Transurethral Incision with Transverse Mucosal Realignment (TUITMR)
Transurethral incision with transverse mucosal realignment (TUITMR) is an endoscopic procedure for nonobliterative bladder-neck contracture (BNC) and vesicourethral anastomotic stenosis (VUAS). The scar is incised cystoscopically, and adjacent healthy bladder mucosa is advanced across the defect with a transurethral suturing device, in the manner of a Y-V plasty. Abramowitz and colleagues described it in 2021. Their 19-patient single-surgeon retrospective series reported 17/19 (89%) with passage of a 17 Fr cystoscope at four months after one TUITMR; both initial failures passed a 17 Fr scope four months after repeat TUITMR. No de novo incontinence was reported among the 11 patients continent before surgery.[1]
See BNC, VUAS, and standard incision.
Rationale
After a standard incision the scar bed heals by secondary intention, and the contracture recurs if fibrosis outpaces re-epithelialization. TUITMR is intended to cover the incised scar with viable bladder mucosa, as an open Y-V plasty advances a flap into the stenotic segment. Whether mucosal coverage prevents recurrence has not been tested against standard incision.[1]
Operative concept
The steps below follow the published description.[1]
- Document prior surgery, radiation, baseline continence and any membranous involvement before selecting TUITMR. The 2025 single-surgeon protocol also uses pelvic CT and MRI for VUAS to assess calcification, dehiscence and proximity to the rectum and pubic bone.[13] Assess the lumen cystoscopically, establish wire access under direct vision, and dilate as needed for controlled instrumentation.
- In the 2025 single-surgeon protocol, incise BNC after benign prostate surgery at 3 and 9 o’clock, resect the posterior scar bed from 2 to 10 o’clock while sparing the anterior bladder neck, create a prostatic shelf, and test mucosal mobility before suturing. For VUAS, restrict resection to 8–10 and 2–4 o’clock to avoid the pubic bone and rectum, and keep the scar bed short enough for mucosal advancement.[13] Do not treat a completely obliterated posterior stenosis endoluminally .[2] For VUAS or radiation-induced bulbomembranous stenosis, avoid deep DVIU incisions at 6 and 12 o'clock .[2]
- In early 2021 cases, a 5 Fr rigid ureteroscope and RD180 suturing device passed together through the retained 26 Fr cystourethroscope sheath. Later cases used a 24 Fr Neoscope offset scope with a 6 mm working channel.[1] Place the proximal 2-0 Monoglide bite in viable bladder mucosa beyond the resection bed and the distal bite at the urethral mucosal lip, minimizing scar-bed capture. Advance the mucosa and secure it with the Ti-Knot fastener; add bites where exposed scar remains.[13] The fastener avoids intracorporeal knot tying as healthy bladder mucosa is advanced transversely across the incision.[1] The later technical report uses the JNW UrTrac sheath with a flexible digital ureteroscope; it describes limited lateral resection for VUAS and advises against TUITMR with bladder-neck necrosis with soft-tissue calcification, significant dehiscence, membranous involvement, or rectal or pubic fistula.[13]
- Confirm patency and hemostasis and establish catheter drainage. The index series left an 18 Fr catheter for one week.[1] At four-month cystoscopy, assess 17 Fr passage and inspect for retained Ti-Knot clips; remove clips found because they may calcify.[1][13]
The suturing platform is a laparoscopic device adapted for transurethral use, and the learning curve has not been characterized.[1]
Positioning and VTE Prophylaxis
TUITMR is performed transurethrally with the patient in lithotomy. The AUA guideline recommends assessing lower-extremity mobility before positioning and careful extremity padding in lithotomy to avoid pressure on the calf muscles, peroneal nerve and ulnar nerve, with sequential compression devices to reduce both venous thromboembolism and nerve-compression injury; it frames added parenteral VTE prophylaxis mainly as a consideration for open urethral reconstruction, not a brief transurethral procedure such as this one. Neither the AUA nor EAU stricture guideline states a BNC- or VUAS-specific pharmacologic VTE recommendation; apply the general risk framework (age, obesity, prior VTE, malignancy, prolonged operation or immobility) on the VTE Prophylaxis page.[12]
Abramowitz used an 18 Fr catheter for one week. In the 2025 single-surgeon technical report, the authors describe 14 days of catheterization after BNC or nonirradiated VUAS and four weeks after irradiated VUAS.[13] The AUA guideline describes variable catheter duration, generally shorter after endoscopic intervention than open reconstruction.[1][12]
Published evidence
| Index study characteristic | Abramowitz 2021 |
|---|---|
| Design | Retrospective, 19 patients, one surgeon |
| Period | July 2019 to December 2020 |
| Case mix | 53% VUAS, 47% BNC; 32% previously irradiated |
| Follow-up | Median 6 months; patients with at least 4 months were included |
| Success definition | Passage of a 17 Fr flexible cystoscope at 4 months |
