Skip to main content

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. EAU 2026 strongly recommends transecting EPA for short post-traumatic bulbar strictures with nearly complete obliteration and full-thickness spongiofibrosis. It weakly recommends non-transecting EPA or a free graft instead of transecting EPA for short bulbar strictures unrelated to 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. For the origins of EPA with Marion and Heitz-Boyer, see the History of Urethral Surgery.

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 other procedures is <90%.[2]
  • The AUA Urethral Stricture Disease Guideline (2023) says surgeons may offer dilation, DVIU or urethroplasty initially for a short (<2 cm) bulbar stricture . It recommends urethroplasty initially for bulbar strictures ≥2 cm and instead of repeated endoscopic management for recurrent anterior strictures after failed dilation or DVIU . For recurrent bulbar strictures <3 cm, surgeons may also offer dilation or DVIU combined with a drug-coated balloon .[6]
  • Selected focal penile strictures. In a retrospective two-center series of 14 men (12 with traumatic or iatrogenic strictures, including four after penile fracture; median stricture length 1.0 cm), 13/14 (93%) remained patent without further reconstruction at a median follow-up of 43 months.[7] EAU 2026 strongly recommends against anastomotic urethroplasty for penile strictures >1 cm because of postoperative chordee risk.[16]
  • Appropriate for both primary and recurrent strictures, including repeat EPA after prior failed EPA, with comparable success rates (approximately 94–95%).[8]

In a single-surgeon cohort comparing anatomic location, 72 proximal bulbar strictures (within 5 cm of the membranous urethra, median length 2 cm, range 1–5 cm) were all reconstructed with EPA, with a 1.4% recurrence (1/72); 40 distal bulbar strictures (the segment from there to the penoscrotal junction) were treated predominantly with substitution grafting (90%, 36/40) and had a 28% recurrence rate (11/40).[5]

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​

After recent catheterization, self-dilation, dilation or DVIU, allow urethral rest before measuring the mature stricture and selecting EPA. EAU 2026 describes evaluation after about two months and urethroplasty after about three months, with suprapubic drainage for retention and longer rest if infection or inflammation persists.[17] EAU also describes urine culture one to two weeks before urethroplasty and preoperative antibiotic treatment for infection or colonization. It strongly recommends an intraoperative prophylactic antibiotic regimen selected to local resistance patterns.[17]

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. In transecting bulbar EPA, divide the urethra and corpus spongiosum through their full thickness at the stricture, then excise the fibrotic segment back to healthy, well-vascularized ends.[16]
  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 rather than 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. For persistent significant extravasation, maintain or reinsert the catheter and repeat urethrography after one week; a low-grade wisp-like leak may permit catheter removal. EAU notes an indwelling catheter is commonly left two to three weeks, with extravasation of 2.2–11.5% at three weeks across different urethroplasty techniques; after uncomplicated anterior EPA, removal at one versus two weeks gave similar extravasation (6.8% vs 4.5%) and recurrence (4.9% vs 5.2%) in one study. [17]

Anastomotic Closure by Layer​

De Win describes closing the relatively thin dorsal bulbar spongiosum in a single layer with three interrupted sutures. Because the ventral spongiosum is thicker, his sequence closes the urethral mucosa with at least three interrupted sutures and then adds a separate spongiosal layer, using 5-0 poliglecaprone (Monocryl) or 4-0 polyglactin (Vicryl). This layering and suture choice reflect De Win’s chapter-described technique.[22]

Extended Repair for a Proximal Bulbar Defect Under Tension​

For a selected proximal bulbar defect that remains under tension after standard mobilization, splitting the intercrural septum lets the distal urethra lie within the crural space, straightening the native bulbar curve and gaining additional length. In a single-institution series of 11 patients with strictures 2.6–5.0 cm long (mean 3.78 cm) reconstructed this way, 10 of 11 (91%) were successful at a mean follow-up of 22.1 months, with no increase in recurrence or erectile complaints compared to a similarly sized group with shorter proximal bulbar strictures repaired by the same technique.[23]

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 supplyBulbar arteries to the proximal segment sacrificed during mobilizationPreserved: arteries dissected off the urethra before it is divided[26]
Success rate93.8% pooled EPA; 98.8% and 97.1% in selected EPA seriesEAU ntEPA series (not VS-EPA-specific): 93.2–99% patency, defined by no further intervention (median follow-up 17.6–37.1 months)[1][2][3][16]
Erectile dysfunction riskReported ED 6/260 (2.3%) in one EPA series; ≥5-point SHIM decline in 41/215 (19.1%) six-month questionnaire respondents in anotherPooled non-transecting bulbar techniques, including graft repair: ED RR 0.73 (95% CI 0.49–1.08) versus transecting techniques[1][3][4][20][21]
Penile complicationsHigher in pooled transecting comparisonsLower for pooled non-transecting techniques, including graft repair (RR 0.47, 95% CI 0.28–0.76)[20]
Failure rate (single-center cohort, differing follow-up)11.6%6.8%[10]

