Skip to main content

Combined Abdominoperineal Reconstruction

Combined abdominal and perineal access is an option for selected complex posterior defects when a single route cannot provide adequate exposure, tissue reach or associated repair. It can be entirely open or combine robotic abdominal dissection with open perineal work.[1][2][3]

Definition​

In the modified perineal pull-through techniques described by Wang and Yin, the bulbar urethra is mobilized extensively through a perineal incision.[11][12] The scarred or obliterated segment is excised, and the healthy distal urethra is advanced to the proximal stump (prostatic urethra or bladder neck) for a spatulated, mucosa-to-mucosa, tension-free anastomosis over a catheter. Progressive perineal end-to-end urethroplasty also uses distal urethral mobilization and, when needed, corporal separation, inferior pubectomy or rerouting to achieve a tension-free anastomosis.[4] Combined reconstruction can be entirely open or use robotic abdominal dissection with open perineal work.[1][2][3] Wang and Yin described perineal pull-through without an abdominal component.[11][12]

Indications​

  • Selected complex PFUDD when a tension-free repair or associated injury cannot be addressed from the perineum.[1][5] The EAU weakly recommends that open reconstruction for post-traumatic posterior stenosis be performed only in high-volume centres.[1] Webster's perineal series included defects of 1.5–7 cm, and Wang and Yin also reported perineal pull-through.[4][11][12]
  • Recalcitrant posterior stenosis, including VUAS after radical prostatectomy when endoscopic treatment has failed.[2][3]
  • Wang's and Yin's PFUI pull-through cohorts reported previous failed management in 52/113 (46%) and 31/76 (41%) patients, respectively.[11][12]
  • Posterior urethral stricture with urethrorectal fistula requires fistula repair; vascularized interposition can be considered when indicated.[1] Guo used transperineal gracilis interposition, and Wang also repaired PFUI-associated fistulas transperineally.[17][18] A fistula below the verumontanum can be repaired perineally; reserve combined access for associated anatomy that cannot be addressed from below.[1]
  • Pediatric or adolescent posterior trauma may require reconstruction.[19] In Wang's 22-boy PFUI series, a combined transpubic-perineal route was used in 2 boys with exceptionally long distraction defects; the other 20 underwent perineal approaches.[20]
  • In Patil's eight selected patients with defunctionalized bladders and recalcitrant posterior stenosis, salvage cystectomy, ileal neobladder formation and urethral pull-through were described; the EAU states that further validation is needed before this approach can be recommended.[1][10]

Distinguish PFUI from post-prostatectomy VUAS​

For most delayed PFUI repairs, progressive perineal anastomotic urethroplasty is the standard reconstructive approach. A combined route is reserved for complexity such as associated rectourethral fistula, bladder-neck or prostatic injury or difficult recurrent anatomy.[1][4][5] Corporal separation or inferior pubectomy can sometimes be performed through the perineum alone.[1][4][5]

After prostatectomy, the anastomotic defect, residual sphincter and radiation injury create a different situation. For transperineal redo VUA, the EAU strongly recommends counseling that incontinence is inevitable and later continence surgery may be needed after at least 3–6 months; it weakly recommends a retropubic route when the patient is continent preoperatively.[1] See primary reanastomosis for VUAS evidence.

Operative principles​

The repair is performed through a perineal incision in lithotomy (standard, high or exaggerated); for deferred PFUI repair, the EAU strongly recommends a midline perineal incision, whereas Wang's suspension technique describes an inverted-Y incision.[1][21] After pelvic fracture urethral injury, lithotomy may be limited until orthopedic and soft-tissue injuries have resolved.[21][25] The steps of the open operation are:

  1. Divide the bulbospongiosus muscle and expose the bulbar urethra circumferentially.
  2. Mobilize the urethra proximally and distally to gain length, distally as far as the penoscrotal junction in some techniques.[11][21]
  3. Transect and excise the scar. In Sa's progressive strategy the urethra is transected first at the proximal margin of the stenosis. If the proximal end is too deep to mobilize fully, transection is made at the distal margin and the scar is cored out to expose the proximal lumen.[13]
  4. Identify the proximal (prostatic) lumen with a sound or catheter passed through the suprapubic tract.
  5. Advance the mobilized distal urethra and suture it to the proximal stump with interrupted absorbable sutures over a catheter.[11][13]

