Transvesical Approaches to BNC and VUAS
Transvesical access reaches the bladder neck and vesicourethral anastomosis through a cystotomy; the extent of retropubic dissection depends on the operation.[1][2] Three transvesical operations are detailed below: robotic bladder-neck reconstruction with mucosa-to-mucosa anastomosis for VUAS, subtrigonal buccal graft inlay for refractory bladder-neck contracture (BNC), and transvesical prostatectomy for recalcitrant BNC with residual prostate after HoLEP. A related single-port posterior urethroplasty with a buccal graft has also been described using intraabdominal or extraperitoneal transvesical access for VUAS and other posterior defects; some cases required perineal dissection or tissue flaps.[11]
Robotic transvesical bladder-neck reconstruction
Lee and Eun (2025) describe a posterior transvesical approach for VUAS. The bladder is opened and the fibrotic scar is excised circumferentially. A tension-free, watertight mucosa-to-mucosa anastomosis is then made between bladder-neck mucosa and the posterior urethra. The retrospective single-institution cohort included 11 patients treated in 2021 to 2024. All strictures were shorter than 2 cm, and two patients (18%) had prior salvage radiotherapy.[1]
| Finding | Index cohort |
|---|---|
| Success definition | No further surgical intervention for recurrent stenosis |
| Success | 10/11 (91%) 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 gives direct view of the mucosal edges and may reduce the need to dissect a hostile retropubic plane after prostatectomy, radiation or repeated endoscopy.[1]
The retropubic robotic approach used by the TURNS consortium dissects the space of Retzius, excises the fibrotic tissue and reconstructs with a primary anastomosis or an anterior bladder flap. The 32-patient TURNS cohort had 50% prior radiation and 47% obliterative VUAS. At median 12 months, 24/32 (75%) met the study's cystoscopy-or-flow patency endpoint and 26/32 (81%) were voiding per urethra.[2] Of 13 men without preexisting SUI, 11 (85%) remained continent.[2] The earlier 12-patient TURNS report included 7 BNC and 5 VUAS repairs using varied techniques, including redo anastomosis, Y-V plasty and partial prostatectomy.[4] At median 13.5 months, 9/12 (75%) met its cystoscopy-or-flow success endpoint, and 82% of men without preoperative incontinence were continent.[3] Its 216-minute operative time and 85 mL EBL are means from that cohort, not medians from the 32-patient study.[3] One of 12 patients developed osteitis pubis and a pubovesical fistula requiring repair and pubic bone debridement (Clavien IIIb).[3] A systematic review of ten robotic bladder-neck reconstruction series (119 men; techniques and etiologies varied) reported pooled patency of 80% and pooled de novo incontinence of 17% (8/47).[4]
| Feature | Robotic transvesical (Lee 2025) | Robotic retropubic (TURNS, Shakir 2022) |
|---|---|---|
| Access | Posterior, through the bladder | Anterior, space of Retzius |
| Reconstruction | Mucosa-to-mucosa anastomosis | Primary anastomosis or anterior bladder flap |
| Patients | 11, VUAS only | 32, VUAS |
| Radiation | 18% salvage radiotherapy[1] | 50% prior pelvic radiation[2] |
| Stenosis | All shorter than 2 cm[1] | 47% obliterative[2] |
| Reported endpoint | 10/11 without surgical reintervention for recurrent stenosis at median 22 months[1] | 24/32 met 17 Fr cystoscopy or Qmax >15 mL/s at median 12 months[2] |
Subtrigonal buccal graft inlay
Avallone and Flynn (2019) describe one robotic transvesical subtrigonal buccal mucosal graft (BMG) inlay for refractory BNC after photovaporization of the prostate. The bladder is opened, the contracture is approached from the subtrigonal aspect, and a graft (5 × 5 × 4 cm in this case) is inlaid to augment the bladder-neck lumen. Qmax improved from 2 to 27 mL/s and PVR from 200 to 3 mL.[5] The urethral catheter was removed at 2 weeks and the suprapubic catheter at 4 weeks, when VCUG showed no obstruction or extravasation. No recurrence was reported at last follow-up, but the duration of follow-up was not stated.[5] In a separate open transvesical subtrigonal BMG series, ureteral orifices were identified and protected with guidewires before the subtrigonal incisions. Ten of 11 men required no BNC reintervention at median 36 months (range 13–56); one developed de novo urge incontinence, and four (36%) reported retrograde ejaculation, which may have preceded reconstruction after prior BPH surgery.[9] None had prior pelvic radiation or surgery for pelvic malignancy.[9]
See subtrigonal inlay for the named technique. Its graft bed and orientation differ from a perineal dorsal-onlay operation.
