteries — branches of the internal pudendal artery supplying the penile bulb
  • Urethral artery — supplies the corpus spongiosum and anastomoses with the dorsal artery at the glans[4]
  • Preserving every mucosal communicant vessel is not a feature of mucosectomy; mucosal sparing is the separate aim of MsANTA.[6]

An important anatomical caveat: color Doppler studies have shown that the urethral arteries are not reliably located at the 3 and 9 o'clock positions as traditionally taught — they are distributed unpredictably around the circumference of the urethra.[7][8] This variability further supports preserving the entire spongiosal shell rather than attempting selective arterial identification and sparing.

Indications​

  • Short isolated bulbar urethral strictures, typically 0.5–3 cm (mean 1.78 cm in the original multi-institutional series)[3]
  • Posterior urethral strictures (88.5% success rate in a 26-patient dedicated series)[5]
  • Post-radical prostatectomy bulbomembranous strictures — Jordan specifically highlighted the advantage of vascular preservation in patients who may later require artificial urinary sphincter (AUS) implantation, as preserved blood supply might help a subsequent cuff; the original report proposed this benefit without establishing reduced erosion[1]
  • Both primary and recurrent strictures
  • The original cohort included several etiologies; current EAU guidance favors tEPA for short nearly obliterative straddle-injury strictures with full-thickness fibrosis, and ntEPA or a graft for other short bulbar strictures. [18]

Surgical Technique​

Jordan’s original operation preserves the arteries to the bulb by developing a plane between the proximal blood supply and the urethra. Subsequent dorsal non-transecting modifications should be distinguished from the original description.[1]

The Verla/Lumen dorsal protocol exposes the bulbar urethra through the perineum, opens the dorsal stricture and excises scar while retaining healthy ventral spongiosum. The ventral urethral edges are reapproximated internally; the dorsal edges are spatulated and closed transversely, with spongioplasty. A dorsal stricturotomy is not merely a mucosal incision: the depth needed to reach the lumen and the amount of scar removed depend on anatomy.[5]

Avoid twisting or devascularizing retained attachments. Confirm a tension-free, adequately calibrated reconstruction; extensive full-thickness fibrosis may make vessel-sparing repair unsuitable. For technical variations and ventral access, see Non-Transecting Bulbar Urethroplasty.

Catheter duration is individualized; it is not universally shorter because a repair is non-transecting. Assess extravasation with urethrography before removal. [19]

Outcomes​

Original Jordan Series (2007)​

Jordan's landmark publication reported the first 10 patients (7 with adequate follow-up):[1]

  • Age range: 15–72 years (mean 47); one patient was 2 years old with a congenital stricture
  • Etiologies: 3 post-radical prostatectomy, 6 straddle trauma, 1 congenital
  • Stricture length: 0.5–2.5 cm (mean 1.5 cm)
  • Follow-up: Mean 12.5 months (range 6–38 months)
  • All seven with adequate follow-up had a widely patent repair; the other three had only short follow-up, so these data should not be presented as ten equally followed successes.

Multi-Institutional Validation — Virasoro et al., 2015​

A dedicated VS-EPA series, drawn from 5 international institutions:[3]

ParameterResult
Patients68
Age range3–82 years (mean 51.2)
Stricture length1–3 cm (mean 1.78 cm)
Follow-upMean 17.6 months
Success rate95.6% (widely patent urethral lumen)
Failures3 patients required DVIU/dilation; all symptom-free after

Verla / Lumen Series (2019) — Largest Single-Center Experience​

Verla et al. published the most detailed step-by-step protocol alongside the largest single-center cohort:[5][9]

  • 117 patients (91 bulbar, 26 posterior)
  • Bulbar VS-EPA success: 93.4%
  • Posterior VS-EPA success: 88.5%
  • Median operative time: 95 minutes
  • Median hospital stay: 2 days

Sexual Function — Key Comparative Data​

The Chapman et al. multi-institutional comparative analysis (352 patients, 4 surgeons) is the pivotal comparative study:[10]

  • De novo sexual dysfunction: 4.3% (non-transecting) vs. 14.3% (transecting) (p = 0.008)
  • On multivariate analysis, only the transecting technique was independently associated with sexual dysfunction (p = 0.01)
  • Age, stricture length, etiology, and surgeon were not independently predictive

The Scandinavian randomized trial (151 patients) compared tEPA with BMG, not Jordan VS-EPA. It found more penile complaints after tEPA but no significant IIEF-5 difference. Recurrence was 12.9% in both arms at 12 months, with insufficient power to establish equivalent recurrence risk.[11]

Potential Benefits and Evidence Limits​

Preserving urethral arterial inflow and a viable bed for future reconstruction is an anatomic goal. The Chapman result is a retrospective association for non-transecting anastomotic repairs, with a composite sexual-dysfunction endpoint; it is not a Jordan-specific erectile-dysfunction trial.[10] Lower subsequent AUS erosion remains a proposed benefit.[1]

The 2026 long-term Scandinavian report reinforces fewer penile complications with BMG than tEPA. It supports counseling about shortening and reduced glans filling while leaving the comparative benefits of individual vessel-sparing variants unresolved. [20]