| Initial success | 17/19 (89%) |
| After repeat TUITMR | 19/19 (100%) at four-month cystoscopy after retreatment; one of the two initial failures had an unsuccessful robotic Y-V plasty between TUITMR procedures |
| Incontinence and clip removal | No de novo incontinence reported; retained Ti-Knot clips were found at four-month cystoscopy in 4/19, with three removed in office and one in the operating room |
The index series found no significant change in mean IPSS (14.6 before versus 14.4 after; P = 0.95) or PVR.[1]
A later registry from the same group followed 92 men with BNC after benign prostate surgery (November 2021 to July 2025) for a median of 15.9 months. Anatomic success was 93.5%, and 83.7% needed no reintervention after a single procedure. Final anatomic success after up to two procedures was 96.7%. No patient had de novo incontinence, and complications occurred in 12%, mostly minor urinary tract infection. The senior author is a consultant for Olympus.[3]
The 2021 full text reports preoperative incontinence in 8/19 patients; all eight had persistent incontinence after TUITMR, four later underwent successful anti-incontinence procedures, and no de novo incontinence was reported among the other 11.[1] The 2026 registry abstract reports no de novo incontinence but does not give a baseline continence denominator or preoperative AUS and sling status.[3] The two single-institution TUITMR cohorts (111 patients total, mostly BNC after benign prostate surgery) reported no de novo incontinence. EAU gives a weak recommendation to warn patients that endoluminal treatment of posterior urethral stenosis can cause de novo incontinence or worsen existing incontinence, and its summary of evidence gives de novo incontinence of up to 25% and worsening of existing incontinence of up to 15% after any form of endoluminal treatment (level of evidence 3); after reconstruction it reports de novo incontinence of up to 14% after Y-V or T-plasty bladder-neck reconstruction and incontinence of up to 25% after reconstruction of bulbomembranous strictures following surgery for benign prostatic obstruction.[2] See Bladder Neck Contracture for the fuller continence discussion.
Comparison with established treatment
Endoscopic treatment of VUAS has variable outcomes. A 2024 systematic review of 40 studies and 1,452 patients estimated freedom from study-defined VUAS recurrence at the end of follow-up at 72.8% (95% CI 64.4–79.9%); median study follow-up was 23.7 months (IQR 13–32).[4] The estimate fell to 62.9% (53.6–71.4%) after correction for publication bias.[4] Radiotherapy was associated with lower success.[4] A 2025 review cites reported success rates of 40–72% for traditional dilation or direct vision internal urethrotomy, with or without injectables, with about 90% of patients needing repeat intervention within 2 years, and short-term success approaching 85–90% for drug-coated balloon dilation and TUITMR.[5]
| Technique | Cohort | Success | Definition |
|---|---|---|---|
| TUITMR | 19 patients, mixed BNC/VUAS, median 6 months[1] | 89% after one, 100% after two | 17 Fr flexible cystoscope at 4 months |
| TUITMR | 92 men, BNC after benign prostate surgery, median 15.9 months[3] | 93.5% anatomic; 83.7% without reintervention after one | Anatomic patency; freedom from reintervention |
| Deep lateral TUIBNC | 123 patients with BNC of mixed etiology; 76 after radical prostatectomy with or without radiation[6] | 82.1% after one and 94.3% after two; median overall follow-up 12 months, with patency assessed at median two-month cystoscopy | Patent bladder neck with 16 Fr cystoscope passage at 2 months |
| Deep lateral TUIBNC | 50 patients, mostly refractory[7] | 72% after one, 86% after two | No further surgery for obstruction at mean 12.9 months |
| DVIU with mitomycin C | 86 patients, recurrent BNC/VUAS[8] | 65% after one, 90% cumulative including third or later procedures; overall 94% nonradiated vs 76% radiated | 17 Fr cystoscope passage without further procedures |
These cohorts differ in case mix, follow-up and success definition.
Clinical positioning
EAU recommends transurethral resection or hot-knife incision first line for nonobliterative BNS after benign outlet surgery , and visually controlled dilation or DVIU first line for nonobliterative VUAS .[2] It also supports repeat endoluminal treatment for nonobliterative VUAS or BNS to stabilize the stenosis .[2] Reconstruction may be considered when endoluminal treatment repeatedly fails or the stenosis is obliterated. EAU advises against endoluminal treatment of complete obliteration , against deep incisions at 6 and 12 o’clock during DVIU for VUAS or radiation-induced BMS , and against posterior urethral stents .[2] Mitomycin C for posterior stenosis should be used only within a clinical trial.[2] The AUA 2023 amendment notes that repeat endoscopic treatment may be necessary and that no studies compare treatment strategies for BNC after endoscopic prostate procedures. It gives robotic or open reconstruction for recalcitrant stenosis a Conditional Recommendation .[11] Neither guideline addresses TUITMR.