Transvesical prostatectomy after HoLEP
Yu and colleagues (2025) report eight selected men with recurrent BNC after HoLEP and residual prostate tissue, treated by transvesical robot-assisted radical prostatectomy. The authors screened for prostate tumors with PSA testing or MRI before surgery.[6] The residual prostate was excised transvesically and a new vesicourethral anastomosis was created. All eight met the authors' success endpoint (17 Fr cystoscope passage or flow above 15 mL/s) and were continent at 3 months. Minimum follow-up was 6 months. At 6 months Qmax rose from 4.15 to 17.7 mL/s, PVR fell from 190 to 17.5 mL and IPSS fell from 31 to 10.5. Median operative time was 123 minutes, median EBL 50 mL and median hospital stay 7.5 days.[6]
This is a small feasibility series of an extensive salvage operation. It removes residual prostate tissue, a presumed source of recurrent contracture in this series. The operation applies only when prostate tissue remains, and it is not an option for VUAS after a completed radical prostatectomy. See salvage prostatectomy for the reconstructive context.
Clinical role and limitations
Access and reconstruction are chosen by stenosis site, length, residual lumen, tissue quality, prior surgery or radiation, bladder function and continence goals. For redo VUA after radical prostatectomy, EAU states that bladder function should be adequate and urethral necrosis, calcification and fistulation should be absent.[7] EAU states that reconstruction may be considered in fit patients motivated to undergo surgery when endoluminal treatment repeatedly fails or the stenosis is obliterated, with the choice depending on length, location, calibre, etiology, continence, bladder function, radiation history, patient preference and surgeon expertise.[7] EAU gives a weak recommendation to offer retropubic redo VUA to patients who were continent before surgery.[7] The AUA 2023 amendment gives robotic or open reconstruction for recalcitrant BNC or VUAS a Conditional Recommendation .[8] The 2025 transvesical reports postdate it.[8]
All three reports above are small retrospective series or a case report from single institutions. Follow-up is short to intermediate, and the techniques require advanced robotic skill and experience with intravesical robotic surgery. A 2026 reconstruction meta-analysis pooled robotic patency separately for BNS (92%; n = 95) and VUAS (75%; n = 96), but heterogeneous techniques and endpoints limit its use for choosing an access route.[10] No direct comparison establishes an optimal transvesical technique or an advantage over Y-V plasty, perineal repair or standard retropubic reconstruction. Counseling covers recurrence, incontinence, tissue injury and possible additional reconstruction. EAU gives a strong recommendation to warn that urinary incontinence is inevitable after transperineal redo VUA and that staged continence surgery may be needed after at least three to six months.[7] AUS placement should be deferred until VUA patency is stable, because a cuff complicates treatment of recurrent stenosis.[7]
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;88(5):519-524. 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. Zhang TR, Alford A, Zhao LC. "Summarizing the Evidence for Robotic-Assisted Bladder Neck Reconstruction: Systematic Review of Patency and Incontinence Outcomes." Asian Journal of Urology. 2024;11(3):341-347. doi:10.1016/j.ajur.2023.08.007
5. 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
6. 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
7. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.
8. 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
9. Bozkurt O, Sarıkaya EA, Ozer MS, Şen V, Demir Ö, Esen AA. "Long-Term outcomes of subtrigonal inlay patch in case series – Buccal mucosal graft technique for recurrent bladder neck stenosis." BMC Urol. 2025;25(1):253. doi:10.1186/s12894-025-01947-9
10. Roessler N, Klemm J, Fisch M, Dahlem R, Vetterlein MW; Trauma and Reconstructive Urology Working Party of the European Association of Urology Young Academic Urologists. "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
11. Liu W, Shakir N, Zhao LC. "Single-Port Robotic Posterior Urethroplasty Using Buccal Mucosa Grafts: Technique and Outcomes." Urology. 2022;159:214-221. doi:10.1016/j.urology.2021.07.049