Robotic Bladder Flap Posterior Urethroplasty
The robotic bladder flap posterior urethroplasty is a novel reconstructive technique for recalcitrant bladder neck contracture (BNC) and vesicourethral anastomotic stenosis (VUAS) described by Zhao, Shakir, and Zhao (NYU) in Urology Video Journal 2022. The technique creates a new vesicourethral anastomosis (VUA) from an anterior bladder wall flap after the diseased bladder neck has been transected and dystrophic tissue excised. It was developed to spare patients with refractory posterior stenosis from the morbidity of open transperineal reanastomosis or cystectomy with urinary diversion, while still producing a robust mucosa-bearing anastomosis in a potentially hostile or radiated field.[1]
Conceptual Rationale
When endoscopic management fails, the residual stenotic segment is typically an obliterated, fibrotic vesicourethral junction with little usable native mucosa. Standard robotic primary re-anastomosis (TURNS pattern) excises the scar and re-anastomoses healthy bladder neck to membranous urethra, but in severely radiated or multiply-operated patients there may be insufficient healthy bladder neck mucosa to bridge the gap without tension. The bladder flap technique sidesteps this by discarding the diseased bladder neck entirely and constructing a new VUA from the well-vascularized anterior bladder wall, advanced caudally to meet the urethral stump.[1] Conceptually it is closer to the Tanagho anterior bladder tube than to a Y-V plasty, but uses the flap to form a new anastomosis rather than to widen an incised contracture.
Surgical Technique
Transperitoneal robotic approach.[1]
- Access and exposure: Standard robotic port placement; transperitoneal entry into the space of Retzius. The bladder is mobilized anteriorly from the symphysis pubis.
- Identification of the stenotic segment: Cystoscopic transillumination (Firefly / ICG) localizes the diseased vesicourethral junction.
- Transection of the bladder neck: The diseased bladder neck is transected and dystrophic / fibrotic tissue at the vesicourethral junction is excised completely until healthy, well-vascularized bladder wall and urethral stump are exposed.
- Anterior bladder flap design: A cystotomy is created in the anterior bladder wall, and a flap is fashioned from the anterior bladder wall tissue. The flap's caudal margin will form the new bladder-neck mucosal edge.
- Vesicourethral anastomosis: The advancing edge of the bladder flap is anastomosed to the urethral stump in a mucosa-to-mucosa, watertight, tension-free fashion, creating a new VUA.
- Closure: The remaining bladder defect is closed primarily.
- Catheter management: Urethral catheter left in place; suprapubic catheter optional. A drain is left in the pelvis as needed.
Ancillary procedures (e.g., omental flap interposition, repair of associated fistula) were performed concurrently in a subset of patients.[1]
Published Outcomes
Index series — Zhao, Shakir, Zhao (Urology Video Journal 2022, n=9):[1]
| Parameter | Result |
|---|---|
| Number of patients | 9 |
| Indication | Recalcitrant BNC or VUAS after failed endoscopic management |
| Approach | Transperitoneal robotic |
| Mean operative time (all patients) | 295.5 min |
| Mean operative time (excluding 3 pts with ancillary procedures) | 264.5 min |
| Intraoperative complications | None |
| 30-day postoperative complications | 2 (one abdominal wall abscess, Clavien ≥ III) |
| Mean follow-up | 21.1 weeks |
| Patency (no recurrent stricture) | 78% (7/9) |
| Continence (≤ 1 pad / day) | 100% |
The investigators concluded that short- and medium-term data support durable patency with low morbidity in recalcitrant BNC and VUAS using this approach.[1]
Comparison to Other Robotic Posterior Reconstructions
| Technique | n | Patency | De Novo SUI / Continence | Best For |
|---|---|---|---|---|
| Robotic bladder flap urethroplasty (Zhao 2022)[1] | 9 | 78% at 21 wk | 100% continent (≤1 pad/d) | Recalcitrant BNC/VUAS where bladder neck must be discarded and a new VUA built from anterior bladder wall |
| Y-V plasty (robotic / open) | 30 | 83–100% | 0% (BNC), 83% (VUAS) | Stenosis ≤ 2 cm where flap advancement into the contracture is feasible |
| Primary re-anastomosis (TURNS) | 32 | 75% | 85% continence preserved | Recalcitrant VUAS amenable to direct mucosa-to-mucosa anastomosis after scar excision |
| Robotic transvesical BNR | 11 | 91% | 0% de novo SUI | Recalcitrant VUAS with hostile space of Retzius |
| Tanagho anterior bladder tube | 50 | 70% | Variable | Total urinary incontinence with usable anterior bladder wall (historical) |
The bladder flap urethroplasty differs from Tanagho's procedure in that it builds a single mucosa-bearing VUA rather than tubularizing a long neo-urethral conduit, and differs from Y-V plasty in that the diseased bladder neck is transected and discarded rather than incised and widened.[1]
Limitations and Evidence Level
- Single-institution case series (n=9), short-to-medium-term follow-up (mean 21.1 weeks).[1]
- No comparative trial against standard robotic primary re-anastomosis, Y-V plasty, or transvesical reconstruction.
- The continence result (100% ≤ 1 pad/day) is striking but reflects a small cohort and short follow-up; long-term durability and de novo SUI rates are not yet established.
- Technique requires advanced robotic reconstructive expertise.
References
1. Zhao CC, Shakir NA, Zhao LC. "Robotic Bladder Flap Posterior Urethroplasty for Recalcitrant Bladder Neck Contracture and Vesicourethral Anastomotic Stenosis." Urology Video Journal. 2022;13:100133. doi:10.1016/j.urolvj.2022.100133