Primary Reanastomosis for Refractory Posterior Stenosis
Primary reanastomosis excises unsuitable scar and reconnects viable bladder-neck and urethral tissue. It is most often used for refractory post-prostatectomy VUAS. A flap or graft is a different strategy when a tension-free direct anastomosis is not possible. Four routes are described: open retropubic, open perineal, robotic retropubic and robotic transvesical.[1][2]
Selection
The 2026 EAU guideline weakly recommends redo VUA for obliterative or endoluminal-refractory VUAS in nonirradiated patients and irradiated patients with adequate bladder function; it also weakly recommends retropubic redo VUA when the patient is continent before surgery.[3] Define location, length, degree of obliteration, prior radiation or operations, fistula, necrosis or calcification, baseline continence, bladder function and the patient's goals. Before planned reconstruction, obtain a prostate-specific antigen test to assess for recurrent prostate cancer, which can change the treatment plan. Combined retrograde and voiding urethrography plus cystoscopy help define the defect and external sphincter involvement.[19] The EAU guideline states that redo VUA should be performed only with adequate bladder function and no urethral necrosis, calcification or fistulation; its panel advises reconstruction in experienced high-volume centers, particularly after prior radiotherapy.[3] Nonobliterative disease can sometimes be stabilized endoscopically; complete obliteration should not undergo endoluminal treatment. Reconstructive access may be retropubic, perineal, transvesical or combined, depending on the defect.[3]
Counsel separately about patency and continence. Redo vesicourethral anastomosis can cause major SUI, especially with transperineal dissection; later continence surgery may be needed. Prior prostatectomy differs substantially from PFUI, where the bladder neck may remain intact.[3]
The AUA 2023 urethral stricture guideline amendment states that surgeons may perform robotic or open reconstruction for recalcitrant bladder-neck or post-prostatectomy VUAS stenosis .[13] The accompanying text summarizes published series: patency of 72.7–75% for robotic reconstruction, with 82% of preoperatively continent patients continent afterward, and 70–100% for open retropubic or perineal reconstruction.[16] Among preoperatively continent patients, 10% were incontinent after retropubic repair and 83.3% after perineal repair.[16] These figures come from small series with different populations. First-time endoscopic treatment of VUAS succeeds in about 50–80%, less often after pelvic radiation.[13][16]
Operative approaches
Retropubic
Open access uses a lower midline or Pfannenstiel incision into the space of Retzius. Robotic access dissects the same space. Both permit bladder mobilization and exposure of the anastomosis. Scar is excised to viable edges, adjacent structures are preserved and a watertight, tension-free mucosa-to-mucosa anastomosis is created. If direct approximation would place tension on the repair, a bladder-flap or graft reconstruction is the alternative. In the TURNS robotic series the choice between primary anastomosis and an anterior bladder flap was made intraoperatively.[4][1][2]
Transperineal
Perineal exposure allows proximal urethral mobilization and scar excision, with the patient in exaggerated lithotomy. Progressive maneuvers such as corporal separation or limited inferior pubectomy may be needed for access or tension reduction. The rectum is protected during urethral mobilization. In the Hamburg transperineal technique, eight circumferential anastomotic sutures are preplaced; the three dorsal sutures are tied first, followed by Foley placement and completion of the remaining sutures. The anastomosis is leak-tested and a perineal drain is placed before layered closure.[17] Transsphincteric mobilization carries a high risk of sphincteric incontinence after prostatectomy. For transperineal redo VUA, the 2026 EAU guideline strongly recommends warning that urinary incontinence is inevitable and that staged anti-incontinence surgery may be needed after at least three to six months.[3] Published perineal cohorts largely enrolled men who were already incontinent.[5][6][3] In the 15-patient Reiss series, erectile dysfunction was reported in 13/15, and 5/15 reported impaired erectile function after surgery compared with preoperative status.[6]
Combined abdominoperineal reconstruction may be needed when neither route alone provides sufficient exposure or tissue reach. Schlossberg and Jordan described combined abdominal and perineal dissection with partial pubectomy and omental wrapping in two men with obliterative stenosis and defects longer than 1.5 cm. Both were voiding without pads at 18 and 7 months.[7] Rodriguez described a robotic retropubic dissection combined with transperineal urethral advancement, to reach the bladder neck when the proximal urethra is too short for a tension-free anastomosis and the patient prefers to keep an orthotopic tract over an ileal conduit. Incontinence is expected, and staged AUS placement can be considered in subsequent months.[8] Wessells reported four men with obliterated anastomoses treated with different single-stage techniques (primary excision and anastomosis, penile fasciocutaneous flap, free graft with rectus flap, or anterior bladder tube with omental pedicle flap). All had patency at a mean of 33.8 months and none was continent.[15] Omental or other vascularized interposition can be used in selected complex repairs, especially with associated fistula or compromised tissues.
