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Robotic Bladder Flap Posterior Urethroplasty

This reconstruction uses an anterior bladder-wall flap to form a new vesicourethral anastomosis after division of a diseased outlet and removal of unsuitable scar. Zhao, Shakir and Zhao described it for selected recalcitrant BNC/VUAS in a nine-patient retrospective technical series. It is a specialist option with limited follow-up, not a proven way to avoid incontinence or diversion in all patients.[1]

Anatomical role​

The flap supplies bladder tissue when direct reanastomosis may otherwise be difficult. It differs from Y-V plasty, which widens an incised stenosis, and from a Tanagho tube, which creates a longer tubularized conduit. Viable bladder tissue, adequate mobility, bladder function and the urethral target determine whether this approach is feasible.[1]

Recurrent stenosis is not necessarily complete obliteration. Evaluate its location, length, residual lumen, radiation damage, fistula and baseline continence. EAU supports individualized reconstruction for appropriate refractory posterior disease; no guideline establishes this particular flap as superior to other reconstructions.[2]

Operative sequence​

The published operation uses transperitoneal robotic access.[1]

  1. Mobilize the anterior bladder and expose the diseased outlet, protecting adjacent pelvic structures.
  2. Localize the stenosis with combined endoscopic and robotic assessment. Cystoscopic transillumination is light localization; it does not require ICG injection. Near-infrared viewing of a cystoscope's light and fluorescence after administration of ICG are distinct techniques.[3]
  3. Divide the diseased bladder neck and remove unsuitable scar sufficiently to reach viable tissue. Avoid assuming that maximal circumferential excision improves every radiated repair.
  4. Fashion an anterior bladder-wall flap that reaches the urethral target without tension and preserves its blood supply.
  5. Create a mucosa-to-mucosa vesicourethral anastomosis and close the remaining bladder defect. Confirm hemostasis, watertight closure and catheter drainage.
  6. Add tissue interposition or associated fistula repair when indicated. Individualize drainage and healing assessment.

The original report and operative video provide the technique-specific flap design. Tissue viability and available length determine the final construction; a fixed flap size or universal catheter duration is not established by this series.

Index-series outcomes​

OutcomeZhao 2022, n=9
Mean operative time295.5 minutes overall; 264.5 minutes excluding three patients with ancillary procedures
ComplicationsNo intraoperative complications reported; two postoperative complications
Follow-upMean 21.1 weeks
Freedom from recurrent stenosis7/9 (78%) without recurrence; both recurrences underwent balloon dilation
New stress incontinence0/3 patients continent before surgery developed new SUI

The continence result does not mean all nine patients became continent or used at most one pad. Short follow-up in a tiny selected cohort does not establish durable patency, low comparative morbidity or zero future continence risk.[1]

Alternatives and evidence limits​

Primary reanastomosis, Y-V plasty, transvesical reconstruction, graft augmentation and urinary diversion address different anatomical situations. Percentages from their separate case series cannot be ranked as though they came from comparable patients. Discuss the possibility of further stenosis treatment and staged continence surgery, with patency and bladder function reassessed first.[2]

Videos​

Robotic Bladder Flap Posterior Urethroplasty
Lee C. Zhao, MD

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

2. European Association of Urology. EAU Guidelines on Urethral Strictures. 2026. Disease management in males, sections 6.3.5–6.3.6. Guideline.

3. 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.