The principles that apply to both open and combined repair are:

  1. Map the urethral and bladder ends, defect length, fistula, tissue quality and baseline continence. For PFUI, combine RUG and VCUG to define the defect .[29] Review stump position relative to the inferior pubic margin when planning exposure; one retrospective series associated a higher stump with advanced perineal maneuvers or combined repair, not abdominal access alone.[27] If further detail about bladder-neck competence, fistula or false passage is needed, add retrograde urethroscopy and antegrade cystoscopy through the suprapubic tract .[29] For posterior stenosis, consider MRI urethrography as an ancillary test .[29] In complex radiated cases, pelvic MRI can clarify suspected fistula or contained abscess before choosing reconstruction or diversion.[29][30] Confirm the intended reservoir and drainage plan.
  2. Position for safe perineal and abdominal access, accounting for operative duration and pressure and nerve injury risk.
  3. Perineal dissection exposes the distal urethra. In Findlay et al.'s combined robotic technique, the abdominal component exposes the proximal target by separating the bladder or prostate from the rectum and developing the retropubic space; the bladder is mobilized as needed, and a suprapubic catheter already present is kept in place during dissection.[30] After the anastomosis, the bladder is approximated to the abdominal wall immediately distal to the anastomosis and around the suprapubic tract to reduce tension.[30]
  4. Mobilize only as much as needed for a viable, tension-free repair. Routine maximal mobilization beyond the penoscrotal junction can jeopardize vascularity or length.
  5. Excise unsuitable scar, identify viable mucosal edges and construct the anastomosis. Add length-gaining maneuvers or tissue transfer according to anatomy. In redo PFUI with an ischemic or necrotic bulbar urethra, or when no viable tension-free anastomosis is possible, reassess for substitution repair or urinary diversion.[1]
  6. Repair associated fistula and consider vascularized interposition when extensive fibrosis resection leaves dead space or suture lines after concomitant rectourethral fistula repair need separation .[1] Confirm watertightness and durable drainage.[1][2][3][4]

"Pull-through" publications describe several modifications, many performed perineally.

Adjunctive maneuvers for gaining length​

When mobilization alone is insufficient, the maneuvers are added sequentially, as Webster and Ramon described in 74 patients with a 96% rate of excellent results (defects 1.5 to 7 cm).[4]

  • Corporal separation divides the intercorporal septum so that the urethra passes between the corpora.
  • Inferior pubectomy removes the inferior margin of the pubic symphysis when needed for exposure. Avoid total pubectomy during abdominoperineal reconstruction: the EAU strongly recommends against it because morbidity rises without an exposure gain.[1]
  • Supracrural rerouting passes the urethra around one side of the corpora cavernosa. Li reported this in 37 patients with long-segment complex stricture, with 31 of the 34 followed achieving unobstructed voiding (mean follow-up 41 months).[22]
  • Urethral suspension suspends the proximal urethra and surrounding tissues with sutures at the 2, 5, 7 and 10 o'clock positions to expose the proximal mucosa. Wang reported unobstructed flow in 22 of 24 patients (91.7%) with a median stricture length of 5.1 cm, at a median follow-up of 13.6 months.[21]

In the multicenter TURNS series of 122 posterior urethroplasties after PFUI, 95% were performed perineally and 5% abdominoperineally. Corporal splitting was used in 36%, pubectomy in 13% and supracrural rerouting in 2%. Younger age, longer defects and angioembolization were associated with the need for ancillary maneuvers, and 91% needed no repeat intervention.[5] In Fu's series of 301 patients, success was 89.3% with simple perineal anastomosis, 86.5% with corporal separation, 84.2% with inferior pubectomy and 85.7% with rerouting. The groups were not randomized, and the authors concluded that the maneuvers are useful for achieving a tension-free anastomosis.[14]