In a retrospective single-center cohort, failure occurred in 6/88 (6.8%) after ntEPA at median 32 months versus 13/112 (11.6%) after tEPA at median 118 months (p = 0.333); unequal follow-up limits a durability comparison. The study found no observed increase in high-grade complications or operative time with ntEPA. Diabetes and prior urethroplasty were associated with failure, whereas technique was not independently associated with failure in this cohort.[10] A 2026 phase II VeSpAR randomized trial conference abstract reported 24-month failure-free survival of 93.6% among 51 patients assigned vessel-sparing repair versus 88.3% among 49 assigned transecting repair (intention to treat); failure was inability to pass a 16 Fr cystoscope without mucosal disruption. The abstract reported that its prespecified 10% noninferiority criterion was met; 9/51 vessel-sparing assignments converted intraoperatively for full-thickness spongiofibrosis, and 12-month erectile-function data were available for only 20 and 33 men, respectively.[24]

Outcomes​

EPA has high reported success in selected cohorts, but endpoint definitions differ.[1] In Eltahawy's retrospective series, 257/260 (98.8%) were symptom-free and needed no further procedures at mean 50.2-month follow-up.[1]

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]268 / 19 / 18251/268 (94%) / 18/19 (95%) / 17/18 (94%)overall mean 41.5 mo; each group >30 mo
Jasionowska 2022 SR[11]—89.7% (median across 5 studies; median stricture length 2.1 cm)—

In Horiguchi's retrospective cohort, mean Qmax improved from 7.7 to 24.1 mL/s; 212/215 six-month questionnaire respondents (98.6%) reported being satisfied or very satisfied. Only 215/308 patients (69.8%) completed the questionnaire.[3]

Complications​

Older series reported low perioperative complication rates.[1][2]

ComplicationRateReference
Erectile functionReported ED: 6/260 (2.3%) in Eltahawy's retrospective series; ≥5-point SHIM decline at six months: 41/215 questionnaire respondents (19.1%) in Horiguchi's retrospective series; postoperative SHIM >15 in 69% after both transecting EPA and dorsal onlay among Furr's questionnaire respondents (no preoperative SHIM); definitions differ across reports[1][3][4][12]
Urinary tract infection~5%[1]
Position-related neuropraxia~3.4%[1]
Scrotalgia~1.5%[1]
Wound complications~1.5%[1]
Postoperative scrotal/perineal hematoma in the Scandinavian short-bulbar RCT18/75 (24%) after transecting EPA vs 3/76 (3.9%) after BMG[18]
Tethering with erections23.4% after EPA vs 3.1% after dorsal onlay among postoperative questionnaire respondents (128/179 of the cohort participated)[12]
Postvoid dribbling most or all of the time8.3% after EPA vs 28.1% after dorsal onlay among postoperative questionnaire respondents (128/179 of the cohort; 96 EPA, 32 onlay)[12]
Incontinence~1% (2/150; series included posterior and pelvic-fracture repairs)[13]

In the Eltahawy and Jordan series, ED occurred in 2.3% (6/260), with 4 of 6 having a history of significant straddle trauma.[1] In Horiguchi's retrospective 308-patient cohort, 41/215 six-month questionnaire respondents (19.1%) had ≥5-point SHIM deterioration.[3] Among Furr's postoperative questionnaire respondents (96 EPA, 32 dorsal onlay), SHIM scores did not differ significantly; tethering with erections was reported by 23.4% versus 3.1%, respectively.[12] Pooled data favor non-transecting repair for penile complications and, in one meta-analysis, ED.[20][21]

EPA vs. Other Urethroplasty Techniques​

The 151-patient Scandinavian randomized trial compared transecting EPA with BMG for bulbar strictures ≤2 cm in adults aged 18–70 without prior open urethroplasty; median stricture length was 1 cm in each arm.[18] At 12 months, reduced glans stiffness during erection was reported by 13/70 (19%) after transecting EPA versus 5/74 (6.8%) after BMG, and perceived erect penile shortening by 18/70 (26%) versus 4/74 (5.4%), respectively.[18] IIEF-5 scores did not differ significantly. Recurrence, defined as need for retreatment, was 12.9% overall among 147 with recurrence data at 12 months: 12.0% after transecting EPA (9/75 randomized) versus 13.2% after BMG (10/76 randomized).[18][19] The trial was not powered to establish equal recurrence risk.[18][19] A 2026 update of the trial, reporting the same 3- and 12-month data, found one or more penile complications (reduced glans stiffness, loss of glans sensation, shortening or changed direction of the erect penis) at 12 months in 23 men (33%) after transecting EPA versus 12 (16%) after BMG (p = 0.02); the authors advise avoiding transection of the corpus spongiosum when possible, and follow-up of at least 6 years is planned.[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.[5]

