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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 for selected proximal bulbar or bulbomembranous strictures: the urethra was divided while the bulbar arteries and adjacent spongiosum were preserved, except in one midbulbar case that required spongiosal division distal to the vessels.[1] Selected cohorts report high patency.[1][3][22] 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 (see Penis Anatomy and Physiology). In standard transecting EPA, full-thickness spongiosal transection interrupts antegrade bulbar arterial inflow at the repair.[18] 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] Doppler-guided sparing of one or both bulbar arteries has also been described for pelvic fracture urethral injury repair (26 patients, mean follow-up 20 months).[4]

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

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]

A further anatomical caution: marked distal mobilization or a history of severe hypospadias may compromise the retrograde limb of urethral perfusion.[21] When dual inflow is compromised, anastomotic repair can risk proximal ischemia, and substitution repair may be preferable.[21]

Indications​

  • Short isolated bulbar urethral strictures, 1–3 cm in the cited multi-institutional series (mean 1.78 cm)[3]
  • Selected posterior urethral stenoses: the Verla/Lumen variant achieved freedom from repeat manipulation in 23/26 patients (88.5%) at median 45 months.[5] A separate 2025 vessel-sparing posterior series reported repair success in 121/127 (95%) at median 43 months, with stress incontinence in 24/127 (19%) and grade III or higher complications in 6/127 (5%).[26]
  • 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 recommends tEPA for short post-traumatic bulbar strictures with nearly complete obliteration and full-thickness spongiofibrosis , and ntEPA or free graft urethroplasty instead of tEPA for short bulbar strictures not related to straddle injury .[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. The depth of the dorsal stricturotomy needed to reach the lumen and the amount of scar removed depend on anatomy.[5]

For a tension-free repair, Delong, Monn, Jordan and Virasoro describe releasing Buck's fascia and mobilizing distally no farther than the penoscrotal junction and proximally toward the membranous urethra; when more proximal reach is needed, they describe dividing the triangular ligament and dissecting into the intracrural space.[22][24]

Avoid twisting or devascularizing retained attachments. Confirm a tension-free, adequately calibrated reconstruction. If the stricture proves too long for tension-free approximation, consider conversion to an augmented repair with a free graft or pedicled flap; the Verla/Lumen protocol favors a dorsal onlay graft after dorsal stricturotomy.[5] In the Verla/Lumen posterior protocol, inadequate access to the proximal scar, including access limited by pelvic-fracture distortion, prompts conversion to transecting repair so that all fibrotic tissue can be excised; extensive full-thickness fibrosis may also make vessel-sparing repair unsuitable.[5] For technical variations and ventral access, see Non-Transecting Bulbar Urethroplasty.

Catheter duration is individualized. 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]

  • Among seven patients with adequate follow-up, the age range was 15–72 years (mean 47); a separate patient with a congenital stricture was 2 years old.[1]
  • Etiologies: 3 post-radical prostatectomy, 6 straddle trauma, 1 congenital
  • Stricture length: 0.5–2.5 cm (mean 1.5 cm)[1]
  • Follow-up: Mean 12.5 months (range 6–38 months)
  • All seven with adequate follow-up had a patent urethra on urethrocystoscopy at 6 months and no voiding difficulty; the other three had not reached 6 months, and all 10 appeared stricture-free at submission.[1]

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 a detailed step-by-step protocol with a 117-patient single-center cohort. Their success endpoint was freedom from repeat urethral manipulation: 85/91 (93.4%) bulbar patients at median 35 months and 23/26 (88.5%) posterior patients at median 45 months.[5]

  • In 117 patients (91 bulbar, 26 posterior), complications occurred in 28/117 (23.9%), including one grade IIIb hematoma drained under general anesthesia.[5]
  • Bulbar VS-EPA success: 93.4%[5]
  • Posterior VS-EPA success: 88.5%[5]

In the earlier Lumen 2016 report of 75 patients treated with nontransecting anastomotic repair (55 short bulbar, 20 posterior), median operative time was 95 minutes and median hospital stay 2 days. At median follow-up of 30 months, stricture had recurred in 6 patients (8%), all diagnosed within 7 months.[9] De novo erectile dysfunction was reported by 7 of 32 evaluable patients (21.9%) and post-void dribbling by 2 of 42 (4.7%) at 3 months.[9]