Open pull-through and perineal outcomes​

SeriesnIndicationSuccessFollow-up
Wang 2008 (modified pull-through)[11]113Posttraumatic posterior stricture109/113 (96.5%) primary; 100% after secondary proceduresMean 48.5 months
Yin 2011[12]76PFUDD68/76 (89%); all failures salvagedMean 42.5 months
Sa 2021 (progressive strategy)[13]1,475 with follow-up (of 1,637)PFUDD1,363/1,475 (92.4%)—
Fu 2009 (transperineal bulboprostatic anastomosis)[14]301PFUDD263/301 (87.4%)—
Koraitim 1995 (perineal anastomotic subgroup)[15]78 of 145Posttraumatic posterior stricture95%17-year case series
Johnsen 2020 (TURNS)[5]122 (116 perineal; 6 abdominoperineal)PFUI111/122 (91%) in the full mixed cohort needed no repeat intervention—

Success is defined in most of these series as no postoperative procedure needed. The series are retrospective and single-center except TURNS.

Pull-through and standard anastomotic urethroplasty​

  • Wang's group describes the pull-through as simple and less demanding, and especially suitable in patients with previous failed treatment. Yin's group suggests it might be less demanding and less time-consuming. Neither series compared it with standard end-to-end repair.[11][12]
  • Koraitim advised attempting anastomosis through the perineum first in every case, with the transpubic route used only when a tension-free bulboprostatic anastomosis could not be achieved from below.[15]
  • Netto (1985) preferred the transpubic approach for complex strictures, damaged urethral lengths above 3 cm and small children, reserving perineal pull-through for low-lying strictures under 3 cm. Good results were reported in 69% of adults with the transpubic approach and 66% with perineal pull-through.[16]

Combined robotic/perineal evidence​

The AUA guideline states that surgeons may perform robotic or open reconstruction for recalcitrant bladder-neck or vesicourethral anastomotic stenosis . It reports robotic patency of 72.7% to 75% and open retropubic or perineal patency of 70% to 100%. Among men continent before surgery, 82% remained continent after robotic reconstruction, 10% became incontinent after an open retropubic approach and 83.3% after a perineal reconstruction.[25]

A robotic abdominal component can help expose the proximal target in a combined repair.[2][3] Unterberg described a distinct perineal application: all 10 patients underwent standard perineal dissection with robotic-assisted proximal suture placement; set-up took 15 minutes, suture placement 30 to 45 minutes, and no postoperative VCUG showed extravasation.[23] Cavallo's combined series included prostatectomy and gracilis muscle flaps.[3] Zhang's broader robotic series included bladder-neck resitting.[6] Liu's nine-patient single-port buccal-graft series used rectus, omental or gracilis flaps when needed.[24]

Cavallo's retrospective multi-institutional series comprised 12 complex posterior reconstructions, with mean follow-up 596 days. Eight required prostatectomy, four gracilis interposition and one corporal splitting.[3]

OutcomeCavallo 2021
Recurrent stenosis2/12; mean time to recurrence 187.5 postoperative days
Reported new SUI4 patients; this is distinct from the number subsequently receiving an AUS
AUS placement9/12, at mean 359.2 days after reconstruction; no erosion reported during observed follow-up
Other complicationsOne urinary leak, one thromboembolic event, two wound abscesses; two reported new ED cases

The cohort demonstrates feasibility in selected complex anatomy.[3]

Rodriguez's technical report describes perineal urethral advancement when robotic retropubic dissection alone cannot achieve a tension-free anastomosis. The distal urethra is mobilized through a perineal incision and advanced to create a tension-free vesicourethral anastomosis, preserving an orthotopic voiding configuration. Incontinence is expected, and an AUS is planned in the following months.[2]

Robotic posterior reconstruction series​

SeriesnApproachPatencyContinence / AUSFollow-up
Zhang 2023[6]105Robotic; 41 (39%) combined abdominoperineal75.2% of the full cohort needed no reinterventionAUS in 30 (28.6%)Mean 18.7 months
Shakir 2022 (TURNS)[7]32Robotic transabdominal, VUAS24/32 (75%) met patency definition (17-Fr scope passage or peak flow >15 mL/s); 26 (81%) voiding per urethra11 of 13 without preexisting SUI (85%) remained continentMedian 12 months
Cavallo 2021[3]12Combined robotic and open transperinealStenosis recurrence in 2/12 (16.7%)New SUI 4/12; AUS 9/12Mean 596 days
Bearrick 2022[9]21 (including 1 trauma case)Robotic; BPH-treatment (n=5), prostatectomy (n=10) and radiation (n=5) subgroupsUltimate anatomic success 100%, 90% and 80%; reintervention required in 0%, 10% and 80%, respectivelyAUS 0%, 30% and 80%—
Savun 2025[8]2810 robotic vs 18 open perinealComposite patency (16-Fr scope passage or maximum flow >15 mL/s): 80.0% vs 77.8% (p = 0.944)Among patients continent before reconstruction, de novo incontinence was 16.6% vs 100% (p = 0.031)—