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 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 stricture excision, paired ventral plication sutures in the proximal corpora shorten the gap until the urethral ends can be approximated without tension; the ends are then anastomosed. 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; in the original series it did not change significantly.[15]

Key technical principles:

  • EPAPP uses ventral corporal plication to reduce the urethral gap. Peyronie plication also shortens tunica; its location depends on curvature.
  • Symmetry first (paired sutures across both corporal bodies), with unilateral sutures only as needed to correct any residual asymmetry.
  • 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 urethral defects. In the 10-patient EPAPP series, the mean intraoperative gap between urethral ends after excision was 3.75 ± 1.4 cm.[15]
  • Avoiding graft harvest. VanDyke and colleagues describe EPAPP candidates as older men with multiple comorbidities and obliterative strictures greater than 2 cm after failed endoscopic management, particularly when they wish to avoid graft harvest and preserve standing voiding.[15]
  • The original 10-patient cohort had a mean age of 66.6 years, and most men were not sexually active before surgery.[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 by one surgeon at the originating institution)[15]
Mean intraoperative urethral defect length3.75 ± 1.4 cm[15]
Mean age66.6 yr (vs 55.6 yr for the general urethroplasty cohort)
Sexually active preoperativelyminority
Postop VCUGurethral patency without extravasation in all 10
Asymptomatic without retreatment8/10 (80%) at median follow-up 9.7 mo (IQR 8.5–11.5)[15]
Recurrence2/10 — both managed with a single balloon dilation[15]

Most men in the original 10-patient EPAPP series were not sexually active before surgery, and postoperative sexual function was not measured. Discuss potential penile shortening and curvature during selection.[15]

Patient counseling​

  • Penile shortening. In the original 10-patient series, stretched penile length did not change significantly (13.2 vs 12.8 cm, p = 0.68); the authors hypothesize that this reflects plication placed in the perineum or scrotum, proximal to the visible shaft. Measure length before and after repair.[15]
  • 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; it 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 single-stage option for selected older or 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.[14]

  • Lichen sclerosus (generally excluded from EPA candidacy)

Follow-Up​

Eltahawy's retrospective cohort used a patent six-month postoperative cystoscopy as the condition for later telephone contact in patients who did not return to clinic.[1] EAU 2026 strongly recommends at least one year of follow-up, patient-reported outcome measures and validated sexual-function questionnaires after urethroplasty; it weakly recommends flexible cystoscopy at three months and risk-adjusted surveillance. For low-risk bulbar anastomotic repair without prior radiotherapy, hypospadias or lichen sclerosus, its proposed schedule uses uroflowmetry and patient-reported measures at 3, 12 and 24 months, with anatomic assessment at three months and later as indicated. Anastomotic bulbar repairs after radiotherapy and penile or non-traumatic posterior repairs enter a longer standard-risk schedule.[25] 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
EPA Urethroplasty for Bulbar Straddle Injury
Sean Elliott, MD

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. doi:10.1159/000480803

  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, sections 6.3.2 (bulbar urethroplasty; the short-stricture limit is usually about 2 cm). 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.

  20. Oszczudlowski M, Yepes C, Dobruch J, Martins FE. Outcomes of transecting versus non-transecting urethroplasty for bulbar urethral stricture: a meta-analysis. BJU Int. 2023;132(3):252-261. doi:10.1111/bju.16108.

  21. Zhao X, Xing Y, Zhang X, et al. Low risk of erectile dysfunction after nontransecting bulbar urethroplasty for urethral stricture: a systematic review and meta-analysis. J Sex Med. 2024;21(1):11-19. doi:10.1093/jsxmed/qdad141.

  22. De Win G. Anastomotic and Augmented Anastomotic Urethroplasty. In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:53-55.

  23. Morey AF, Kizer WS. Proximal bulbar urethroplasty via extended anastomotic approach--what are the limits? J Urol. 2006;175(6):2145-9. doi:10.1016/S0022-5347(06)00259-X.

  24. Verla W, Waterloos M, Waterschoot M, et al. "IP39-01 VeSpAR trial: a randomized controlled trial comparing vessel-sparing anastomotic repair and transecting anastomotic repair in isolated, short, bulbar urethral strictures." J Urol. 2026;215(5S):e805. doi:10.1097/01.JU.0001191512.50502.2b.01.

  25. European Association of Urology. "EAU Guidelines on Urethral Strictures: Follow Up." In: EAU Guidelines. 2026 ed. EAU Guidelines Office; 2026. ISBN 978-94-92761-32-5. Guideline chapter.

  26. 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.