Robotic Posterior Urethroplasty
Robotic-assisted posterior urethroplasty (RPU) is an alternative to the perineal or transpubic abdominoperineal approach for recalcitrant posterior urethral obstruction. The AUA 2023 urethral stricture guideline amendment states that surgeons may perform robotic or open reconstruction for recalcitrant bladder-neck contracture or post-prostatectomy vesicourethral anastomotic stenosis (VUAS) .[1]
For the canonical PFUI workflow, see Pelvic Fracture Urethral Injury (PFUI). For open anastomotic reconstruction, see Excision and Primary Anastomosis. Core-through urethrotomy is not open urethroplasty and is not a standard repair for obliterative PFUI. For the broader VUAS / BNC framework, see Bladder Neck Reconstruction & VUAS. For the fully transurethral BMG alternative, see Endoscopic Urethroplasty.
Indications
For nonobliterative posterior stenoses, RPU may follow failed endoscopic treatment; for complete obliteration of VUAS, bulbomembranous stenosis, or bladder-neck stenosis, the EAU 2026 guideline strongly recommends against endoluminal treatment.[2][3][10] In Bearrick's series, median prior endoscopic treatments were 2–3 by etiology.[2] Before redo vesicourethral anastomosis, assess bladder function and periurethral necrosis, calcification, or fistulation. For operative planning, Boswell et al. use retrograde urethrography, voiding cystourethrography, and retrograde and antegrade cystoscopy to define stenosis length and distal extent, sphincter coaptation, and proximal anatomy.[12] The EAU 2026 guideline limits redo VUA to patients with adequate bladder function and no such adverse tissue findings; radiation-related bladder toxicity may make reconstruction futile.[10] Bearrick’s 21-patient series included:[2]
- Post-prostatectomy VUAS without radiation. Ten of 21 men (48%).[2]
- Bladder-neck contracture after endoscopic prostate procedures (BPH treatment): approximately 24%.[2]
- Post-prostatectomy VUAS with radiation. Five of 21 men (24%).[2]
- Trauma. One of 21 patients (5%).[2] Zhang’s larger cohort instead reported prior radiation in 57.1%.[4]
Surgical Approaches
The technique is tailored to location and complexity of the stenosis.[3][4][5][6] Boswell et al. describe adding perineal mobilization when stenosis extends through the pelvic floor and an abdominal approach cannot provide a tension-free anastomosis.[12] In this combined approach, both bulbar arteries are often sacrificed; Boswell et al. caution against excessive distal urethral mobilization or division of the crura beyond their divergence because of retrograde vascular dependence and potential limits on later transcorporal AUS placement.[12] For a preoperatively continent patient undergoing redo VUA, the EAU 2026 guideline weakly recommends retropubic access and strongly recommends counseling about expected incontinence after transperineal redo.[10]
| Approach | Use |
|---|---|
| Transabdominal (intra- or extraperitoneal) | Standard robotic dock for deep pelvic dissection; transvesical access; cystoscopy defines stricture extent |
| Combined robotic transabdominal + open transperineal | A combined abdominoperineal approach was required in 41/105 (39%) of Zhang's patients[4]; Cavallo's 12-patient series describes robotic transabdominal plus open transperineal reconstruction for complex anastomotic disease[5] |
| Robotic-assisted perineal (Buckley) | Robot used for proximal suture placement after standard perineal dissection in ten posterior or proximal bulbar repairs; five of ten strictures were bulbar. Mean robotic setup was 15 min, with 30–45 min for suture placement.[6] |
| Single-port robotic | Supraumbilical access for intraabdominal or extraperitoneal transvesical reconstruction; described with BMG augmentation by Liu / Shakir / Zhao |
Reconstructive techniques employed (Zhang 2023 distribution)[4]
| Technique | Share |
|---|---|
| Excision and primary anastomosis | For redo VUA, excise the stenosis and mobilize the bladder, bulbar urethra, or both as needed for a tension-free anastomosis.[10] |
| Resitting of the bladder neck | 24.8% |
| Y-V plasty | 20% in Zhang's cohort.[4] Boswell et al. describe Y-V advancement for nonobliterative stenosis with a viable urethral plate; a scarred epithelialized gap may instead need excision and anastomosis.[12] |
| Buccal mucosa graft (BMG) urethroplasty | 13.3% |
Ancillary procedures
Ancillary procedures include gracilis muscle flap interposition (33.3% in Cavallo's series), rectus abdominis flap, omental flap, and concurrent prostatectomy (66.7% in Cavallo's combined-approach series).[3][5]
Potential Advantages and Comparative Evidence
- Visualization. Magnified 3D optics improve the view in the deep pelvis, where open visualization is limited.[6][7]