Transvesical
Robotic transvesical reconstruction accesses the outlet from within the bladder and may limit dissection of a hostile retropubic plane in selected short VUAS.[9]
Positioning, Drainage and VTE Prophylaxis
Preoperative urine culture identifies bacteriuria to treat before mucosa-breaching reconstruction. The EAU guideline gives intraoperative antibiotic prophylaxis for urethral surgery a Strong recommendation.[18] For the transperineal route with exaggerated lithotomy, the AUA guideline recommends assessing lower-extremity mobility beforehand and careful extremity padding to avoid pressure on the calf muscles, peroneal nerve and ulnar nerve, with sequential compression devices to reduce both thromboembolism and nerve-compression injury; it frames added parenteral VTE prophylaxis as a consideration in select circumstances for open urethral reconstruction such as this repair.[16] Neither the AUA nor EAU stricture guideline states a reanastomosis-specific pharmacologic VTE recommendation, and none of the cohorts below (Pfalzgraf, Reiss, Schuettfort, Kirshenbaum, Shakir, Savun, Lee) report a VTE event rate; given the pelvic dissection and operative time, assess patient and procedure VTE risk, bleeding risk and mobility using the VTE Prophylaxis framework.
For catheter drainage, the AUA guideline describes shorter catheterization after endoscopic treatment than after open urethral reconstruction; urethrography or voiding cystography is typically performed at about two to three weeks after open reconstruction to assess healing, with catheter replacement recommended if a leak persists.[16] Lavollé's six-patient extraperitoneal robotic series removed the bladder catheter after seven days.[14]
Primary cohorts and meaningful denominators
| Study | Population and follow-up | Findings |
|---|---|---|
| Pfalzgraf 2011 | 20 open retropubic repairs after a mean of 3.7 prior operations; median 59.2 months | Recurrence-free after reanastomosis 12/20 at median 59.2 months; seven of eight recurrences treated endoscopically, giving 19/20 after additional treatment. Four patients developed new incontinence (reported as 31%, with an unclear at-risk denominator), and 13 were completely incontinent, of whom 9 were treated with AUS. One patient required urinary diversion.[4] |
| Reiss 2014 | 15 transperineal repairs; mean 20.5 months | 14/15 initially patent; remaining recurrence treated endoscopically. 14/15 were incontinent before surgery; incontinence worsened in 9/15. No new incontinence reported; this is a very small initially continent subgroup. Ten underwent AUS placement. [6] The later expanded cohort averaged 4.69 prior operations.[5] |
| Schuettfort 2017 | Expanded transperineal cohort, 23 patients; median 45 months | 20/23 initially successful; three recurrences treated endoscopically. All had pre- and postoperative incontinence; 17/23 received an AUS. Two of 23 had Clavien II/III complications; the EAU evidence table identifies a rectal injury and a lower-leg paresthesia in this series.[5][3] This extends the earlier experience.[5] |
| Kirshenbaum 2018 | 12 robotic reconstructions, 7 BNC and 5 VUAS; median 13.5 months | 9/12 met the study's cystoscopy-or-flow patency definition (17 Fr passage or Qmax >15 mL/s); 82% of those continent before surgery remained continent. Mean operative time 216 minutes and EBL 85 mL. One serious osteitis/pubovesical-fistula complication occurred.[2] |
| Shakir 2022 | 32 robotic VUAS reconstructions with mixed anastomotic/flap techniques; 50% irradiated, 47% obliterative; median 12 months | 24/32 met the study's patency definition (17 Fr cystoscope passage or Qmax >15 mL/s), while 26/32 voided per urethra; these are different endpoints. Eleven of 13 without prior SUI remained continent. Eight recurrences required further reconstruction, endoscopy or catheterization.[1] |
| Lavollé 2019 | 6 extraperitoneal robotic repairs after failed endoscopic treatment, 3 with salvage radiation | Three recurrences, all managed endoscopically; three patients had postoperative incontinence treated with AUS. Mean operative time 108 minutes.[14] |
| Lee 2025 | 11 transvesical repairs for selected VUAS shorter than 2 cm, 2 irradiated; median 22 months | 10/11 required no further surgery for recurrent stenosis; no new SUI reported. Small retrospective feasibility series.[9] |
These cohorts differ in selection, baseline continence, radiation, reconstruction type and whether salvage procedures count as success. A 2026 etiology-stratified meta-analysis of heterogeneous reconstruction series estimated VUAS patency at 75% after robotic repair (n = 96) and 80% after open repair (n = 85), with differing techniques, endpoints and follow-up limiting comparison.[20] Savun's 28-patient retrospective comparison of open perineal (n = 18) and robotic (n = 10) reconstruction found similar composite patency (77.8% vs 80.0%), defined as passage of a 16 Fr cystoscope or Qmax >15 mL/s.[10] Robotic repair had less blood loss (100 vs 200 mL) and a shorter stay (3 vs 4 days), and among patients continent before surgery, de novo incontinence was reported in 16.6% versus 100%.[10] Pelvic radiotherapy and preoperative incontinence were associated with patency failure. The study is small and the groups may differ in baseline continence.[10]
Associated fistula and tissue transfer
Fistula repair may require vascularized coverage, removal of diseased tissue or a different urinary diversion. Escandón's 56-patient urosymphyseal-fistula cohort compared primary closure, omentum and VRAM in selected patients; omentum was associated with lower 90-day sepsis (3% vs 18% for primary repair and 27% for VRAM) and lower odds of fistula recurrence than primary repair (OR 0.012). That difference was not seen against VRAM. Some patients with nonviable sphincters or severe radiation-related bladder disease required exenterative surgery.[11]
Follow-up and continence planning
Maintain drainage through healing and assess patency before catheter removal according to the repair and imaging findings. Follow symptoms, flow, residual and recurrent infection, with cystoscopy or imaging when indicated. Record additional procedures explicitly.