Sexual Function — Key Comparative Data​

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

  • De novo sexual dysfunction at 6 months: 4.3% (non-transecting) versus 14.3% (transecting) (p = 0.008)[10]
  • 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. It found more penile complaints after tEPA but no significant IIEF-5 difference. Recurrence, defined as need for retreatment, was 12.9% overall among 147 with recurrence data: 12.0% after tEPA (9/75 randomized) and 13.2% after BMG (10/76 randomized) at 12 months[11][20]; the trial was not designed 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.[10] Meta-analyses of largely retrospective non-transecting bulbar comparisons differed on erectile dysfunction: Oszczudlowski et al. found no statistically significant difference (RR 0.73, 95% CI 0.49–1.08), whereas Zhao et al. found a lower incidence after non-transecting repair.[27][28] Oszczudlowski et al. found fewer penile complications (RR 0.47, 95% CI 0.28–0.76).[27][28] Jordan proposed lower subsequent AUS erosion as a potential benefit.[1] A 2026 meta-analysis of four observational studies (533 AUS recipients across all comparisons) associated prior transecting versus non-transecting urethroplasty with higher erosion (RR 2.34, 95% CI 1.30–4.21).[23]

A 2026 update of the Scandinavian trial, restating its 12-month results, reported more penile complications after tEPA than BMG, especially shortening (26% vs 5.4%) and reduced glans stiffness (19% vs 6.8%). The authors credit Jordan (2007) with introducing non-transecting EPA and note that no randomized trial has compared tEPA with ntEPA.[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]
  • Direct randomized evidence (2026 VeSpAR conference abstract). In 100 men randomized to vessel-sparing or transecting anastomotic repair, 24-month failure-free survival, with failure defined as inability to pass a 16 Fr cystoscope without mucosal disruption, was 93.6% versus 88.3%; the authors reported noninferiority under their prespecified 10% margin and 80% confidence-interval criterion.[25] Nine of 51 vessel-sparing assignments converted intraoperatively because of full-thickness spongiofibrosis. Erectile-dysfunction differences were not statistically significant, with 24-month questionnaire data for only 20 versus 31 men. The tested protocol postdated Jordan's original artery dissection.[25][5] Earlier comparative evidence was retrospective.[10]

Evolution and Legacy​

Jordan VS-EPA preceded a family of non-transecting techniques that share the aim of preserving vascular supply (see also the History of Urethral Surgery):[12]

  • Andrich / Mundy (2012). Described a non-transecting anastomotic approach in a 22-patient preliminary series; the 16 patients with at least 1 year of follow-up had no recurrence on symptoms and uroflowmetry[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]

In the TURNS multi-institutional database (2,098 anterior urethroplasties by 10 surgeons, 2010 to 2017), the share of bulbar excisional repairs performed without transection rose by 430% over the 7-year period.[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. Gomez RG, Campos RA, Velarde LG. "Reconstruction of Pelvic Fracture Urethral Injuries With Sparing of the Bulbar Arteries." Urology. 2016;88:207–212. doi:10.1016/j.urology.2015.09.032

  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. doi:10.1016/s0022-5347(01)63734-0

  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.

  21. Brandes SB. Vascular Anatomy of Genital Skin and the Urethra: Implications for Urethral Reconstruction. In: Brandes SB, Morey AF, eds. Advanced Male Urethral and Genital Reconstructive Surgery. 2nd ed. Humana Press; 2014:30-31.

  22. Gur U, Jordan GH. Vessel-sparing excision and primary anastomosis (for proximal bulbar urethral strictures). BJU Int. 2008;101(9):1183-95. doi:10.1111/j.1464-410X.2008.07619.x.

  23. Deameh MG, Mohamed H, Abdelshafi A, Mohamed T, Ramez M. "Association of Prior Urethroplasty and Technique With Outcomes After Artificial Urinary Sphincter Implantation: A Systematic Review and Meta-analysis." Urology. 2026;214:135–142. doi:10.1016/j.urology.2026.05.024

  24. Delong J, Monn MF, Jordan G, Virasoro R. "Jordan Vessel-Sparing EPA Urethroplasty." In: Joshi PM, Aubé-Peterkin M, Kulkarni SB, Datar G, eds. Surgical Atlas of Urethroplasty. Springer; 2024:71–76. doi:10.1007/978-981-97-5196-9_9

  25. 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 [conference abstract]. doi:10.1097/01.JU.0001191512.50502.2b.01

  26. Gómez RG, Velarde LG, Campos RA, Barrientos V. "Vessel-sparing non-transecting anastomotic reconstruction of the posterior urethra: single center experience with long-term follow-up." Urology. 2025;196:283–289. doi:10.1016/j.urology.2024.10.059

  27. 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

  28. 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