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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 paradigm-shifting modification of traditional transecting EPA.[1] By preserving the corpus spongiosum and its dual arterial blood supply while excising only the diseased mucosal segment, VS-EPA achieves stricture-free rates of 90–98% with a significantly reduced risk of erectile dysfunction and glans ischemia compared to classical transecting repair.[2][3]

Anatomical Rationale​

The fundamental insight behind the Jordan technique is that traditional transecting EPA inflicts unnecessary vascular collateral damage. 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 recognized that since EPA requires only excision of the narrowed mucosal segment and surrounding spongiofibrosis, complete spongiosal transection is surgically unnecessary.[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]
  • Communicant vessels — from the corpus spongiosum to the urethral mucosa[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 well-vascularized urethral tissue reduces cuff erosion risk[1]
  • Both primary and recurrent strictures
  • Etiologies: straddle trauma, iatrogenic, idiopathic, and congenital[1]

Surgical Technique​

The procedure is performed via a perineal incision in dorsal lithotomy position.

Step 1 — Exposure and Identification

  • Midline perineal incision; bulbospongiosus muscle divided in the midline.
  • The strictured segment is confirmed by palpation and intraoperative assessment (bougie, flexible cystoscopy, or retrograde urethrography).

Step 2 — Mobilization of the Corpus Spongiosum

  • The corpus spongiosum is mobilized from the underlying corpora cavernosa.
  • A plane is developed between the urethra and the proximal blood supply at the bulbospongiosum, preserving the arteries to the bulb without dividing the spongy tissue.[1]
  • The corpus spongiosum is then rotated 180° to expose the dorsal surface.

Step 3 — Dorsal Urethrotomy

  • A dorsal midline urethrotomy is made through the strictured segment, extended proximally and distally into healthy, well-calibrated urethra (confirmed by passage of a 20 Fr sound or cystoscope).
  • The corpus spongiosum is not transected — only the mucosal layer is incised.

Step 4 — Mucosectomy

  • Fibrotic mucosal tissue and surrounding spongiofibrosis are excised from within the intact spongiosal shell.
  • This is the defining departure from traditional EPA: only the diseased mucosa is removed; the outer corpus spongiosum with its vascular supply remains intact throughout.
  • Excision is carried back to healthy, well-vascularized mucosal tissue on both ends.

Step 5 — Spatulation and Anastomosis

  • Healthy mucosal edges are spatulated on opposite sides to widen the anastomotic lumen.
  • A tension-free, mucosa-to-mucosa anastomosis is performed using 5-0 absorbable sutures (polyglycolic acid or monofilament) in interrupted or running fashion.
  • The dorsal urethrotomy is then closed.

Step 6 — Spongioplasty

  • The corpus spongiosum is closed over the anastomosis with 4-0 absorbable sutures, restoring a well-vascularized tissue cover.

Step 7 — Closure and Catheterization

  • Bulbospongiosus muscle reapproximated; perineal wound closed in layers.
  • A 16–18 Fr urethral catheter is left in place for 9–14 days — shorter than the 14–21 days typical of transecting EPA.[5][9]

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)
  • Success: All 10 patients stricture-free at last follow-up

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

The largest 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 Urethroplasty Study (only RCT, 151 patients) confirmed that transecting EPA produced significantly more penile complications (p = 0.02), including reduced glans filling (p = 0.03) and penile shortening (p = 0.001), with no difference in stricture recurrence rates (12.9% in both arms).[11]

Advantages Specific to the Jordan Technique​

  1. Erectile function preservation — The primary clinical advantage. De novo sexual dysfunction reduced from 14.3% to 4.3% (p = 0.008)[10]
  2. Glans perfusion — Preserved bulbar arteries maintain antegrade blood flow to the glans, reducing glans ischemia — particularly relevant in patients with pre-existing vascular risk factors[2][1]
  3. Future reconstructive options — An intact, well-vascularized spongiosal bed is available for redo urethroplasty with free grafts (buccal mucosa graft take depends on recipient bed vascularity)[5]
  4. AUS compatibility — In post-prostatectomy patients who may later require an artificial urinary sphincter, preserved urethral blood supply reduces the risk of cuff erosion[1]
  5. Reduced penile shortening — Significantly less shortening and chordee compared to transecting EPA (Scandinavian RCT, p = 0.001)[11]
  6. Shorter catheterization — Approximately 9–14 days vs. 14–21 days for transecting EPA[5][9]

Limitations​

  • Technical demand — Jordan himself acknowledged that "preservation of blood supply is always a noble achievement in surgery; however, it technically often requires significant effort."[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]

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