These are single-institution or consortium retrospective series with different definitions of success and different case mixes. A 2026 systematic review of 33 reconstructive studies (667 patients) found lower pooled patency for VUAS than BNS within both robotic and open cohorts; heterogeneity prevented a reliable access-route ranking.[26]

Broader robotic studies are not combined-approach trials​

Zhang's 105-patient robotic series included 41 combined approaches and several reconstruction types. Overall reintervention was approximately one quarter; 30 patients received an AUS. Shakir's 32-patient cohort likewise mixed techniques and reported 24 patent outlets versus 26 patients voiding per urethra.[6][7]

Savun compared only 18 open perineal and 10 robotic cases retrospectively. Blood loss and hospital stay were significantly lower in the robot-assisted group (p = 0.001 for each), and operative time and complication rates did not differ significantly. Pelvic radiotherapy, preoperative incontinence and postoperative complications were associated with patency failure.[8]

Radiation affects selection and healing. Before redo VUA after radiation, assess bladder capacity and compliance and exclude urethral necrosis, calcification or fistula; impaired bladder function or these tissue findings can make reconstruction futile and favor diversion.[1] In Zhang's series 57.1% of patients had prior pelvic radiation, and in the TURNS series 50% did.[6][7] Bearrick's irradiated subgroup contained only five patients: four required reintervention, four ultimately achieved anatomic success, three functional success and four an AUS.[9]

Complications​

  • Urinary incontinence. Among 1,475 patients with follow-up in Sa's series, 125 (8.5%) had some degree of incontinence after final repair.[13] Wang and Yin reported all patients continent. Cavallo's mixed 12-patient combined robotic/perineal posterior reconstruction cohort reported de novo SUI in 4/12 (33.3%).[3] The Wang and Yin cohorts studied pelvic-fracture pull-through repairs.[11][12]
  • Erectile dysfunction. Sa reported 15 de novo erectile dysfunction cases among 1,475 followed patients, and Wang reported five postoperative cases among 113. Yin reported two new cases (5% of previously potent men). Koraitim attributed impotence mainly to the original injury (15%) and rarely to the urethroplasty (2.5%).[11][12][13][15]
  • Recurrent stricture. Wang and Yin reported failures only within the first 8 and 6 months respectively, mostly managed endoscopically or by repeat urethroplasty.[11][12]
  • Penile deformity. No chordee, penile shortening or urethral diverticula were reported in the Wang, Yin and Sunay series.[11][12][19]

Special contexts​

  • Urethrorectal fistula. Transperineal urethroplasty with gracilis interposition achieved success in 29/32 patients (91%) in Guo’s series. In Wang’s later proximal-transection and fistula-repair series, all 40 patients underwent fecal diversion before repair; 36/40 (90%) had final success, 75% had postoperative erectile dysfunction and 77.5% had normal continence.[17][18]
  • Children and adolescents. Sunay's 75-patient pediatric/adolescent series included 38 bulbar and 37 posterior injuries; across this mixed cohort, primary success was 52/75 (69.3%) and overall success after secondary procedures was 70/75 (93.3%).[19] Wang reported 20 of 22 boys (90.9%) successfully treated, most by a transperineal inferior pubic approach.[19][20]