Limitations​

  • Technical demand — preserving the blood supply can require additional dissection, time and expertise, as emphasized by the multi-institutional authors.[3]
  • Stricture length — Best suited for strictures <3 cm; longer strictures may require augmentation with buccal mucosal grafts (ANTA, MANTA, or ntAAU variants)[3][12]
  • Dense spongiofibrosis — Extensive periurethral fibrosis may make the plane between mucosa and spongiosum difficult to develop, potentially necessitating conversion to a transecting approach[12]
  • No direct RCT vs. transecting EPA — The Scandinavian RCT compared tEPA to BMG (non-transecting), not VS-EPA specifically; most comparative data remains retrospective[11][10]

Evolution and Legacy​

The Jordan VS-EPA has established the founding principle for an entire family of non-transecting techniques, each building on vascular preservation:[12]

  • Andrich / Mundy (2012) — Formalized the non-transecting anastomotic approach with a 22-patient series showing 100% success at 1 year[13]
  • Welk / Kodama (2012) — Extended the concept to augmented non-transected anastomotic urethroplasty (ANTA) with buccal mucosal grafts for longer strictures[14]
  • Joshi / Kulkarni (2022) — Introduced mucosal-sparing ANTA (MsANTA), preserving even the communicant mucosal vessels within the anastomotic segment[6]
  • Marks et al. (2023) — Developed MANTA (ventral mucomucosal anastomotic non-transecting augmentation) for obliterative segments within longer strictures[15]
  • Morán et al. (2021) — Described the ventral approach as an alternative avoiding circumferential dorsal spongiosa mobilization[16]

Contemporary data confirm the impact: across a multi-institutional urethroplasty cohort, bulbar excisional repairs performed without transection increased by +430% over a 7-year period (2010–2017), reflecting rapid adoption of the Jordan principle across international centers.[17]

Videos​

Jordan Vessel-Sparing EPA
Operative technique

References​

  1. Jordan GH, Eltahawy EA, Virasoro R. "The technique of vessel sparing excision and primary anastomosis for proximal bulbous urethral reconstruction." J Urol. 2007;177(5):1799–1802. doi:10.1016/j.juro.2007.01.036

  2. 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

  3. Virasoro R, Zuckerman JM, McCammon KA, et al. "International multi-institutional experience with the vessel-sparing technique to reconstruct the proximal bulbar urethra: mid-term results." World J Urol. 2015;33(12):2153–2157. doi:10.1007/s00345-015-1512-9

  4. Lee JY, Spratt DE, Liss AL, McLaughlin PW. "Vessel-sparing radiation and functional anatomy-based preservation for erectile function after prostate radiotherapy." Lancet Oncol. 2016;17(5):e198–208. doi:10.1016/S1470-2045(16)00063-2

  5. Verla W, Oosterlinck W, Waterloos M, Lumen N. "Vessel-sparing excision and primary anastomosis." J Vis Exp. 2019;(143). doi:10.3791/58214

  6. Joshi P, Bandini M, Kulkarni SB. "Mucosal-sparing augmented non-transected anastomotic (MsANTA) urethroplasty: a step forward in ANTA urethroplasty." BJU Int. 2022;130(1):133–136. doi:10.1111/bju.15734

  7. Chiou RK, Donovan JM, Anderson JC, et al. "Color Doppler ultrasound assessment of urethral artery location: potential implication for technique of visual internal urethrotomy." J Urol. 1998;159(3):796–799.

  8. Kishore TA, Bhat S, John RP. "Colour Doppler ultrasonographic location of the bulbourethral artery, and its impact on surgical outcome." BJU Int. 2005;96(4):624–628. doi:10.1111/j.1464-410X.2005.05696.x

  9. Lumen N, Poelaert F, Oosterlinck W, et al. "Nontransecting anastomotic repair in urethral reconstruction: surgical and functional outcomes." J Urol. 2016;196(6):1679–1684. doi:10.1016/j.juro.2016.06.016

  10. Chapman DW, Cotter K, Johnsen NV, et al. "Nontransecting techniques reduce sexual dysfunction after anastomotic bulbar urethroplasty: results of a multi-institutional comparative analysis." J Urol. 2019;201(2):364–370. doi:10.1016/j.juro.2018.09.051

  11. 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

  12. Coddington N, Higgins M, Mian A, Flynn B. "Non-transecting urethroplasty for bulbar urethral strictures — narrative review and treatment algorithm." J Clin Med. 2022;11(23):7033. doi:10.3390/jcm11237033

  13. Andrich DE, Mundy AR. "Non-transecting anastomotic bulbar urethroplasty: a preliminary report." BJU Int. 2012;109(7):1090–1094. doi:10.1111/j.1464-410X.2011.10508.x

  14. Welk BK, Kodama RT. "The augmented nontransected anastomotic urethroplasty for the treatment of bulbar urethral strictures." Urology. 2012;79(4):917–921. doi:10.1016/j.urology.2011.12.008

  15. Marks P, Dahlem R, Janisch F, et al. "Mucomucosal anastomotic non-transecting augmentation (MANTA) urethroplasty: a ventral modification for obliterative strictures." BJU Int. 2023;132(4):444–451. doi:10.1111/bju.16112

  16. Morán E, Sáez Moreno I, Bonillo MA, et al. "Ventral approach for the non-transecting bulbar urethroplasty." Urology. 2021;152:197–198. doi:10.1016/j.urology.2021.02.003

  17. Cotter KJ, Hahn AE, Voelzke BB, et al. "Trends in urethral stricture disease etiology and urethroplasty technique from a multi-institutional surgical outcomes research group." Urology. 2019;130:167–174. doi:10.1016/j.urology.2019.01.046

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

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

  20. 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.