Y-V Plasty for BNC and VUAS
Y-V plasty advances a vascularized bladder-wall flap into an opened stenotic outlet. It can be performed open, laparoscopically or robotically. It is a reconstructive option for selected refractory bladder-neck contracture (BNC) or vesicourethral anastomotic stenosis (VUAS). Recurrent scarring and incontinence remain possible.[1][2][3]
The rationale is that a well-vascularized flap replaces fibrotic tissue with healthy mucosa at the opened outlet. After endoscopic incision, by contrast, the scar heals by secondary intention. No randomized trial compares Y-V plasty with repeat endoscopic treatment.[4]
Guideline position
In its section on bladder-neck stenosis after surgery for benign prostatic obstruction, the 2026 EAU guideline weakly recommends Y-V or T-plasty for disease refractory to endoscopic treatment.[5] It reports patency of 83–100% with 14–45 months of follow-up and de novo incontinence of 0–14% in these series (level of evidence 3), and it strongly recommends warning patients about de novo incontinence. EAU also notes that a minimally invasive approach is increasingly used.[5]
The AUA 2023 amendment states that surgeons may perform robotic or open reconstruction for recalcitrant BNC or post-prostatectomy VUAS .[4] It reports robotic patency of 72.7–75% and, among men continent before surgery, 82% continence afterward. Open reconstruction had patency of 70–100%. Among preoperatively continent men, 10% were incontinent after a retropubic approach and 83.3% after a perineal approach. It advises tailoring treatment to patient preference, prior radiotherapy and baseline incontinence, and it notes that reconstruction may cause incontinence requiring a later artificial urinary sphincter.[4] EAU notes that retropubic and perineal approaches have not been compared directly for incontinence.[5]
Selection
Define stenosis location, length, residual lumen, prior surgery or radiation, tissue quality, bladder function and baseline continence. The EAU panel advises that VUAS reconstruction be performed only in experienced high-volume centers, particularly after radiotherapy or other energy-ablative treatment.[5] Reported series usually enroll men after about two failed endoscopic treatments (a mean of two prior attempts in Granieri's cohort), but no fixed rule requires reconstruction after exactly two failures. Repeated endoscopic treatment remains an option for selected nonobliterative recurrence.[1][5]
A viable bladder flap must reach the opened outlet without tension. Obliteration, inadequate tissue or a long gap may call for a different reconstruction. Zheng’s modified Y-V cohort selected obliterations of 2 cm or less; Lee’s separate transvesical reanastomosis cohort selected VUAS under 2 cm. Neither establishes a length cutoff for Y-V flap selection.[7][24] BNC after benign prostate surgery and VUAS after prostatectomy have different relationships to the remaining sphincter, so counsel about new or worsened SUI and possible later AUS treatment.[6][7][5]
Magnetic resonance urethrography (MRU) measured obliteration length more accurately than RUG/VCUG in a multicenter series: 0.91 cm on MRU and 1.72 cm on RUG/VCUG against an intraoperative length of 0.96 cm. MRU also detected false passages and diverticula.[7]
Robotic anterior Y-V sequence
The Granieri/Zhao description uses transperitoneal robotic exposure.[1]
- Place standard robotic ports. Open the space of Retzius and mobilize the bladder while protecting adjacent structures.
- Localize the stenosis with cystoscopy. Firefly imaging is used to identify the stenosis from the abdominal side.
- Open the stenosis anteriorly into viable urethra and extend the incision proximally onto the bladder to create the Y and its V-shaped bladder flap. Scar resection varies by technique.[1][5]
- Advance the flap's distally directed apex into the distal urethrotomy and suture viable mucosal edges without tension. The apex does not point proximally while being advanced distally.
- Close the remaining defect, assess hemostasis and watertightness, and establish catheter drainage. The index protocol placed a closed suction drain, removed before discharge, and a 22 Fr catheter, removed in the office at about two weeks (median 15 days).[1] The median operative time was 240 minutes.[1] Adapt catheter duration to healing and operative findings.
In Rinderknecht's robotic Y-V series, the outlet was incised until a 20 Fr catheter passed without resistance before flap fixation.[22] Y-V plasty widens the opened outlet by tissue advancement. It is not synonymous with circumferential excision and primary reanastomosis. Scar excision and flap geometry depend on the chosen modification.