Stable patency and adequate bladder function should precede continence surgery. A later Hamburg cohort extending the earlier transperineal experience (46 patients, one previously irradiated) reported retreatment-free survival of 91% at two years and 88% at five years; 30/46 received staged AUS, and 7/30 devices were explanted at median AUS follow-up of 97 months, including five erosions.[17] EAU describes delaying AUS implantation for at least 3–6 months after redo VUA to confirm stability; timing and device suitability remain individualized. Patients may prefer ongoing drainage or diversion rather than a staged reconstructive and AUS pathway.[3]
Britton's registry of 17,904 prostatectomies (851 with VUAS) associated adjuvant radiation, BMI, prostate volume, urine leak, transfusion and non-nerve-sparing technique with VUAS formation. Endoscopic retreatment rates were 34% at 1 year and 42% at 5 years, and 82% of treated men had endoscopic dilation.[12]
Videos
References
1. 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
2. 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
3. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.
4. Pfalzgraf D, Beuke M, Isbarn H, et al. "Open Retropubic Reanastomosis for Highly Recurrent and Complex Bladder Neck Stenosis." The Journal of Urology. 2011;186(5):1944-7. doi:10.1016/j.juro.2011.07.040
5. Schuettfort VM, Dahlem R, Kluth L, et al. "Transperineal Reanastomosis for Treatment of Highly Recurrent Anastomotic Strictures After Radical Retropubic Prostatectomy: Extended Follow-Up." World Journal of Urology. 2017;35(12):1885-1890. doi:10.1007/s00345-017-2067-8
6. Reiss CP, Pfalzgraf D, Kluth LA, et al. "Transperineal Reanastomosis for the Treatment for Highly Recurrent Anastomotic Strictures as a Last Option Before Urinary Diversion." World Journal of Urology. 2014;32(5):1185-90. doi:10.1007/s00345-013-1180-6
7. Schlossberg S, Jordan G, Schellhammer P. "Repair of Obliterative Vesicourethral Stricture After Radical Prostatectomy: A Technique for Preservation of Continence." Urology. 1995;45(3):510-3. doi:10.1016/S0090-4295(99)80025-9
8. 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
9. Lee M, Lesgart M, McPartland C, Lee R, Eun DD. "Robotic Transvesical Bladder Neck Reconstruction: A Novel Approach to Managing Vesicourethral Anastomotic Stenosis." European Urology. 2025. doi:10.1016/j.eururo.2025.04.026
10. 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
11. Escandón JM, Kreutz-Rodrigues L, Fadel AE, et al. "Optimizing Flap Selection for Urosymphyseal Fistula Repair: A Comparative Analysis of Surgical Outcomes." Microsurgery. 2026;46(3):e70197. doi:10.1002/micr.70197
12. Britton CJ, Sharma V, Fadel AE, et al. "Vesicourethral Anastomotic Stenosis Following Radical Prostatectomy: Risk Factors, Natural History, and Treatment Outcomes." The Journal of Urology. 2023;210(2):312-322. doi:10.1097/JU.0000000000003488
13. 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
14. Lavollé A, de la Taille A, Chahwan C, et al. "Extraperitoneal Robot-Assisted Vesicourethral Reconstruction to Manage Anastomotic Stricture Following Radical Prostatectomy." Urology. 2019;133:129-134. doi:10.1016/j.urology.2019.07.027
15. Wessells H, Morey AF, McAninch JW. "Obliterative Vesicourethral Strictures Following Radical Prostatectomy for Prostate Cancer: Reconstructive Armamentarium." The Journal of Urology. 1998;160(4):1373-5. doi:10.1016/s0022-5347(01)62540-0. PMID 9751356
16. American Urological Association. Urethral Stricture Disease: AUA Guideline (published 2016; amended 2023), unabridged version. Guideline.
17. Klemm J, Oberneder K, Roessler N, et al. "Patient-reported outcomes of transperineal reanastomosis for recurrent or obliterative post-prostatectomy vesicourethral anastomotic stenosis." Int Braz J Urol. 2026;52(4):e20260112. doi:10.1590/S1677-5538.IBJU.2026.0112
18. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Chapter 10, Perioperative Care of Urethral Surgery. Guideline.
19. Rosenbaum CM, Fisch M, Vetterlein MW. "Contemporary Management of Vesico-Urethral Anastomotic Stenosis After Radical Prostatectomy." Front Surg. 2020;7:587271. doi:10.3389/fsurg.2020.587271
20. Roessler N, Klemm J, Fisch M, Dahlem R, Vetterlein MW. "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