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Primary Re-Anastomosis for BNC and VUAS

Primary re-anastomosis for BNC / VUAS involves excision of fibrotic scar tissue and creation of a new end-to-end vesicourethral anastomosis without the use of a bladder flap or tissue graft. Four distinct surgical approaches are described: open retropubic, open perineal (transperineal), robotic retropubic, and robotic transvesical.

Practice Guideline​

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

Patency and continence outcomes by approach (per AUA):[1]

  • Robotic-assisted reconstruction: Patency 72.7–75%. In preoperatively continent patients, 82% continent postoperatively.
  • Open retropubic reconstruction: Patency 70–100%. In preoperatively continent patients, only 10% incontinent postoperatively.
  • Open perineal reconstruction: Patency 70–100%, but 83.3% incontinence in preoperatively continent patients — significantly higher than the retropubic approach.

First-time endoscopic treatment of VUAS is successful in 50–80% of cases (similar across modalities); success is lower with prior pelvic radiation. Patients should be counseled about the risk of incontinence after any of these procedures.[1]

1. Open Retropubic Primary Re-Anastomosis​

The earliest described approach for recalcitrant BNC/VUAS reconstruction.

Technique​

A lower midline or Pfannenstiel incision provides access to the space of Retzius. The bladder is mobilized, the fibrotic tissue at the vesicourethral junction is excised, and a new running or interrupted anastomosis is created between healthy bladder neck mucosa and the membranous urethra. The key principle is achieving a tension-free, mucosa-to-mucosa anastomosis with well-vascularized tissue.[2][3]

Outcomes — Pfalzgraf et al. 2011 (n=20)[2]​

  • Patients had a mean of 3.7 prior surgeries before open reanastomosis.
  • Initial patency 60% (12/20) at median follow-up of 59.2 months — the longest follow-up in the literature.
  • 7/8 recurrences successfully treated endoscopically → combined success rate 95%.
  • De novo incontinence 31% (4/20 with new-onset SUI). An additional 13 were already completely incontinent preoperatively; 9 of these were successfully treated with AUS.
  • 1 patient ultimately required urinary diversion.

Advantages and disadvantages​

  • Advantages: Excellent visualization of the bladder neck, ability to mobilize the bladder for a tension-free anastomosis, preservation of the perineal plane for future AUS placement.
  • Disadvantages: Higher morbidity than minimally invasive approaches; initial patency (60%) is lower than robotic series (combined success with secondary endoscopic treatment is 95%).[2]

2. Open Transperineal Re-Anastomosis (TPRA)​

Technique​

Patient in exaggerated lithotomy. A perineal incision provides access to the bulbar urethra, which is mobilized proximally. The fibrotic segment is excised, and the healthy urethra is advanced and re-anastomosed to the bladder neck. This approach is analogous to posterior urethroplasty for pelvic fracture urethral injury, with the critical difference that the sphincter mechanism has already been compromised by prior prostatectomy. Partial pubectomy may be required to bridge longer defects.[4][5][6]

Schlossberg/Jordan technique (1995): Combined abdominal and perineal dissection with partial pubectomy and omental wrapping of the anastomosis. Two patients with obliterative BNC (defects >1.5 cm) were voiding normally without pads at 18 and 7 months, demonstrating that continence preservation is possible even with this approach.[6]

Outcomes — Reiss et al. 2014 (n=15)[5]​

  • Mean 4.69 prior surgeries before TPRA.
  • Patency 93.3% (14/15). The single recurrence was treated endoscopically.
  • Incontinence: 93.3% incontinent preoperatively; incontinence worsened in 60% after surgery. No de novo incontinence (all were already incontinent).
  • AUS successfully implanted in 10 patients.
  • QoL improvement in 86.7%; patient satisfaction high (72.7%).