Counseling and follow-up​

Discuss recurrent stenosis, leakage or fistula, rectal injury, infection, wound problems, thromboembolism, sexual effects and substantial new or worsened SUI risk.[1] A patient may require several procedures to achieve acceptable voiding and continence; distinguish single-operation patency from later functional success.[31] In a 178-patient, 15-institution retrospective AUS-after-urethroplasty cohort (median follow-up 33.5 months), transecting repairs were associated with more AUS explantation than nontransecting repairs (56.2% versus 23.5%), including more erosion-related explantation.[31] Before urethral catheter removal after urethroplasty, assess the anastomosis for extravasation with validated urethrography ; if a significant leak persists, maintain or reinsert the catheter and repeat imaging after one week.[28] In Findlay's combined protocol, CT cystography checks for extravasation before urethral-catheter removal, and the suprapubic catheter is capped for a week to confirm voiding and emptying.[30] Establish stable patency and acceptable bladder function before continence surgery.[1] In Findlay et al.'s protocol, repeat cystoscopy checks urethral patency before later anti-incontinence surgery.[30]

For an unsalvageable bladder or outlet, chronic drainage or diversion may better match the patient's goals.[1] In Patil's eight-patient salvage cystectomy and neobladder pull-through series, four patients had AUS cuff erosion requiring removal and reimplantation, and a median of two revision surgeries after staged AUS placement preceded social continence.[10]

Videos​

VUAS Reconstruction: Combined Perineal and Abdominal Approach
Breakthroughs for Physicians (2025)
Perineal and Robotic Reconstruction of Vesicourethral Anastomotic Stricture
Bartoletti R, et al. Urology Video Journal 2022 (CC BY-NC-ND 4.0)
Open source videoRead the article

References​

1. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.

2. Rodriguez VI, Celis V, Sayegh A, et al. "Robotic Management of Complex Vesicourethral Anastomosis Stenosis With Transperineal Urethral Advancement: A Step-by-Step Technique." Urology. 2024;184:e256-e257. doi:10.1016/j.urology.2023.10.035

3. Cavallo JA, Vanni AJ, Dy GW, et al. "Clinical Outcomes of a Combined Robotic, Transabdominal, and Open Transperineal Approach for Anastomotic Posterior Urethroplasty." Journal of Endourology. 2021;35(9):1372-1377. doi:10.1089/end.2020.0973

4. Webster GD, Ramon J. "Repair of Pelvic Fracture Posterior Urethral Defects Using an Elaborated Perineal Approach: Experience With 74 Cases." The Journal of Urology. 1991;145(4):744-8. doi:10.1016/s0022-5347(17)38442-2

5. Johnsen NV, Moses RA, Elliott SP, et al. "Multicenter Analysis of Posterior Urethroplasty Complexity and Outcomes Following Pelvic Fracture Urethral Injury." World Journal of Urology. 2020;38(4):1073-1079. doi:10.1007/s00345-019-02824-5

6. 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

7. Shakir NA, Alsikafi NF, Buesser JF, et al. "Durable Treatment of Refractory Vesicourethral Anastomotic Stenosis via Robotic-Assisted Reconstruction: A Trauma and Urologic Reconstructive Network of Surgeons Study." European Urology. 2022;81(2):176-183. doi:10.1016/j.eururo.2021.08.013

8. Savun M, Çolakoğlu Y, Özdemir H, et al. "Comparison of Open Perineal and Robot-Assisted Reconstruction in Vesicourethral Anastomotic Stenosis." World Journal of Urology. 2025;43(1):413. doi:10.1007/s00345-025-05808-w

9. 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

10. Patil MB, Hannoun D, Reyblat P, Boyd SD. "Total Bladder and Posterior Urethral Reconstruction: Salvage Technique for Defunctionalized Bladder With Recalcitrant Posterior Urethral Stenosis." The Journal of Urology. 2015;193(5):1649-54. doi:10.1016/j.juro.2014.11.102

11. Wang P, Fan M, Zhang Y, et al. "Modified Urethral Pull-Through Operation for Posterior Urethral Stricture and Long-Term Outcome." The Journal of Urology. 2008;180(6):2479-85. doi:10.1016/j.juro.2008.08.039

12. Yin L, Li Z, Kong C, et al. "Urethral Pull-Through Operation for the Management of Pelvic Fracture Urethral Distraction Defects." Urology. 2011;78(4):946-50. doi:10.1016/j.urology.2011.05.027

13. Sa Y, Wang L, Lv R, et al. "Transperineal Anastomotic Urethroplasty for the Treatment of Pelvic Fracture Urethral Distraction Defects: A Progressive Surgical Strategy." World Journal of Urology. 2021;39(12):4435-4441. doi:10.1007/s00345-021-03789-0

