There are many options for male urethral stricture reconstruction surgery; however, regardless of the approach, there is a high incidence of postoperative sexual dysfunction, particularly erectile dysfunction. There is a paucity of research in this area, using different methods, so it is difficult to conclusively determine the exact incidence of sexual dysfunction after urethral reconstruction surgery. In order to study the factors affecting erectile function and sexual quality of life in men with urethral stenosis treated by urethral reconstruction surgery, we retrospectively analyzed the clinical data of 326 male patients who underwent urethral reconstruction surgery and used a standard and validated questionnaire to assess erectile function and sexual quality of life.
1. Materials and methods
1.1 Clinical data A total of 517 male patients with urethral stricture who underwent urethral reconstruction surgery in our department between January 2003 and January 2007 were selected according to the need of the study. 326 male patients aged 20 to 65 years were selected, all of whom were married or had regular sexual partners; other diseases that may cause erectile dysfunction (ED) (such as diabetes mellitus, depression, etc.) were excluded; other diseases that may cause erectile dysfunction (ED) (such as diabetes mellitus, depression, etc.) were excluded. Patients with bladder irrigation chemotherapy or radiotherapy or chemotherapy for other tumors were excluded; no history of surgery within 6 months after surgery.
1.2 Questionnaire survey and scoring Patients completed three forms, namely, the QoL, IIEF-5, and SLQQ, to assess their preoperative, 3-month, and 6-month postoperative conditions, respectively, through three methods: outpatient follow-up, form correspondence, and telephone follow-up, with follow-up times ranging from 6 to 54 (28.5±13.0) months. 13.0) months. Preoperative and 3-month postoperative conditions were assessed by recall, while the recent urinary flow rate was recorded. The need for regular postoperative urethral dilatation or a maximum urinary flow rate (Qmax) <15 ml/s was considered a recurrence. the first 10 questions measuring sexual quality of life were selected from the SLQQ table [2], and the original entry score range of -4 to + 4 each plus 4 points was converted into a range of 0 to 8 points, i.e., each score plus 4 points, and then the total score for each entry was calculated.
1.3 Statistical treatment The SAS 6.12 data package was used for statistical analysis. Data were expressed as -`x±s, paired t-tests were used for pre- and post-surgery for measurement data, group t-tests were used for inter-group comparisons, and x2 tests were used for count data. Risk factors leading to postoperative ED were analyzed by multifactorial logistic regression. p < 0.05 was statistically significant.
2, Results
A total of 172 (52.8%) valid data were collected in 326 patients followed up, aged 41.8 ± 12.0 years, including 80 cases <40 years, 47 cases 40 ~ 50 years, 32 cases 50 ~ 60 years, and 13 cases ≥60 years. There were 93 cases of anterior urethral stricture and 79 cases of posterior urethral stricture. The length of stricture was 0.5 ~ 20(3.7±3.9) cm, and the length of stricture was <50px in 65 cases, 2 ~ 125px in 70 cases, 5 ~ 250px in 16 cases, and ≥250px in 21 cases. The surgery was performed by endourethrotomy in 56 cases, transconjunctival urethral anastomosis in 57 cases, transcubital urethral anastomosis in 7 cases, and various autologous tissue replacement urethral reconstruction in 52 cases. The number of surgical procedures ranged from 1 to 9 (1.9±1.4). Overall, QoL score and Qmax improved significantly after surgery, p < 0.05; IIEF-5 and SLQQ scores decreased significantly after surgery compared with preoperative scores, p < 0.05 (Table 1).
Table 1 Comparison of Qmax, QoL, IIEF-5, and SLQQ before and after surgery (`x±s)
Table1. comparison of Qmax, QoL, IIEF-5, SLQQ before surgery with
6 months after surgery(`x±s )
Before surgery 6 months after surgery P
Qmax (ml/s) 6.8±4.6 23.4±9.0 0.000
QoL 4.9±1.2 1.1±1.4 0.000
IIEF-5 18.6±9.6 16.0±10.2 0.002
SLQQ 55.2±31.3 49.6±33.1 0.026
According to the age group, IIEF-5 decreased significantly in patients <40 years old and 40-50 years old compared with the preoperative period; according to the stenosis length group, IIEF-5 decreased significantly in patients in the 2 ~ 125 px group after surgery; according to the stenosis site group, IIEF-5 decreased significantly in patients with posterior urethral stenosis after surgery; according to the procedure group, only the perineal route urethral anastomosis had the most significant effect on erectile function (Table 2).