Extended follow-up — Schuettfort et al. 2017 (n=23)[4]​

  • Median follow-up extended to 45 months.
  • Patency 87% (20/23). Three recurrences treated endoscopically.
  • All patients had urinary incontinence pre- and postoperatively. AUS successfully implanted in 73.9% (17/23).
  • Complication rate low (8.7%, Clavien II–III).
  • EQ-5D-VAS showed good general health (73.5/100).

Critical limitation​

The perineal approach carries an 83.3% de novo incontinence rate in preoperatively continent patients (per AUA), dramatically higher than the retropubic approach (10%).[1] This is because transsphincteric urethral mobilization inherently disrupts the external sphincter mechanism. TPRA is generally reserved for patients who are already incontinent and will require AUS regardless.

3. Robotic Retropubic Primary Re-Anastomosis​

The most extensively studied minimally invasive approach, primarily reported by the TURNS consortium.

Technique​

The space of Retzius is dissected robotically. Fibrotic tissue at the vesicourethral anastomosis is excised. Reconstruction is performed with either a primary anastomotic technique (direct re-anastomosis) or an anterior bladder flap-based technique (see Y-V plasty), depending on the gap length and tissue quality. The decision is made intraoperatively based on whether a tension-free direct anastomosis is achievable.[7][8]

TURNS-1 — Kirshenbaum/Zhao 2018 (n=12)[8]​

  • 7 post-endoscopic prostate procedure, 5 post-radical prostatectomy.
  • Mean operative time 216 min; mean EBL 85 cc; median LOS 1 d.
  • Patency 75% (9/12) at median 13.5 mo.
  • Continence preservation 82% (of preoperatively continent patients).
  • One Clavien IIIb complication (osteitis pubis and pubovesical fistula).

TURNS-2 — Shakir/Alsikafi 2022 (n=32)[7]​

  • 50% had prior pelvic radiation; 47% had obliterative VUAS — significantly more complex cohort.
  • Median LOS 1 d.
  • Patency 75% (24/32) at median 12 mo; 81% voiding per urethra.
  • Continence preservation 85% (11/13 without preexisting SUI remained continent).
  • Eight recurrences managed with: redo robotic reconstruction (2), endoscopic treatment (4), catheterization (2).
  • No patients required urinary diversion.

Lavollé et al. 2019 (n=6) — extraperitoneal robotic[3]​

  • All had failed endoscopic management; 3 had prior salvage radiation.
  • Mean operative time 108 min (notably shorter than TURNS).
  • Patency 50% (3/6 recurred, all managed endoscopically).
  • Incontinence 50% (3/6 required AUS).
  • Lower success rate likely reflects the high proportion of radiated patients (50%).

4. Robotic Transvesical Primary Re-Anastomosis (RTV-BNR)​

A novel posterior transvesical approach by Lee/Eun et al. (European Urology 2025) — see the dedicated Transvesical Approaches page for details.[9]

  • 91% patency (10/11) at median 22 mo.
  • 0% de novo SUI — the best continence outcome of any approach.
  • Strictures <2 cm; 18% had prior radiation.

5. Combined Robotic-Perineal Approach (Transperineal Urethral Advancement)​

Rodriguez et al. (Urology 2024) described a hybrid technique for complex VUAS where the healthy proximal urethra is too short for a tension-free anastomosis via the retropubic approach alone. A transperineal urethral mobilization is performed simultaneously with robotic retropubic dissection, allowing the urethra to be advanced superiorly to reach the bladder neck. Preserves orthotopic urinary tract configuration as an alternative to ileal conduit diversion. Urinary incontinence is expected and managed with subsequent AUS.[10]

6. Tissue Interposition in Primary Re-Anastomosis​

Adjunctive tissue interposition strategies are often used in the radiated pelvis:

  • Omental wrapping/interposition: Schlossberg and Jordan (1995) described omental wrapping around the re-anastomosis to provide vascularized tissue coverage.[6] Wessells et al. (1998) used an anterior bladder tube with omental pedicle flap for obliterative VUAS, achieving patency in all 4 patients (though none were continent).[11]
  • Omental flap for urosymphyseal fistula (USF): In USF repair (which often coexists with VUAS in the radiated pelvis), Escandón et al. 2026 demonstrated that omental flap interposition had significantly lower fistula recurrence (vs primary repair, OR 0.012, p = 0.011) and lower 90-day sepsis rates (3% vs 18–27%).[12]

See also salvage prostatectomy reconstructive options for related rectus / omental flap interposition strategies.