In the open technique of Masumoto, a midline lower abdominal incision exposes the bladder neck. A V-shaped incision in the anterior bladder wall forms the flap, and the bladder neck is incised from the apex of the V to healthy urethra, forming the Y. Fibrotic tissue is excised, the posterior urethra and bladder are anastomosed, and the flap is sutured to healthy urethra with 4-0 PDS interrupted sutures.[3]
Variants
Abo Youssef and John described an extraperitoneal robotic "inverted" Y-V plasty that avoids intraperitoneal entry. Median skin-to-skin time was 131 minutes and the catheter was removed at a median of 10 days.[2]
Zang and colleagues describe an extraperitoneal laparoscopic modification with two absorbable barbed sutures. The mucosa and submucosa are closed continuously in a V shape, and serosa and muscularis are then sutured to reinforce the closure. The authors describe this as reducing anastomotic leakage and operative time compared with interrupted sutures, without a comparative test.[8] Zheng's 31-patient multicenter series used the same modification with incisions at 5 and 7 o'clock and layered barbed closure. The median operative time was 75 minutes (range 62–192). The series selected obliteration segments of 2 cm or less without false passages or diverticula on MRU.[7]
Results with study-specific definitions
| Study | Patients and follow-up | Findings |
|---|---|---|
| Granieri 2018 | 7 patients: 6 BNC, 1 VUAS; median 8 months | All patent. Two had persistent incontinence at one pad daily.[1] |
| Shamout 2022 (open) | 18 patients with refractory BNC after TURP; mean 14.8 months | Success (no further instrumentation or surgery) 100%. Persistent storage symptoms in 61%; higher BMI and baseline IPSS predicted a worse OAB-V8 change.[9] |
| Abo Youssef 2023 | 30 patients; median 27 months | Five treatment failures at 24 months, of which two were restrictures. The 83.3% treatment-success endpoint is not simply anatomic patency. Two major complications (Clavien IIIa and IV).[2] |
| Viegas 2024 | 21 patients: 15 BNC, 6 VUAS | Five patients had SUI, all in the six-patient VUAS subgroup. One already had an AUS and three had concomitant AUS implantation.[6] |
| Zheng 2024 | 31 selected short obliterative outlets | Patency 28/31 (90.3%); four had persistent SUI with leakage of 80–120 g/day. Three recurrences were treated by direct vision internal urethrotomy.[7] |
| Rinderknecht 2025 (robotic) | 12 Y-V repairs for recurrent BNS; subgroup median 6.5 months | Three met the study failure endpoint of further bladder-neck surgery or permanent drainage; one had grade IVa urosepsis.[22] |
| Masumoto 2025 | 5 open post-TURP repairs; median 13 months | All patent; three used one to two pads postoperatively.[3] |
In Abo Youssef's 30 patients, IPSS fell from 17 to 11 in the short term (1–6 months) and 6 in the intermediate term (6–24 months). Qmax rose from 7.4 to 13 and then 17 mL/s, and PVR fell from 90 mL to 0 mL. SF-8 quality-of-life improvement was not significant.[2]
These observational series differ in approach, anatomy and endpoints. A systematic review of ten robotic bladder-neck reconstruction case series (119 men; techniques, etiologies and success definitions varied) reported pooled patency of 80% (95/119) and de novo incontinence of 17% (8/47); study median follow-up ranged from 5 to 23 months.[10] Some series counted patients as patent at last follow-up after endoscopic reintervention.[10] The TURNS cohorts and Zhang's 105-patient robotic series also mix reconstruction types. In the 105-patient series (mean follow-up 18.7 months), 57.1% had prior pelvic radiation, 6.7% had a Clavien grade 3 or higher complication within 30 days, and 24.8% needed at least one reintervention.[13][11][12]
BNC versus VUAS
Viegas compared robotic Y-V plasty in BNC after endoscopic BPH treatment and in VUAS. The 21-man cohort found no statistically significant difference in stricture recurrence (p = 0.50).[6] A 2026 review of 33 heterogeneous reconstruction studies (667 patients) reported pooled robotic patency of 92% for BNS (n = 95) and 75% for VUAS (n = 96); these are not Y-V-specific comparative effects.[23] In Viegas's 21-man Y-V cohort, VUAS operations took longer and required longer hospital stays; postoperative complications were numerically higher (4/6 versus 4/15; p = 0.14).[6]
| Parameter | BNC (n = 15) | VUAS (n = 6) | p |
|---|---|---|---|
| Operative time | 146.7 min | 277.5 min | 0.008 |
| Hospital stay | 1.7 days | 3.2 days | 0.03 |
| Postoperative complications | 26.7% | 66.7% | 0.14 |
| SUI (including existing or concomitant AUS) | 0% | 83.3% | less than 0.0001 |
| Long-term reoperation | 0 | 3 patients | 0.05 |
