T-Plasty for Recurrent Bladder Neck Stenosis
T-plasty is a modification of Y-V plasty that advances two bladder-wall flaps, instead of one, into an opened stenotic bladder neck. The Hamburg group (Reiss, Rosenbaum, Dahlem and colleagues) developed it for highly recurrent stenosis after transurethral surgery for benign prostatic obstruction and reported it in two overlapping single-center series.[1][2] A robot-assisted version has since been described in seven patients.[5] Evidence for post-prostatectomy VUAS or radiated patients is lacking.
Rationale
The standard Y-V plasty advances a single V-shaped bladder flap into the incised contracture. The Hamburg authors designed the T-plasty to reconstruct a wide bladder neck with two well-vascularized flaps in a single stage, without a graft, tissue interposition or staged procedure.[2] These advantages are the authors' stated rationale. No comparison with a single-flap repair exists, so superior patency, blood supply or a "backup" flap has not been shown.
Operative concept
The following outline is general.[1][2]
- Access. The bladder is exposed through retropubic access.
- Localize the stenosis. A cystoscope or sound passed transurethrally identifies the level and extent of the stenosis from the abdominal side.
- Open the stenosis. Incise the stenosis through its full thickness into an unobstructed prostatic urethra, as described in the laparoscopic variant.[10] In the original open repair, excise bladder-neck scar and perform a dorsal mucosa-to-mucosa anastomosis between the trigone and prostatic cavity.[2]
- Create two flaps. Make a T-shaped incision in the anterior bladder wall to raise bilateral flaps. In the published laparoscopic variant, cold scissors extend the full-thickness incision to unobstructed prostatic urethra to avoid thermal injury to the flaps.[2][10]
- Rotate and suture. In the original open repair, rotate the bilateral flaps and suture them to the prostatic apex without tension. The laparoscopic variant sutures the flaps in a V configuration with interrupted 3-0 polyglactin.[2][10]
- Close and drain. Close the bladder defect, check for leakage and establish catheter drainage. In the laparoscopic series, the authors placed urethral and suprapubic catheters and a pelvic drain, kept the urethral catheter for 3–4 weeks, and obtained uroflowmetry and cystourethrography at removal.[10]
Preserve bladder-wall vascularity and protect the sphincter and ureteral orifices. Additional reconstruction or interposition depends on the defect and the assessment of healing.
Published cohorts
The two Hamburg reports overlap. The expanded study identified all patients who underwent T-plasty at the center between December 2008 and July 2016.[1][2]
| Parameter | Reiss 2016, index report[2] | Rosenbaum 2017, expanded cohort[1] |
|---|---|---|
| Patients | 10, with multiple prior endoscopic treatments | 30, including 25 after TURP (83.3%) |
| Age | Mean 69.2 years (range 61 to 79) | Median 69 years (IQR 62 to 73) |
| Follow-up | Mean 26 months (range 3 to 46) | Median 45 months (IQR 18 to 64); 3 lost to follow-up |
| Success | 100% | 100% (27/27 evaluable) |
| Serious complications | None of Clavien grade III or higher | No severe blood loss or severe perioperative complications |
| De novo incontinence | No de novo stress incontinence | 1 patient; mean ICIQ-SF 1.2 (SD 2.27) |
| Function | Stream very strong to moderate in 80%; mean IPSS 11.3 (range 4 to 29); mean IPSS-QoL 2.4 (range 1 to 5) | Qmax 6.79 to 24.42 mL/s (p = 0.009); PVR 140.77 to 14.5 mL (p = 0.004) |
| Satisfaction and quality of life | Satisfaction very high or high in 90%; QoL improved in 90%; SF-8 comparable to the reference population | Pleased or delighted 88.5%; QoL improved or strongly improved in 75% |
The EAU 2026 guideline gives a Weak recommendation to perform Y-V or T-plasty for refractory bladder-neck stenosis after benign prostatic obstruction surgery and a Strong recommendation to warn patients about de novo urinary incontinence. It summarizes patency of 83% to 100% at 14 to 45 months and incontinence in up to 14% (level of evidence 3).[4]
Paired flow measurements were available for only six patients and paired residual measurements for ten in the expanded cohort.[1]
A separate nine-patient laparoscopic T-plasty series after TURP reported no recurrent voiding difficulty in eight men at mean 14.7 months (range 3–22); one recurrence was treated endoscopically. Its authors used an anterior T incision to advance two bladder-wall flaps.[10] The robot-assisted T-plasty series (Lumen 2025) included 7 patients, 6 after TURP and 1 after simple prostatectomy, with a median of 3 prior endoscopic treatments. Median operative time was 123 minutes and three patients had a grade 2 complication. At a median follow-up of 27 months (range 4 to 74), the study reported 7/7 free of recurrence; follow-up used symptoms, uroflowmetry and postvoid residual, with cystoscopy if symptoms were present or Qmax <15 mL/s, and recurrence defined by inability to pass a 14 Fr scope.[5] No de novo incontinence or erectile dysfunction was reported.[5]
Comparison with other reconstructions
These are case-series figures from different populations, definitions of success and follow-up.
