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Robotic Bladder Flap Posterior Urethroplasty

Robotic bladder flap posterior urethroplasty uses an anterior bladder-wall flap to form a new vesicourethral anastomosis after division of a diseased outlet and removal of unsuitable scar. Zhao, Shakir and Zhao described it for selected recalcitrant BNC/VUAS in a nine-patient retrospective technical series.[1] Follow-up was short.[1]

Anatomical role​

The flap supplies bladder tissue when direct reanastomosis may otherwise be difficult. It differs from Y-V plasty, which widens an incised stenosis, and from a Tanagho tube, which creates a longer tubularized conduit. Viable bladder tissue, adequate mobility, bladder function and the urethral target determine whether this approach is feasible.[1]

Evaluate its location, length, residual lumen, radiation damage, fistula and baseline continence. For fit patients motivated to undergo surgery after repeated endoluminal failure or complete posterior stenosis, the EAU guideline says reconstruction may be considered.[2] The 2023 AUA guideline gives a Conditional Recommendation for robotic or open reconstruction of recalcitrant BNS or post-prostatectomy VUAS; neither guideline favors this specific bladder flap over other reconstructions.[2][6]

Operative sequence​

The published operation uses transperitoneal robotic access.[1]

  1. Mobilize the anterior bladder and expose the diseased outlet, protecting adjacent pelvic structures.
  2. Localize the stenosis with combined endoscopic and robotic assessment. Cystoscopic light transillumination does not require ICG injection and is distinct from fluorescence after ICG administration.[3]
  3. Divide the diseased bladder neck and remove unsuitable scar until viable tissue is reached. In Zhao's illustrative post-prostatectomy case, hydrodissection was used to transect the prior VUA before dystrophic urethral and periurethral tissue was excised.[4]
  4. Fashion an anterior bladder-wall flap that reaches the urethral target without tension and preserves its blood supply.
  5. Close the native bladder neck, create a new anterior bladder-wall cystotomy and anastomose its mucosa to the urethral stump to form the new VUA.[4] Confirm hemostasis and watertight closure, and maintain catheter drainage. In Zhao's illustrative case, a suprapubic catheter was placed before the space of Retzius was closed.[4]
  6. Add tissue interposition or associated fistula repair when indicated. Individualize drainage and healing assessment.

The original report and operative video give the flap design. Tissue viability and available length determine the final construction.

Index-series outcomes​

OutcomeZhao 2022, n=9
Mean operative time295.5 minutes overall; 264.5 minutes excluding three patients with ancillary procedures
ComplicationsNo intraoperative complications reported; two postoperative complications
Follow-upMean 21.1 weeks
Freedom from recurrent stenosis7/9 (78%) without recurrence at mean 21.1 weeks; both recurrences underwent balloon dilation, and one remained patent at mean post-dilation follow-up of 14.5 weeks[1]
New stress incontinence0/3 patients without preoperative SUI developed de novo SUI[1]

Alternatives and evidence limits​

Primary reanastomosis, Y-V plasty, transvesical reconstruction, graft augmentation and urinary diversion address different anatomical situations. Patients are counseled about further stenosis treatment and staged continence surgery, with patency and bladder function reassessed first.[2] A 2026 synthesis of 33 reconstruction studies found pooled robotic patency of 92% in BNS (n = 95) and 75% in VUAS (n = 96); mixed techniques, endpoints and follow-up prevent a bladder-flap-specific estimate.[5]

Videos​

Robotic Bladder Flap Posterior Urethroplasty
Lee C. Zhao, MD
Robotic Bladder Flap Posterior Urethroplasty
Zhao CC, et al. Urology Video Journal 2022 (CC BY-NC-ND 4.0)
Open source videoRead the article

References​

1. Zhao CC, Shakir NA, Zhao LC. "Robotic Bladder Flap Posterior Urethroplasty for Recalcitrant Bladder Neck Contracture and Vesicourethral Anastomotic Stenosis." Urology Video Journal. 2022;13:100133. doi:10.1016/j.urolvj.2022.100133

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

3. Granieri MA, Weinberg AC, Sun JY, Stifelman MD, Zhao LC. Robotic Y-V plasty for recalcitrant bladder neck contracture. Urology. 2018;117:163–165. doi:10.1016/j.urology.2018.04.017.

4. Zhao C, Shakir N, Zhao LC. "V10-02 Robotic bladder flap posterior urethroplasty for recalcitrant bladder neck contracture and vesicourethral anastomotic stricture." J Urol. 2021;206(Suppl 3):e755. doi:10.1097/JU.0000000000002061.02

5. 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

6. 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