| Improved (PGI-I 1–2) | 80% | 83.3% | 0.31 |
Stricture recurrence occurred in 9.5% of the whole cohort with no difference between groups (p = 0.50).[6]
Robotic versus open perineal reconstruction
In a 28-patient retrospective comparison of VUAS reconstruction (18 open perineal, 10 robot-assisted), study-defined patency (passage of a 16 Fr cystoscope or Qmax >15 mL/s) was similar (77.8% vs 80.0%; p = 0.944).[14] Among men without preoperative incontinence, de novo incontinence was lower in the robotic group (16.6% vs 100%; p = 0.031), with less blood loss (100 vs 200 mL) and a shorter hospital stay (3 vs 4 days).[14] Operative times were comparable (120 vs 150 min; p = 0.175).[14] EAU advises warning patients that incontinence is inevitable after transperineal redo anastomosis, and it offers a retropubic approach to men who are continent before surgery .[5]
Radiation and additional reconstruction
Radiation injury affects tissue selection and healing. In a 21-man single-surgeon series of robotic posterior reconstruction, the five irradiated men had reintervention in 80% (vs 0% and 10% in the benign and prostatectomy groups), functional success of 60% (vs 100% and 100%) and AUS placement in 80% (vs 0% and 30%).[15] In a retrospective cohort of 809 men after robotic prostatectomy (VUAS in 2.3%, urethral stenosis in 1.2%), radiotherapy was independently associated with the combined endpoint of VUAS or urethral stenosis (estimated 5-year risk 7.3% with radiotherapy versus 2.1% without).[16] In the Savun comparison, radiotherapy and preoperative incontinence were associated with patency failure (p = 0.007 and p = 0.041).[14] EAU notes that flaps such as gracilis or peritoneum may help protect the anastomosis in irradiated patients, and that ReDo anastomosis needs adequate bladder function and no urethral necrosis, calcification or fistula.[5]
When local tissue is inadequate, consider dorsal BMG, subtrigonal inlay, transvesical repair, reanastomosis, or combined reconstruction according to anatomy.
- Buccal mucosal graft. A multi-institutional retrospective series of dorsal onlay BMG urethroplasty after prostatectomy and radiation (45 men) had 7 recurrences. No de novo SUI was reported among men classified continent before surgery; baseline continence was unknown in six catheter-dependent men, and postoperative continence was assessed at 3–6 months.[17] Median follow-up in men without recurrence was 21 months, and 28 men were incontinent both before and after surgery.[17] A robotic subtrigonal BMG inlay for refractory BNC improved Qmax from 2 to 27 mL/s in a single case report.[18]
- Vascularized tissue. Rectus abdominis, omental and gracilis flaps were used as ancillary procedures in a nine-patient single-port robotic BMG series. Omental, rectus and gracilis transfers need different harvest approaches.[19] A perivesical fat rotational flap has been described as an omental alternative in three salvage-prostatectomy or fistula repairs; the series did not include BNC or VUAS reconstruction.[20]
- Transperineal urethral advancement. When a tension-free anastomosis cannot be achieved, robotic anastomosis assisted by transperineal urethral mobilization preserves the orthotopic tract. Incontinence is expected, and an AUS can be placed in the following months. This is a technique report.[21]
Complications and follow-up
Discuss recurrent stenosis, leakage or fistula, infection, bleeding and incontinence. Osteitis pubis with pubovesical fistula (Clavien IIIb) occurred in 1 of 12 patients in the first TURNS robotic series and required vesicopubic fistula repair with pubic bone debridement. Two of 30 patients in the Abo Youssef series had major complications.[11][2] SUI and use of an AUS are reported after VUAS reconstruction in these mixed cohorts.[6][13] Persistent storage symptoms were reported in 11/18 men after open Y-V plasty for post-TURP BNC.[9]
Confirm healing and stable patency, then reassess storage function and continence before any AUS surgery. For ReDo VUA, EAU advises deferring AUS implantation until anastomotic patency is stable; most authors wait at least three to six months because a recurrent VUAS is difficult to treat with the cuff in place.[5]
Videos
References
1. 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
2. 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
3. Masumoto H, Horiguchi A, Shinchi M, et al. "Effectiveness of Y-V-Plasty for Refractory Bladder Neck Stenosis After Transurethral Prostate Surgery." International Journal of Urology. 2025;32(4):434-440. doi:10.1111/iju.15676
4. 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
5. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.