- Ergonomics. The robot helps with narrow pelvic anatomy and a long distance from perineal skin to the proximal urethra.[6]
- Blood loss. Median blood loss was 100 mL versus 200 mL with open perineal repair (p = 0.001) in Savun's series.[8]
- Hospital stay. 3 versus 4 days in Savun’s retrospective robotic versus open comparison (p = 0.001); Bearrick’s separate robotic-only groups had 1–2-day stays.[2][8]
- Continence. Among men continent before surgery, Savun reported de novo incontinence in 16.6% after robotic versus 100% after open surgery (p = 0.031) in a small retrospective comparison with baseline continence differences.[8] A 2024 review of ten robotic case series reported 80% patency (95/119) across differing success definitions; some series counted patency after endoscopic reintervention. De novo incontinence was 17% (8/47).[9] A 2026 etiology-stratified synthesis of 33 reconstruction studies (667 patients) estimated robotic patency at 92% for bladder-neck stenosis (n = 95) and 75% for VUAS (n = 96); heterogeneous endpoints and follow-up limit comparison between approaches.[11]
- Adjunctive procedures. Concurrent prostatectomy, flap harvest and tissue transfer can be done in the same operation.[5]
Outcomes
| Series | n | Approach | Success | AUS rate | Complications (endpoint varies) | Follow-up |
|---|---|---|---|---|---|---|
| Zhang 2023[4] | 105 | Robotic (39% combined) | 75.2% (no reintervention) | 28.6% | 6.7% (Clavien-Dindo ≥3 within 30 days) | Mean 18.7 mo |
| Bearrick 2022[2] | 21 (20 in the reported BPH, prostatectomy, and radiation outcome groups) | Robotic | 80–100% anatomic success (by etiology) | 0–80% (by etiology) | 0–40% 30-day complications by etiology | Not reported in abstract |
| Cavallo 2021[5] | 12 | Combined robotic + perineal | 83.3% (stenosis recurrence 16.7%) | 75% | Wound abscess 16.7%, leak 8.3%, VTE 8.3% | Mean 596 days |
| Liu 2022[3] | 9 | Single-port robotic + BMG | — | — | No intraoperative events; 30-day UTI, epididymitis, anemia, recurrent stricture, and bowel obstruction requiring surgery (each n = 1) | Median 11.7 mo |
| Savun 2025[8] | 10 (robotic) vs 18 (open) | Robotic vs open perineal (VUAS) | 80% vs 77.8% composite patency (16 Fr cystoscope passage or Qmax >15 mL/s) | — | Comparable | Not reported in abstract |
The AUA 2023 amendment cites robotic-assisted reconstruction patency rates of 72.7–75%.[1]
Impact of Etiology — the Radiation Signal
Outcomes differed by etiology in Bearrick's 21-man series. Four of five men in the radiation group required reintervention, although four ultimately achieved anatomic success. Reintervention and functional success differed by etiology (P = 0.004 and P = 0.035, respectively).[2]
| Etiology | Anatomic success | Functional success | Reintervention | AUS placement |
|---|---|---|---|---|
| Post-BPH treatment | 100% | 100% | 0% | 0% |
| Post-prostatectomy without radiation | 90% | 100% | 10% | 30% |
| Post-prostatectomy with radiation | 80% | 60% | 80% | 80% (p = 0.013) |
Prior radiation and preoperative incontinence were associated with worse outcomes in these selected cohorts.[2][8]
Complications
- 30-day Clavien-Dindo ≥3 complications: 6.7% in Zhang 2023.[4]
- Wound abscess, leak, and thromboembolism. Cavallo reported wound abscess in 16.7%, urinary leak in 8.3%, and thromboembolism in 8.3%.[5] In a separate 12-man robotic bladder-neck reconstruction series, one patient developed Clavien IIIb osteitis pubis with pubovesical fistula requiring repair and pubic debridement.[13]
- Rectal injury. Boswell et al. identify rectal injury as a risk during posterior dissection and advise discussing possible bowel diversion before complex reoperations, especially after a prior anastomotic leak or rectal injury during prostatectomy or endoscopic treatment.[12]
- Stress urinary incontinence is the main functional concern. AUS placement followed surgery in 28.6% of Zhang's patients and 75% of Cavallo's (whose de novo SUI rate was 33.3%), and in 0–80% by etiology in Bearrick's.[4][5][2] In Boswell et al.'s postoperative protocol, a voiding cystourethrogram confirms an intact repair without extravasation before urethral-catheter removal at three to four weeks.[12] After redo VUA, confirm stable patency before AUS placement; EAU reports that most advise waiting at least three to six months because recurrent stenosis is difficult to treat with a cuff in place.[10]
- Erectile dysfunction. De novo erectile dysfunction occurred in 16.7% in Cavallo's series.[5]
- Operative time. Median operative time was 150 minutes in Savun's robotic group and 377 minutes in Liu's single-port BMG series, in which 5 of 9 patients had ancillary flap harvest.[3][8]
Current Evidence Limitations
- The evidence base is retrospective single-center or small multi-institutional series, and no randomized trials compare robotic with open reconstruction.