14. Fu Q, Zhang J, Sa YL, Jin SB, Xu YM. "Transperineal Bulboprostatic Anastomosis in Patients With Simple Traumatic Posterior Urethral Strictures: A Retrospective Study From a Referral Urethral Center." Urology. 2009;74(5):1132-6. doi:10.1016/j.urology.2009.05.078

15. Koraitim MM. "The Lessons of 145 Posttraumatic Posterior Urethral Strictures Treated in 17 Years." The Journal of Urology. 1995;153(1):63-6. doi:10.1097/00005392-199501000-00024

16. Netto NR Jr. "The Surgical Repair of Posterior Urethral Strictures by the Transpubic Urethroplasty or Pull-Through Technique." The Journal of Urology. 1985;133(3):411-2. doi:10.1016/s0022-5347(17)49000-8

17. Guo H, Sa Y, Fu Q, Jin C, Wang L. "Experience With 32 Pelvic Fracture Urethral Defects Associated With Urethrorectal Fistulas: Transperineal Urethroplasty With Gracilis Muscle Interposition." The Journal of Urology. 2017;198(1):141-147. doi:10.1016/j.juro.2017.01.071

18. Wang L, Song W, Lv R, et al. "Precise Treatment of Pelvic Fracture Urethral Injury Associated With Urethrorectal Fistula." BJU International. 2024;134(4):589-595. doi:10.1111/bju.16401

19. Sunay M, Karabulut A, Dadalı M, et al. "Single-Institution Outcomes of Open Reconstruction Techniques for Management of Pediatric and Adolescent Post-Traumatic Urethral Strictures." Urology. 2011;77(3):706-10. doi:10.1016/j.urology.2010.07.476

20. Wang L, Guo HL, Shu HQ, et al. "Surgical Treatment of Pelvic Fracture Urethral Distraction Defects in Boys: Which Approach Is Suitable?" Asian Journal of Andrology. 2020;22(3):292-295. doi:10.4103/aja.aja_64_19

21. Wang Y, Liu M, Jin C, et al. "Efficacy of Urethral Suspension-Assisted Urethral Anastomosis as a Treatment for Complex Long-Segment Posterior Urethral Stricture." World Journal of Urology. 2025;43(1):77. doi:10.1007/s00345-025-05442-6

22. Li H, Jin C, Li S, et al. "Urethral Rerouting Around One Side of Corpora Cavernosus via a Perineal Approach for Treating Long-Segment, Complex Posterior Urethral Strictures." World Journal of Urology. 2025;43(1):485. doi:10.1007/s00345-025-05825-9

23. 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

24. 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

25. Wessells H, Morey A, Souter L, Rahimi L, Vanni A. "Urethral Stricture Disease Guideline Amendment (2023)." The Journal of Urology. 2023;210(1):64-71. doi:10.1097/JU.0000000000003482

26. Roessler N, Klemm J, Fisch M, Dahlem R, Vetterlein MW, Trauma and Reconstructive Urology Working Party of the EAU Young Academic Urologists. "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

27. Yepes C, Oszczudlowski M, Joshi PM, Anand A, Bhadranavar S, Kulkarni SB. "Predictors of elaborated perineal or a combined abdominoperineal approach during repair for pelvic fracture urethral injury." World J Urol. 2024;42(1):40. doi:10.1007/s00345-023-04733-0

28. European Association of Urology. "EAU Guidelines on Urethral Strictures: Perioperative Care of Urethral Surgery." 2026. Guideline.

29. European Association of Urology. "EAU Guidelines on Urethral Strictures: Diagnostic Evaluation." 2026. Guideline.

30. Findlay BL, Anderson KT, Pinkhasov AM, Miller AJ, Viers BR. "Excisional urethroplasty and the abdominoperineal approach to posterior urethral stenosis: surgical techniques and considerations for the radiated patient." Transl Androl Urol. 2025;14(10):3309-3320. doi:10.21037/tau-2025-281

31. Davis MF, Nikolavsky D, Cavalcanti AG, et al. "Multicenter Analysis of Long-Term Outcomes of Artificial Urinary Sphincter Surgery After Urethroplasty." J Urol. 2026;215(2):203-212. doi:10.1097/JU.0000000000004794