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Robotic Y-V Plasty (BNC and VUAS)

Robotic-assisted Y-V plasty is the most commonly described reconstruction for recalcitrant bladder neck contracture (BNC) and vesicourethral anastomotic stenosis (VUAS) after failure of endoscopic management. Cystotomy with Y-shaped incision at the bladder neck is closed in a V-configuration, advancing a well-vascularized anterior bladder flap into the stenotic segment to widen the outlet. The same operative principles apply when performed open or laparoscopically.

Practice Guideline​

The American Urological Association (AUA) recommends that surgeons may perform robotic or open reconstruction for recalcitrant stenosis of the bladder neck or post-prostatectomy vesicourethral anastomotic stenosis (Conditional Recommendation; Evidence Level: Grade C).[1] Treatment must be tailored to patient preferences, taking into consideration prior radiotherapy and the degree of urinary incontinence. Reconstruction is challenging and may cause significant urinary incontinence requiring subsequent artificial urinary sphincter (AUS) implantation.[1]

Robotic-assisted reconstruction patency rates range from 72.7–75%, and in patients who were preoperatively continent, 82% were continent postoperatively.[1] Open VUAS or bladder neck reconstruction can be performed retropubically or perineally with patency rates ranging from 70–100%. Patients who underwent a retropubic approach had a 10% postoperative incontinence rate, while those who had a perineal reconstruction had an 83.3% incontinence rate postoperatively — a critical distinction favoring the retropubic/robotic approach for continence preservation.[1]

Conceptual Rationale​

The Y-V plasty principle addresses the fundamental limitation of endoscopic incision — re-epithelialization over scar tissue. By advancing a well-vascularized, full-thickness bladder flap into the stenotic segment, the procedure replaces fibrotic tissue with healthy mucosa, preventing re-scarring. The anterior bladder wall is incised in a "Y" configuration, and the resulting V-shaped flap is advanced distally into the incised bladder neck/anastomosis, converting the "Y" into a "V" closure. This brings healthy tissue across the contracture, analogous to a Heineke-Mikulicz principle applied to the bladder outlet.[2][3]

Step-by-Step Surgical Technique​

Transperitoneal approach (Granieri/Zhao technique)[2]​

  1. Port placement and access: Standard robotic port placement. The space of Retzius is developed and the bladder is mobilized anteriorly.
  2. Localization of the contracture: A cystoscope is passed transurethrally to the level of the BNC/VUAS. Firefly (ICG fluorescence) technology is used to transilluminate and precisely localize the contracture from the abdominal side.
  3. Y-incision: The anterior bladder wall is incised in a Y-shaped configuration — two limbs of the "Y" extend proximally on the bladder, and the stem extends distally through the contracture into healthy urethra. Fibrotic tissue is excised.
  4. Flap advancement: The resulting V-shaped bladder flap (apex pointing proximally) is advanced distally into the opened contracture site and sutured in place, converting the Y-incision into a V-closure.
  5. Closure: The anastomosis is completed with absorbable sutures. A 22 Fr catheter is placed and a closed suction drain is left in the space of Retzius.
  6. Postoperative care: Drain removed before discharge (typically POD 1). Catheter removed at ~2 weeks in the office.

Extraperitoneal approach — "inverted Y-V plasty" (Abo Youssef/John technique)[4]​

  • Performed via an extraperitoneal robotic approach, avoiding intraperitoneal entry.
  • Median operative time was notably shorter at 131 minutes (vs 240 min for the transperitoneal approach).
  • Catheter removed at median 10 days.

Extraperitoneal laparoscopic modified technique (Zang/Zheng)[3][5]​

  • Uses barbed sutures for continuous closure (rather than interrupted), reducing operative time and anastomotic leakage.
  • Modified incision positions at 5 and 7 o'clock (rather than anterior) to avoid the dorsal venous complex.
  • Double-layer suture technique: mucosa/submucosa closed first in V-shape, then serosa/muscularis reinforced separately.
  • Median operative time as low as 75 minutes in the multicenter Chinese experience.[5]

Published Outcomes​

StudyNApproachEtiologyPatencyFollow-UpDe Novo SUIMajor Complications
Granieri 2018[2]7Transperitoneal6 BNC, 1 VUAS100%8 mo (median)2 pts (1 pad/d)None
Kirshenbaum 2018 (TURNS)[6]12Robotic (mixed)7 BNC, 5 VUAS75%13.5 mo (median)18% (of continent pts)1 osteitis pubis/fistula (IIIb)
Abo Youssef 2023[4]30ExtraperitonealBNS + VUAS83.3%27 mo (median)Not specified2 (IIIa, IV)
Viegas 2024[7]21Robotic15 BNC, 6 VUAS90.5%Variable23.8% (all VUAS)See below
Zheng 2024 (multicenter)[5]31Laparoscopic modifiedBOO (obliteration)90.3%12+ mo12.9%None intraop
Masumoto 2025[8]5Open Y-V plastyBNC post-TURP100%13 mo (median)60% (1–2 pads)None

Functional outcomes — Abo Youssef et al. (largest dedicated robotic Y-V series)​

In 30 patients followed for a median of 27 months:[4]

  • IPSS: 17 → 11 (short-term) → 6 (intermediate-term)
  • Qmax: 7.4 → 13 → 17 mL/s
  • PVR: 90 → 0 → 0 mL
  • Treatment failure at 24 months: 16.7% (5/30); only 2 were re-strictures.
  • SF-8 quality of life improvement did not reach statistical significance.