- Follow-up is short to intermediate: mean 18.7 months in Zhang’s 105-man series and median 11.7 months in Liu’s nine-patient series.[4][3]
- For recalcitrant bladder-neck or post-prostatectomy vesicourethral anastomotic stenosis, the AUA 2023 recommendation permits robotic or open reconstruction .[1]
- Patient selection is heterogeneous.[7] The EAU Urethral Strictures Panel advises that VUAS reconstruction be performed only in experienced high-volume centers, particularly after radiotherapy or other energy-ablative treatment.[10]
Videos
References
1. 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.
2. Bearrick EN, Findlay BL, Maciejko LA, et al. Robotic urethral reconstruction outcomes in men with posterior urethral stenosis. Urology. 2022;161:118-124. doi:10.1016/j.urology.2021.11.035.
3. Liu W, Shakir N, Zhao LC. Single-port robotic posterior urethroplasty using buccal mucosa grafts: technique and outcomes. Urology. 2022;159:214-221. doi:10.1016/j.urology.2021.07.049.
4. Zhang TR, Alford A, Wang A, Zhao LC. Robotic-assisted posterior urethroplasty: outcomes from 105 men in a single-center experience. Urology. 2023;181:167-173. doi:10.1016/j.urology.2023.05.062.
5. Cavallo JA, Vanni AJ, Dy GW, et al. Clinical outcomes of a combined robotic, transabdominal, and open transperineal approach for anastomotic posterior urethroplasty. J Endourol. 2021;35(9):1372-1377. doi:10.1089/end.2020.0973.
6. Unterberg SH, Patel SH, Fuller TW, Buckley JC. Robotic-assisted proximal perineal urethroplasty: improving visualization and ergonomics. Urology. 2019;125:230-233. doi:10.1016/j.urology.2018.11.011.
7. Kim S, Buckley JC. Robotic lower urinary tract reconstruction. Urol Clin North Am. 2021;48(1):103-112. doi:10.1016/j.ucl.2020.09.006.
8. Savun M, Çolakoğlu Y, Özdemir H, et al. Comparison of open perineal and robot-assisted reconstruction in vesicourethral anastomotic stenosis. World J Urol. 2025;43(1):413. doi:10.1007/s00345-025-05808-w.
9. Zhang TR, Alford A, Zhao LC. Summarizing the evidence for robotic-assisted bladder neck reconstruction: Systematic review of patency and incontinence outcomes. Asian J Urol. 2024;11(3):341-347. doi:10.1016/j.ajur.2023.08.007
10. European Association of Urology. "EAU Guidelines on Urethral Strictures: Disease Management in Males." 2026. Full text
11. Roessler N, Klemm J, Fisch M, et al. "A Systematic Review and Meta-analysis of Surgical Reconstruction for Bladder Neck and Vesicourethral Anastomotic Stenosis: The Case for Etiology-specific Definitions and Reporting." Eur Urol Focus. 2026;12(3):360-372. doi:10.1016/j.euf.2026.06.012
12. Boswell TC, Hebert KJ, Tollefson MK, Viers BR. "Robotic urethral reconstruction: redefining the paradigm of posterior urethroplasty." Transl Androl Urol. 2020;9(1):121-131. doi:10.21037/tau.2019.08.22
13. Kirshenbaum EJ, Zhao LC, Myers JB, et al. "Patency and incontinence rates after robotic bladder neck reconstruction for vesicourethral anastomotic stenosis and recalcitrant bladder neck contractures: The Trauma and Urologic Reconstructive Network of Surgeons experience." Urology. 2018;118:227-233. doi:10.1016/j.urology.2018.05.007