Primary Reanastomosis for Refractory Posterior Stenosis
Primary reanastomosis excises unsuitable scar and reconnects viable bladder-neck and urethral tissue. It is most often discussed for refractory post-prostatectomy VUAS. A flap or graft is a different reconstructive strategy when direct tension-free anastomosis is unsuitable. Published “robotic reconstruction” cohorts frequently mix these operations and should not be presented as pure primary-anastomosis results.[1][2]
Selection
EAU supports individualized reconstruction for appropriate refractory posterior stenosis. Define location, length, degree of obliteration, prior radiation/operations, fistula or necrosis, baseline continence, bladder function and the patient's goals. Nonobliterative disease can sometimes be stabilized endoscopically; complete obliteration should not undergo endoluminal treatment. Reconstructive access may be retropubic, perineal, transvesical or combined, depending on the defect.[3]
Counsel separately about patency and continence. Redo vesicourethral anastomosis can cause major SUI, especially with transperineal dissection; later continence surgery may be needed. Cohort-specific percentages do not prove that an approach causes more or less incontinence in otherwise identical patients. Prior prostatectomy differs substantially from PFUI, where the bladder neck may remain intact.[3]
Operative approaches
Retropubic
Open or robotic access permits bladder mobilization and exposure of the anastomosis. Excise scar as needed to obtain viable edges, preserve adjacent structures and create a watertight, tension-free mucosa-to-mucosa anastomosis. If direct approximation is unsafe, consider a bladder-flap or graft reconstruction rather than forcing tension onto the repair.[4][1][2]
Transperineal
Perineal exposure allows proximal urethral mobilization and scar excision. Progressive maneuvers such as corporal separation or limited inferior pubectomy may be required for access or tension reduction. Positioning and the extent of dissection should be individualized; protect the rectum and recognize the high risk of sphincteric incontinence in a post-prostatectomy patient.[5][6][3]
Combined abdominoperineal reconstruction may be needed when neither route alone provides sufficient exposure or tissue reach. It is not obligatory for all long or recurrent stenoses. Omental or other vascularized interposition can be used in selected complex repairs, especially with associated fistula or compromised tissues.[7][8]
Transvesical
Robotic transvesical reconstruction accesses the outlet from within the bladder and may limit dissection of a hostile retropubic plane in selected short VUAS. Its recent small series does not establish a universal continence advantage.[9]
Primary cohorts and meaningful denominators
| Study | Population and follow-up | Findings |
|---|---|---|
| Pfalzgraf 2011 | 20 open retropubic repairs; median 59.2 months | Initial patency 12/20; seven of eight recurrences treated endoscopically, giving 19/20 after additional treatment. Four patients developed new incontinence; the abstract's percentage uses an unclear at-risk denominator. Thirteen were completely incontinent postoperatively, not 13 additional baseline cases.[4] |
| Reiss 2014 | 15 transperineal repairs; mean 20.5 months | 14/15 initially patent; remaining recurrence treated endoscopically. 14/15 were incontinent before surgery; incontinence worsened in 9/15. No new incontinence reported; this is a very small initially continent subgroup. Ten underwent AUS placement.[6] |
| Schuettfort 2017 | Expanded transperineal cohort, 23 patients; median 45 months | 20/23 initially successful; three recurrences treated endoscopically. All had pre- and postoperative incontinence; 17/23 received an AUS. This extends the earlier experience and is not an independent 23-patient addition to the 15.[5] |
| Kirshenbaum 2018 | 12 robotic reconstructions, 7 BNC and 5 VUAS; median 13.5 months | 9/12 patent; 82% of those continent before surgery remained continent. Mean operative time 216 minutes and EBL 85 mL. One serious osteitis/pubovesical-fistula complication occurred.[2] |
| Shakir 2022 | 32 robotic VUAS reconstructions with mixed anastomotic/flap techniques; 50% irradiated, 47% obliterative; median 12 months | 24/32 patent and 26/32 voiding per urethra are different endpoints. Eleven of 13 without prior SUI remained continent. Eight recurrences required further reconstruction, endoscopy or catheterization.[1] |
| Lee 2025 | 11 transvesical repairs for selected VUAS shorter than 2 cm, 2 irradiated; median 22 months | 10/11 successful; no new SUI reported. Small retrospective feasibility series, not evidence of the “best” continence outcome.[9] |
Do not pool these results or rank access routes without accounting for selection, baseline continence, radiation, reconstruction type and whether salvage procedures count as success. Savun's small 28-patient retrospective perineal-versus-robotic comparison found similar observed patency, but absence of a significant difference does not establish equivalence.[10]
Associated fistula and tissue transfer
Fistula repair may require vascularized coverage, removal of diseased tissue or a different urinary diversion. Escandón's 56-patient urosymphyseal-fistula cohort compared primary closure, omentum and VRAM in selected patients; its adjusted recurrence association for omentum versus primary repair does not establish the best interposition for routine VUAS reanastomosis. Some patients with nonviable sphincters or severe radiation-related bladder disease required exenterative surgery.[11]
Follow-up and continence planning
Maintain drainage through healing and assess patency before catheter removal according to the repair and imaging findings. Follow symptoms, flow, residual and recurrent infection, with cystoscopy or imaging when indicated. Record additional procedures explicitly.
Stable patency and adequate bladder function should precede continence surgery. EAU describes delaying AUS implantation for at least 3–6 months after redo VUA to confirm stability; timing and device suitability remain individualized. Patients may prefer ongoing drainage or diversion rather than a staged reconstructive/AUS pathway.[3]
Risk factors for developing VUAS after prostatectomy are not automatically validated predictors of failure after reconstruction. Britton's large prostatectomy registry addressed formation and subsequent treatment history; its 34% one-year and 42% five-year retreatment estimates do not mean that most men fail endoscopic treatment or predict an individual repair's outcome.[12]
Videos
References
1. 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
2. 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
3. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.
4. 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
5. 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
6. 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
7. 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
8. 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
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. 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
11. 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
12. 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