| Feature | T-plasty (open) | Robotic Y-V plasty | TUITMR | Dorsal onlay BMG |
|---|---|---|---|---|
| Flap or graft | Two bilateral bladder flaps | One V-shaped bladder flap | Mucosal realignment, no flap | Free buccal graft |
| Series | 30 (Hamburg) | 30 (RAYV) | 19 | 107 |
| Reported endpoint | 100% study-defined success (27/27 evaluable)[1] | 25/30 (83.3%) free of further treatment or catheterization at 24 months; two of five failures were restrictures[6] | 89% cystoscopic passage of a 17 Fr scope at four months after one procedure, 100% after a second[7] | 97/107 (90.7%) without intervention for recurrence[3] |
| Follow-up | Median 45 months | Median 27 months | Median 6 months | Mean 59.3 months |
| Population | Post-TURP and other BPH surgery[1] | BNS and VUAS[6] | BNC and VUAS; 32% radiated[7] | Membranous or bulbomembranous stenosis after endoscopic prostate surgery[3] |
| Serious complications | None severe | 2 major (Clavien IIIa and IV) | No major complications | — |
| Graft harvest | No | No | No | Yes (buccal) |
Sources: [1][3][6][7]. The TUITMR column describes the original 19-patient mixed BNC/VUAS series. In a later retrospective series of 92 men with BNC after benign prostate surgery, primary cystoscopic patency was 93.5%, freedom from reintervention after one procedure was 83.7%, and final anatomic patency after up to two procedures was 96.7% at median 15.9 months; no de novo incontinence was reported.[9] In Viegas's 21-patient robotic Y-V series, postoperative SUI was reported in 5 of 21 patients, all within the six-patient VUAS subgroup.[8] One already had an AUS and three underwent concomitant AUS implantation.[8]
Limitations
- Single center. All open T-plasty patients were treated at one center. Reproducibility and the learning curve have not been assessed.[1][2]
- Population. The published patients had stenosis after transurethral BPH surgery.[1][2] The technique has not been reported for post-prostatectomy VUAS or after radiation.[1][2]
- No comparison. No head-to-head data exist against Y-V plasty, BMG or endoscopic techniques.
- Incomplete follow-up. Three of 30 patients were lost to follow-up, and functional measurements were incomplete.[1]
Patient selection
Reconstruction is considered for recurrent stenosis when repeated endoscopic treatment is no longer acceptable or appropriate. The residual lumen, stenosis length, prior operations, radiation, bladder capacity and compliance, continence and available viable tissue are assessed. In the published laparoscopic series, retrograde and voiding cystourethrography mapped lesion location and length, flexible cystoscopy localized the bladder-neck stenosis, and urodynamics was used selectively when detrusor overactivity or abnormal compliance was suspected.[10] No fixed number of failed endoscopic treatments is required. The EAU gives a Weak recommendation for Y-V or T-plasty in bladder-neck stenosis refractory to endoscopic treatment without specifying a minimum number of prior procedures.[4] The original open T-plasty series enrolled men after multiple endoscopic attempts; the robotic series reported a median of three prior treatments (range 1–16).[2][5]
TUIBNC, Y-V plasty, BMG augmentation and reanastomosis are chosen by the anatomy of the individual patient.
References
1. Rosenbaum CM, Dahlem R, Maurer V, et al. "The T-Plasty as Therapy for Recurrent Bladder Neck Stenosis: Success Rate, Functional Outcome, and Patient Satisfaction." World Journal of Urology. 2017;35(12):1907-1911. doi:10.1007/s00345-017-2089-2
2. Reiss CP, Rosenbaum CM, Becker A, et al. "The T-Plasty: A Modified YV-Plasty for Highly Recurrent Bladder Neck Contracture After Transurethral Surgery for Benign Hyperplasia of the Prostate: Clinical Outcome and Patient Satisfaction." World Journal of Urology. 2016;34(10):1437-42. doi:10.1007/s00345-016-1779-5
3. Angulo JC, Dorado JF, Policastro CG, et al. "Multi-Institutional Study of Dorsal Onlay Urethroplasty of the Membranous Urethra After Endoscopic Prostate Procedures: Operative Results, Continence, Erectile Function and Patient Reported Outcomes." Journal of Clinical Medicine. 2021;10(17):3969. doi:10.3390/jcm10173969
4. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.
5. Lumen N, Wang Z, Waterschoot M, et al. "Robot-Assisted T-Plasty for Recalcitrant Bladder Neck Stenosis: Description of Technique and Initial Results." Minerva Urologica e Nefrologica. 2025;77(6):803-809. doi:10.23736/S2724-6051.24.05872-5
6. Abo Youssef N, Obrecht F, Padevit C, Brachlow J, John H. "Short and Intermediate-Term Outcome of Robot-Assisted Inverted YV-Plasty for Recurrent Bladder Neck Stenosis – A Single Centre Study." Urology. 2023;175:196-201. doi:10.1016/j.urology.2023.02.011
7. Abramowitz DJ, Balzano FL, Ruel NH, Chan KG, Warner JN. "Transurethral Incision With Transverse Mucosal Realignment for the Management of Bladder Neck Contracture and Vesicourethral Anastomotic Stenosis." Urology. 2021;152:102-108. doi:10.1016/j.urology.2021.02.035
8. Viegas V, Freton L, Richard C, et al. "Robotic YV Plasty Outcomes for Bladder Neck Contracture vs. Vesico-Urethral Anastomotic Stricture." World Journal of Urology. 2024;42(1):172. doi:10.1007/s00345-024-04814-8
9. Curtis J, Schrup S, Moring N, et al. "Transurethral Incision With Transverse Mucosal Realignment for the Treatment of Bladder Neck Contractures After Benign Prostate Surgery; Mid-term Outcomes." Urology. 2026;online ahead of print. doi:10.1016/j.urology.2026.07.018
10. Shu HQ, Wang L, Jin CR, Hu XY, Gu J, Sa YL. "Laparoscopic T-Plasty for the Treatment of Refractory Bladder Neck Stenosis." Am J Mens Health. 2019;13(5):1557988319873517. doi:10.1177/1557988319873517