Table 2 Comparison of IIEF-5 scores before and after surgery in each group
Table2. Dividing into groups to compare the IIEF-5 score before surgery with 6 months after surgery
Group n (%)
IIEF-5 score(`x±s )
P
Before surgery 6 months after surgery
Age: 172 (100) 18.6±9.6 16.0±10.2 0.002
<40 80 (46.5) 19.5±9.6 16.6±10.4 0.023
40-50 47(27.3) 18.8±9.8 15.4±10.5 0.035
50-60 32 (18.6) 17.1±9.8 14.9±9.7 0.222
>60 13 (7.6) 17.2±9.8 17.8±9.5 0.832
Stricture length:
<50px 65(37.8) 20.8±8.2 20.2±8.8 0.473
2-125px 70(40.7) 18.9±9.7 14.3±10.0 0.001
5-250px 16(9.3) 15.8±11.2 13.4±11.4 0.374
>250px 21(12.2) 13.4±10.4 11.4±10.0 0.547
Stricture location:
AU 93(54.1) 19.2±9.1 19.0±8.9 0.906
PU 79(45.9) 18.0±10.3 12.4±10.5 0.000
Surgery method:
IU 56(32.6) 20.8±8.4 21.2±7.9 0.496
PAUP 57(33.1) 19.3±9.4 14.1±10.0 0.000
PAUSP 7(4.1) 15.7±11.6 10.0±11.2 0.488
SUAT 52(30.2) 16.1±10.5 13.4±10.6 0.138
AU: anterior urethra.
PU: posterior urethra.
IU: internal urethrotomy.
PAUP: posterior anastomotic urethroplasty through perinaeum.
PAUSP: posterior anastomotic urethroplasty through symphysis pubis.
SUAT: substitution urethroplasty with autologous tisse.
There were 56 patients (32.6%) with preoperative ED and 88 patients (51.2%) at postoperative follow-up, an increase of 18.6%, of whom 6 patients with preoperative ED (10.7%) had improved sexual function postoperatively. Preoperatively, 116 patients (67.4%) with normal erectile function and 38 patients (32.8%) with postoperative ED were analyzed univariately postoperatively in these 116 patients, with urethral stricture length (P = 0.0001), stricture site (P = 0.001), surgical approach (P = 0.001), and postoperative recurrence (P = 0.001) as risk factors (Table 3).
Table 3 One factor analysis of influencing postoperative sexual function
Table3. one factor analysis of urethroplasty influencing postoperative sexual function
Group n age length(cm)* times
Location(n)*
Surgery method(n)*
Recurrence rate* (%)
AU/PU
IU PAUP PAUSP SUAT
ED 38 40.4±10.2 4.7±3.9 1.9±1.0 10/28 3 22 2 11 36.8
Normal 78 40.1±11.5 2.3±2.5 1.6±1.1 55/23 42 18 1 17 4.0
*: p < 0.05< span="">
In order to control for interactions and confounding factors among the factors and exclude other interfering terms, all four variables with statistical significance in the univariate analysis were introduced into the conditional logistic multiple regression equation according to the P < 0.05 significance criterion, and the three statistically significant factors were finally screened out, in order of risk, as urethral stricture site, surgical method, and postoperative recurrence (Table 4).
Table 4 Multi-factor logistic regression analysis of urethral reconstruction affecting postoperative sexual function
Table 4: Logistic regression analysis of urethroplasty influencing postoperative sexual function
Variable Parameter Standard Wald P Regression OR
Estimate Error Chi-square Coefficient
Location 3.0123 0.6957 18.7458 0.0001 0.830045 20.334
Method -1.1884 0.3017 15.5158 0.0001 -0.774591 0.305
Recurrence -2.2642 0.7404 9.3530 0.0022 -0.508247 0.104
3 , Discussion
Male urethral stricture is one of the common diseases in urology, and due to the complexity of the lesion, there is no single treatment method. Depending on the etiology, location, length and complications of urethral stricture, the treatment methods mainly include urethral dilatation, endourethrotomy, end-to-end urethral anastomosis, and autologous tissue replacement at the site of urethral stricture. Long urethral strictures are generally not suitable for stenosis segment excision and end-to-end anastomosis because they can lead to penile curvature and painful erection, and alternative urethroplasty, stenosis segment urethral splitting stage II urethroplasty, etc. The urethral substitutes currently used in clinical practice are the inner foreskin plate, tipped penile or scrotal flap, free bladder mucosa, oral mucosa, colonic mucosa, and lingual mucosa, which has recently been applied.