Comparative Summary​

ApproachnPatencyCombined SuccessDe Novo SUIMedian F/UKey Advantage
Open retropubic[2]2060%95%31%59 moLong-term data, excellent combined success
Open perineal (TPRA)[4][5]2387%~100%83% (continent pts)45 moHigh patency; suits already-incontinent pts
Robotic retropubic (TURNS)[7][8]3275%81% voiding15%12 moMinimally invasive, balanced patency/continence
Robotic extraperitoneal[3]650%—50%—Short OR time
Robotic transvesical[9]1191%—0%22 moBest continence; avoids Retzius
Combined robotic + perineal[10]Case series——Expected—Bridges long defects

Key Predictors of Failure Across All Approaches​

A large Mayo Clinic registry study (n=17,904 radical prostatectomies, 851 VUAS cases) identified adjuvant radiation, BMI, prostate volume, urine leak, blood transfusion, and non-nerve-sparing technique as associated with VUAS formation. Endoscopic management was temporizing for most men, with 34% retreatment at 1 year and 42% at 5 years.[13] Savun et al. 2025 confirmed that pelvic radiotherapy (p = 0.007) and preoperative incontinence (p = 0.041) were significantly associated with patency failure regardless of surgical approach.[14]

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. Pfalzgraf D, Beuke M, Isbarn H, et al. "Open Retropubic Reanastomosis for Highly Recurrent and Complex Bladder Neck Stenosis." The Journal of Urology. 2011;186(5):1944-7. doi:10.1016/j.juro.2011.07.040

3. Lavollé A, de la Taille A, Chahwan C, et al. "Extraperitoneal Robot-Assisted Vesicourethral Reconstruction to Manage Anastomotic Stricture Following Radical Prostatectomy." Urology. 2019;133:129-134. doi:10.1016/j.urology.2019.07.027

4. Schuettfort VM, Dahlem R, Kluth L, et al. "Transperineal Reanastomosis for Treatment of Highly Recurrent Anastomotic Strictures After Radical Retropubic Prostatectomy: Extended Follow-Up." World Journal of Urology. 2017;35(12):1885-1890. doi:10.1007/s00345-017-2067-8

5. Reiss CP, Pfalzgraf D, Kluth LA, et al. "Transperineal Reanastomosis for the Treatment for Highly Recurrent Anastomotic Strictures as a Last Option Before Urinary Diversion." World Journal of Urology. 2014;32(5):1185-90. doi:10.1007/s00345-013-1180-6

6. Schlossberg S, Jordan G, Schellhammer P. "Repair of Obliterative Vesicourethral Stricture After Radical Prostatectomy: A Technique for Preservation of Continence." Urology. 1995;45(3):510-3. doi:10.1016/S0090-4295(99)80025-9

7. 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

8. 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

9. 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

10. 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

11. Wessells H, Morey AF, McAninch JW. "Obliterative Vesicourethral Strictures Following Radical Prostatectomy for Prostate Cancer: Reconstructive Armamentarium." The Journal of Urology. 1998;160(4):1373-5.

12. Escandón JM, Kreutz-Rodrigues L, Fadel AE, et al. "Optimizing Flap Selection for Urosymphyseal Fistula Repair: A Comparative Analysis of Surgical Outcomes." Microsurgery. 2026;46(3):e70197. doi:10.1002/micr.70197

13. Britton CJ, Sharma V, Fadel AE, et al. "Vesicourethral Anastomotic Stenosis Following Radical Prostatectomy: Risk Factors, Natural History, and Treatment Outcomes." The Journal of Urology. 2023;210(2):312-322. doi:10.1097/JU.0000000000003488

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