Posterior drug-coated balloon treatment is off-label. For bladder-neck or VUAS use, the 2026 EAU guideline finds evidence too limited for a recommendation and advises data collection in a clinical trial or registry.[2] In a 141-patient retrospective comparison, drug-coated balloon dilation was associated with longer recurrence-free survival than standard endoscopic treatment (HR 0.40, 95% CI 0.19–0.87).[9] In a 319-patient TURNS series, 59 had posterior stenoses spanning bladder-neck/VUAS, membranous, and prostatic sites; median follow-up was 5.7 months for the full cohort.[10] The estimated 1-year functional recurrence-free survival in that analyzed posterior-stenosis subgroup was 75.8% and anatomic recurrence-free survival was 59.4%, with wide confidence intervals; patients managed with intermittent catheterization or without follow-up were excluded from the study cohort.[10] Neither study compares drug-coated balloon with TUITMR. The current Optilume urethral DCB instructions (1111-004 Rev D) apply to anterior strictures and contraindicate use with paclitaxel hypersensitivity or urologic implants such as an artificial urinary sphincter or penile implant.[14] They advise abstinence or condom use for 30 days to limit partner exposure, and highly effective contraception with no fathering of children for at least six months when a partner can conceive.[14]
Videos
References
1. 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
2. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.
3. Curtis J, Schrup S, Moring N, Anderson KT, Viers BR, Ungerer GN, Warner JN. "Transurethral Incision With Transverse Mucosal Realignment for the Treatment of Bladder Neck Contractures After Benign Prostate Surgery; Mid-term Outcomes." Urology. Published online July 16, 2026. doi:10.1016/j.urology.2026.07.018
4. Delchet O, Nourredine M, González Serrano A, et al. "Post-Prostatectomy Anastomotic Stenosis: Systematic Review and Meta-Analysis of Endoscopic Treatment." BJU International. 2024;133(3):237-245. doi:10.1111/bju.16141
5. Hudson CN, Damm T, Monn MF. "Minimally Invasive Treatments for Posterior Urethral Stenosis." Journal of Endourology. 2025;39(10):1078-1084. doi:10.1177/08927790251371037
6. Nealon SW, Bhanvadia RR, Badkhshan S, et al. "Transurethral Incisions for Bladder Neck Contracture: Comparable Results Without Intralesional Injections." Journal of Clinical Medicine. 2022;11(15):4355. doi:10.3390/jcm11154355
7. Ramirez D, Zhao LC, Bagrodia A, et al. "Deep Lateral Transurethral Incisions for Recurrent Bladder Neck Contracture: Promising 5-Year Experience Using a Standardized Approach." Urology. 2013;82(6):1430-5. doi:10.1016/j.urology.2013.08.018
8. Rozanski AT, Zhang LT, Holst DD, et al. "The Effect of Radiation Therapy on the Efficacy of Internal Urethrotomy With Intralesional Mitomycin C for Recurrent Vesicourethral Anastomotic Stenoses and Bladder Neck Contractures: A Multi-Institutional Experience." Urology. 2021;147:294-298. doi:10.1016/j.urology.2020.09.035
9. Berg EK, Mehmedovic S, Askari D, et al. "Efficacy of Drug-Coated Balloon Dilation vs. Endoscopic Standard Treatment in Posterior Urethral Stenosis: A Real-World Comparative Study." Urology. 2025;206:164-170. doi:10.1016/j.urology.2025.07.034
10. Patel HV, Erickson BA, Abbasi B, et al. "Early Real-World Experience With Optilume® Drug-Coated Balloon for Anterior Urethral Strictures and Posterior Urethral Stenoses." Urology. 2026;207:233-238. doi:10.1016/j.urology.2025.10.025
11. 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
12. American Urological Association. Urethral Stricture Disease: AUA Guideline (published 2016; amended 2023), unabridged version. Guideline.
13. Dash ME, Warner JN. "Detailed surgical technique for endoscopic urethroplasty in the treatment of anastomotic stenosis and bladder neck contracture." Transl Androl Urol. 2025;14(11):3745-3756. doi:10.21037/tau-2025-226
14. Urotronic, Inc. Optilume Urethral Drug Coated Balloon Catheter: Instructions for Use. Document 1111-004, Rev D. Manufacturer IFU.