Transvesical Approaches to BNC and VUAS
Transvesical access reaches the outlet from inside the bladder. It can be used for different operations: direct anastomotic reconstruction, subtrigonal graft augmentation, and exceptional salvage prostatectomy when prostate tissue remains. These operations treat different anatomy and should not be grouped into a single success rate.
Robotic transvesical bladder-neck reconstruction
Lee/Eun's 2025 report describes posterior transvesical excision of fibrotic scar and a tension-free, watertight mucosa-to-mucosa anastomosis between bladder-neck mucosa and posterior urethra. The retrospective cohort included 11 VUAS patients, all with stenoses shorter than 2 cm; two had prior salvage radiation.[1]
| Finding | Index cohort |
|---|---|
| Success definition | No further surgical intervention for recurrent stenosis |
| Success | 10/11 at median 22 months |
| New SUI | None reported |
| Median operative time / EBL | 189 minutes / 100 mL |
| Major-complication definition | Clavien grade greater than 2, not grade 2 or higher |
Working from within the bladder may reduce the need to dissect a hostile retropubic plane in selected cases. It does not mean that every transvesical operation avoids Retzius entirely or never requires a flap. The small series cannot prove less SUI or better patency than other approaches.[1]
The TURNS 32-patient cohort included much more radiation exposure and obliterative disease and mixed reconstructive techniques. Its 75% patency and continence results are not a valid head-to-head comparison. The earlier 12-patient TURNS report's 216-minute operative time and 85 mL EBL are means from that cohort, not medians from the 32-patient study.[2][3]
Subtrigonal buccal graft inlay
Avallone/Flynn's 2019 report describes one post-photovaporization BNC, using a robotic transvesical subtrigonal BMG inlay. Qmax improved from 2 to 27 mL/s and PVR from 200 to 3 mL. The urethral catheter was removed at 2 weeks and suprapubic catheter at 4 weeks after healing assessment. These are case-specific observations, not validation of an expected 100% success rate.[4]
See subtrigonal inlay for the named technique. Its graft bed and orientation should not be conflated with a perineal dorsal-onlay operation.
Exceptional transvesical prostatectomy after HoLEP
Yu's 2025 retrospective series involved eight selected men with recurrent BNC after HoLEP, in whom residual prostate tissue remained. All met the authors' success endpoint (17 Fr cystoscope passage or flow above 15 mL/s) and were reported continent at 3 months; minimum follow-up was six months. Median operative time was 123 minutes, EBL 50 mL and hospital stay 7.5 days.[5]
This is a small feasibility series for an extensive salvage operation. It does not establish that residual prostate tissue is the cause of all recurrent BNC or that radical prostatectomy is standard treatment. It is not an option to remove the prostate again in VUAS after a completed radical prostatectomy. See salvage prostatectomy for the distinct reconstructive context.
Clinical role and limitations
Choose access and reconstruction by stenosis site, length, residual lumen, tissue quality, prior surgery/radiation, bladder function and continence goals. EAU supports individualized specialist reconstruction for refractory posterior disease; no guideline assigns a specific evidence grade or preference to these 2025 techniques on the basis of the older AUA amendment.[6]
All three reports above are small uncontrolled experiences. Preserve their feasibility findings while discussing recurrence, incontinence, tissue injury and possible additional reconstruction. No direct comparison establishes an optimal transvesical technique or a universal advantage over Y-V plasty, perineal repair or standard retropubic reconstruction.
Videos
References
1. 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
2. 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
3. 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
4. Avallone MA, Quach A, Warncke J, Nikolavsky D, Flynn BJ. "Robotic-Assisted Laparoscopic Subtrigonal Inlay of Buccal Mucosal Graft for Treatment of Refractory Bladder Neck Contracture." Urology. 2019;130:209. doi:10.1016/j.urology.2019.02.048
5. Yu C, Zhang Q, Quan J, Zhang D, Wang S. "Transvesical Robot-Assisted Radical Prostatectomy for Recalcitrant Bladder Neck Contracture After Holmium Laser Enucleation of Prostate: Initial Experience and Clinical Outcomes." World Journal of Urology. 2025;43(1):117. doi:10.1007/s00345-025-05494-8
6. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.