6. 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
7. Zheng K, Sa Y, Hao C, et al. "Modified Y-V Plasty Based on MRU Evaluation for Iatrogenic Bladder Outlet Obliteration: A Multicentre Experience in China." World Journal of Urology. 2024;42(1):88. doi:10.1007/s00345-023-04765-6
8. Zang Z, Shao D, Zhang H, et al. "Extraperitoneal Laparoscopic Modified Y-V Plasty for the Treatment of Refractory Bladder Neck Contracture." Journal of Visualized Experiments. 2022;(184). doi:10.3791/64011
9. Shamout S, Yao HHI, Mossa AH, Carlson KV, Baverstock RJ. "Persistent Storage Symptoms Following Y-V Plasty Reconstruction for the Treatment of Refractory Bladder Neck Contracture." Neurourology and Urodynamics. 2022;41(5):1082-1090. doi:10.1002/nau.24941
10. 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
11. 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
12. 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
13. Zhang TR, Alford A, Wang A, Zhao LC. "Robotic-Assisted Posterior Urethroplasty: Outcomes From 105 Men in a Single-Center Experience." Urology. 2023;181:167-173. doi:10.1016/j.urology.2023.05.062
14. Savun M, Çolakoğlu Y, Özdemir H, et al. "Comparison of Open Perineal and Robot-Assisted Reconstruction in Vesicourethral Anastomotic Stenosis." World Journal of Urology. 2025;43(1):413. doi:10.1007/s00345-025-05808-w
15. Bearrick EN, Findlay BL, Maciejko LA, et al. "Robotic Urethral Reconstruction Outcomes in Men With Posterior Urethral Stenosis." Urology. 2022;161:118-124. doi:10.1016/j.urology.2021.11.035
16. Massouh K, Leucht K, Leistritz L, Grimm MO. "Retrospective Analysis of Vesicourethral-Anastomosis Stricture/Urethral Stricture After Robotic-Assisted Laparoscopic Radical Prostatectomy With and Without Radiotherapy." International Journal of Urology. 2026;33(1):e70339. doi:10.1111/iju.70339
17. Sterling J, Simhan J, Flynn BJ, et al. "Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis." The Journal of Urology. 2024;211(4):596-604. doi:10.1097/JU.0000000000003848
18. 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
19. 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
20. Hwang A, Watson M, Talluri S, Okafor H, Singh A. "A Novel Perivesical Fat Rotational Flap as an Alternative to Omental Interposition in Challenging Urological Reconstruction." Urology. 2023;182:e262-e263. doi:10.1016/j.urology.2023.08.023
21. Rodriguez VI, Celis V, Sayegh A, et al. "Robotic Management of Complex Vesicourethral Anastomosis Stenosis With Transperineal Urethral Advancement: A Step-by-Step Technique." Urology. 2024;184:e256-e257. doi:10.1016/j.urology.2023.10.035
22. Rinderknecht E, Engelmann SU, Saberi V, et al. "Robotic reconstruction of complex bladder neck stenosis: Single-centre experience with three techniques." BJUI Compass. 2025;6(2):e501. doi:10.1002/bco2.501
23. 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
24. Lee M, Lesgart M, McPartland C, Lee R, Eun DD. "Robotic transvesical bladder neck reconstruction: A novel approach to managing vesicourethral anastomotic stenosis." Eur Urol. 2025;88(5):519-524. doi:10.1016/j.eururo.2025.04.026