Overall, urethral reconstruction can significantly improve patients’ urination and quality of life, while also reducing their postoperative erectile function and quality of sexual life. young and middle-aged patients under 50 years of age are more likely to have ED after surgery, probably due to the greater psychological impact, while older patients have mostly decreased erectile function before surgery, so the impact caused by surgery is relatively reduced. In terms of the site of urethral stricture, ED is highly likely to occur after surgery for posterior urethral stricture, while anterior urethral stricture has few effects after surgery. This is related to intraoperative damage to the penile cavernous nerves that pass through it. In the membranous urethra, the cavernous nerve is located at the 3 and 9 o’clock positions, with some nerve fibers crossing the white membrane of the urethral corpus cavernosum and the remaining nerve fibers at the 1 and 11 o’clock positions, accompanied by branches of the internal pubic nerve artery and cavernous vein into the penile pedicle, making it extremely easy to injure the cavernous nerve that passes through it during posterior urethral reconstruction surgery. In a clinical trial, Chao Feng et al. found that with the same length of urethral stricture, the erectile length, circumference, and even erection duration were significantly lower in patients with posterior urethral injury or surgery than in patients with anterior urethral injury or surgery. The erectile nerves that innervate the penis have branched into the bilateral cavernous network in the anterior urethra, so an injury or surgery to the anterior urethra does not usually completely disrupt the erectile function of the penis. Scar resection urethral anastomosis is a good treatment for simple urethral stricture, and erectile function and sexual quality of life were significantly reduced in patients in this group after transconjunctival urethral anastomosis. moudouni et al. performed endoscopic urethral meeting (30 cases) and conventional end-to-end anastomosis (10 cases) in 40 patients with posterior urethral injury, and four cases developed ED (40%) after end-to-end anastomosis. harwood et al [8 ] concluded that the incidence of ED after end-to-end urethral anastomosis ranged from 3% to 69%, and the reason was related to the fact that the vascular nerve bundle around the urethra may be damaged during the operation of this type of procedure thus increasing the incidence of ED. In our study, patients with strictures of 2 to 125 px had a significant decrease in erectile function after surgery, mainly because most patients with strictures less than 50 px had an endourethral incision. 2 to 125 px posterior urethral strictures were mostly treated with trans-perineal urethral anastomosis, so erectile function decreased significantly after surgery, while strictures in the anterior urethra were not suitable for end-to-end anastomosis because of complications such as penile curvature and painful erection. Most of them are replaced by autologous tissues, while the reconstruction of anterior urethral stricture by autologous tissue replacement does not produce ED.
The quality of sexual life in postoperative patients is closely related to their erectile function, so the analysis of relevant factors in this study was only for the factors affecting erectile function. The analysis showed that the factors affecting postoperative erectile function were related to the site of urethral stricture, surgical approach, and postoperative recurrence. Also a more significant finding was that there were 88 patients (51.2%) with ED after 6 months of surgery, which was 19 fewer than 107 patients (62.2%) at 3 months after surgery. The SLQQ was 40.8±33.9 and 49.6±33.1 at 3 months and 6 months after surgery, respectively, P<0.05, and the IIEF-5 was 14.5±10.9 and 16.0±10.2, respectively, P<0.05, both of which were statistically significant. This suggests that postoperative erectile function and sexual quality of life may gradually improve with longer postoperative time. This finding was also confirmed by the results of Mundy, who retrospectively analyzed more than 200 patients with urethral reconstruction and found that although the occurrence of postoperative decline in erectile function was elevated, most recovered over time. The key reasons for this were the gradual psychological and physical recovery, the return of penile sensitivity, and the reduction of local tissue swelling. corriere evaluated 60 patients with posterior urethral injury, 29 (48%) had no erectile function at all in the immediate postoperative period, decreasing to 20 (33%) after 1 year, demonstrating that there is also a strong association between postoperative recovery time and erectile dysfunction.