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 Apr;81(4):375-382. doi: 10.1016/j.eururo.2021.12.017. Epub 2022 Jan 8.


Background: Open surgical treatment of short bulbar urethral strictures (urethroplasty) is commonly performed as transecting excision and primary anastomosis (tEPA) or buccal mucosa grafting (BMG). Erectile dysfunction and penile complications have been reported, but there is an absence of randomised trials.

Objective: To evaluate sexual dysfunction and penile complications after urethroplasty with tEPA versus BMG.

Design, setting, and participants: Centres in Finland, Sweden and Norway participated. Patients with a bulbar urethral stricture of ≤2 cm without previous urethroplasty were randomised. The primary endpoints were the degree of erectile dysfunction and penile complications. Follow-up was 12 mo.

Intervention: Patients were randomised to either tEPA or BMG urethroplasty.

Outcome measurements and statistical analysis: Sexual dysfunction was measured using the International Index of Erectile Function, 5-item version (IIEF-5) and a penile complications questionnaire (PCQ) designed for this study. Continuous data were analysed using analysis of covariance and categorical data were compared using a χ2 test.

Results and limitations: A total of 151 patients were randomised to either tEPA (n = 75) or BMG (n = 76). The tEPA group reported more penile complications (p = 0.02), especially reduced glans filling (p = 0.03) and a shortened penis (p = 0.001). There were no differences in postoperative IIEF-5 total scores. Recurrence rates were similar in both groups (12.9%) but the study was not designed to detect differences in recurrence rates. The PCQ is not validated, which is a limitation.

Conclusions: More patients reported penile complications after urethroplasty with tEPA than with BMG. This should be considered when choosing the operative method, and patients should be informed accordingly.

Patient summary: This study compared two common operations for repair of narrowing of the male urethra. Neither of the two methods seems to cause worsened erections. However, penile problems are more common after the transection technique than after the grafting technique.

Keywords: Buccal mucosa graft; Erectile dysfunction; Excision and primary anastomosis; Penile complications; Sexual dysfunction; Urethral stricture; Urethroplasty.

Publication types

  • Multicenter Study
  • Randomized Controlled Trial

MeSH terms

  • Anastomosis, Surgical / adverse effects
  • Erectile Dysfunction* / etiology
  • Female
  • Humans
  • Male
  • Mouth Mucosa / transplantation
  • Sexual Dysfunction, Physiological* / etiology
  • Treatment Outcome
  • Triethylenephosphoramide
  • Urethra / surgery
  • Urethral Stricture* / surgery
  • Urologic Surgical Procedures, Male / adverse effects
  • Urologic Surgical Procedures, Male / methods


  • Triethylenephosphoramide