BNC vs. VUAS — A Critical Distinction​

The Viegas 2024 study is the only head-to-head comparison of robotic Y-V plasty outcomes stratified by etiology, and the findings are striking:[7]

ParameterBNC (n=15)VUAS (n=6)p-value
Operative time146.7 min277.5 min0.008
Hospital stay1.7 d3.2 d0.03
Postop complications26.7%66.7%0.14
De novo SUI0%83.3%0.0001
Stricture recurrenceSimilarSimilar0.50
Long-term reoperation0%50%0.05
Patient improvement (PGI-I 1–2)80%83.3%0.31

Bottom line: patency rates are similar between BNC and VUAS, but VUAS patients have dramatically worse perioperative outcomes, significantly higher de novo SUI (83.3% vs 0%), and more frequent need for reoperation. This reflects the proximity of the VUAS to the external sphincter mechanism and more extensive fibrosis in the post-prostatectomy field.[7]

Comparison to Other Robotic Reconstruction Techniques​

TechniqueLargest series NPatencyDe Novo SUIKey Feature
Robotic Y-V plasty3083–100%0% (BNC), 83% (VUAS)Bladder flap advancement[4][7][8]
Robotic excision + primary anastomosis32 (TURNS)75%15%Scar excision, re-anastomosis[9]
Robotic transvesical BNR1191%0%Circumferential excision, mucosa-to-mucosa[10]
Robotic BMG urethroplasty14 (within 105-pt series)~75%28.6% (overall cohort)Graft augmentation for longer defects[11][12]
Robotic + transperineal urethral advancementCase seriesVariableExpected (AUS planned)For tension-free anastomosis when gap too large[13]

Impact of Prior Pelvic Radiation​

Radiation is the single most important adverse prognostic factor across all reconstruction techniques:

  • In the TURNS robotic reconstruction series (n=32), 50% had prior radiation, and overall patency was 75%; radiation-specific subgroup outcomes were not separately reported.[9]
  • In Bearrick et al., radiated patients had dramatically worse outcomes: 80% re-intervention rate, 60% functional success (vs 100% for BPH and prostatectomy etiologies), and 80% required AUS placement (vs 0–30%).[14]
  • Radiotherapy and preoperative incontinence were independently associated with patency failure in a 2025 comparative study (p = 0.007 and p = 0.041, respectively).[15]
  • The 5-year risk of VUAS/US formation is 7.3% with radiotherapy vs 2.1% without (p = 0.003).[16]

Robotic vs. Open Perineal Reconstruction​

A 2025 comparative study (n=28) directly compared open perineal vs robotic reconstruction for VUAS:[15]

  • Patency rates were similar: 77.8% (open) vs 80% (robotic), p = 0.944.
  • De novo incontinence was dramatically lower with robotic: 16.6% vs 100% (p = 0.031).
  • Robotic approach had significantly less blood loss (100 vs 200 mL, p = 0.001) and shorter hospital stay (3 vs 4 days, p = 0.001).
  • Operative times were comparable (120 vs 150 min, p = 0.175).

This supports the robotic retropubic approach over perineal reconstruction when continence preservation is a priority.[15]

Ancillary Procedures and Tissue Interposition​

For complex or radiated cases, additional tissue transfer may be required:

  • Buccal mucosal graft (BMG): Used for longer defects or when local tissue quality is poor. Can be placed as a dorsal onlay or subtrigonal inlay. A robotic subtrigonal BMG inlay for refractory BNC improved Qmax from 2 to 27 mL/s with no recurrence.[17] Multi-institutional data on dorsal onlay BMG for post-prostatectomy/post-radiation stenosis showed 84% patency with 0% de novo incontinence in 45 patients.[18]
  • Flap interposition: Rectus abdominis, omental, or gracilis flaps can be harvested robotically to provide vascularized tissue coverage over the reconstruction, particularly in radiated fields.[12]
  • Perivesical fat flap: A novel alternative to omental interposition when omentum is unavailable (e.g., prior abdominal surgery).[19]

Complications​

  • Osteitis pubis with pubovesical fistula: 1/12 patients in the TURNS RBNR series (Clavien IIIb), requiring vesicopubic fistula repair with pubic bone debridement.[6]
  • Major complications (Clavien ≥III): 2/30 in the Abo Youssef series (IIIa and IV).[4]
  • 30-day complications: 6.7% rate of ≥Clavien III in the largest robotic posterior urethroplasty cohort (n=105).[11]
  • De novo SUI requiring AUS: The most common long-term sequela, particularly for VUAS (83.3% in the Viegas series). Overall, 28.6% of patients in the largest robotic posterior urethroplasty series required AUS placement.[11]

Patient Selection and Preoperative Workup​

  • Indication: Recalcitrant BNC or VUAS after ≥2 failed endoscopic treatments.[2][6]
  • Preoperative imaging: MR urethrography (MRU) is superior to conventional RUG/VCUG for measuring obliteration length (0.91 vs 1.72 cm vs actual 0.96 cm).[5]
  • Stenosis length: Y-V plasty is best suited for stenoses ≤2 cm. Longer defects may require BMG augmentation or combined abdominoperineal approaches.[5][10]
  • Continence status: Preoperative continence assessment is essential. Patients should be counseled that de novo SUI is a significant risk, particularly for VUAS, and AUS placement may be needed subsequently.[7]
  • Radiation history: Radiated patients should be counseled about higher failure rates and the potential need for tissue interposition (flaps/grafts).[14]

Treatment Algorithm​

  1. First-time BNC/VUAS → Endoscopic incision or resection.
  2. First recurrence → Repeat endoscopic treatment (justified by high cumulative success).
  3. Recalcitrant disease (≥2 failed endoscopic treatments):
  4. Obliterative disease → Combined robotic + transperineal approach with urethral advancement if tension-free anastomosis not achievable.[13]
  5. Post-reconstruction SUI → AUS placement (safe after robotic reconstruction; >90% long-term urethral patency).[6][11]

References​

1. 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

2. 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

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

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. 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

18. 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

19. 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