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Transvesical Approaches to BNC and VUAS

The transvesical approach to BNC/VUAS reconstruction is a recently described paradigm that accesses the stenotic segment from within the bladder (posterior transvesical) rather than through the traditional retropubic space of Retzius. Three distinct transvesical techniques have been reported:

  1. Robotic Transvesical Bladder Neck Reconstruction (RTV-BNR) — Lee/Eun 2025, for VUAS.
  2. Robotic Transvesical Subtrigonal Buccal Mucosal Graft Inlay — Avallone/Flynn/Nikolavsky 2019, for refractory BNC. See also the Subtrigonal Inlay (BMG family) page.
  3. Transvesical Robotic-Assisted Radical Prostatectomy (TvRARP) — Yu 2025, for recalcitrant BNC after HoLEP.

Robotic Transvesical Bladder Neck Reconstruction (RTV-BNR)​

The primary transvesical technique described by Lee, Eun et al. (European Urology, 2025) for VUAS management.[1]

Surgical technique​

  • Posterior transvesical route — the bladder is opened and the reconstruction is performed from inside the bladder looking down at the bladder neck, rather than approaching from the anterior retropubic space.
  • The fibrotic scar tissue at the vesicourethral anastomosis is circumferentially excised.
  • A mucosa-to-mucosa, watertight, tension-free anastomosis is then created between the healthy bladder neck mucosa and the posterior urethra.

Outcomes (n=11)[1]​

  • 91% success at median 22 mo follow-up.
  • 0% de novo SUI.
  • 18% had prior pelvic radiation.
  • Median operative time 189 min; median EBL 100 mL.
  • No Clavien ≥ 2 postoperative complications.

Rationale and theoretical advantages over standard retropubic approach​

The standard robotic retropubic approach (TURNS consortium) involves dissecting the space of Retzius, excising fibrotic tissue, and performing either a primary re-anastomosis or anterior bladder flap reconstruction.[2][3] The transvesical approach differs in several key ways:

  • Avoids the space of Retzius entirely — particularly advantageous in patients with dense anterior adhesions from prior prostatectomy, radiation, or multiple endoscopic procedures, where retropubic dissection can be hazardous.
  • Direct visualization of the bladder neck mucosa — working from within the bladder provides excellent visualization of mucosal edges, facilitating a precise mucosa-to-mucosa anastomosis.
  • Potentially less sphincter disruption — the 0% de novo SUI rate in the Lee series is striking compared to the 15–18% de novo SUI rate in the TURNS retropubic series. This may be because the transvesical approach avoids circumferential dissection around the external sphincter from the outside.[1][2]
  • No need for a bladder flap — unlike the retropubic approach where an anterior bladder flap may be needed to bridge a gap, the transvesical approach achieves a direct mucosa-to-mucosa anastomosis.

Robotic Transvesical Subtrigonal Buccal Mucosal Graft Inlay​

Described by Avallone, Nikolavsky, Flynn et al. (Urology, 2019) — a distinct transvesical technique for refractory BNC (not VUAS).[4]

Surgical technique​

  • Robotic-assisted laparoscopic transvesical approach.
  • The bladder is opened and the contracture is accessed from the subtrigonal aspect.
  • A buccal mucosal graft (5 × 5 × 4 cm in the reported case) is harvested and inlaid into the stenotic segment to augment the bladder neck lumen.
  • The graft is placed as a dorsal inlay through the subtrigonal approach.

Outcomes (n=1, case report)[4]​

  • Qmax improved from 2 to 27 mL/s.
  • PVR improved from 200 to 3 mL.
  • Urethral catheter removed at 2 weeks; suprapubic catheter at 4 weeks.
  • VCUG at catheter removal showed no obstruction or extravasation.
  • No recurrence at last follow-up.

Rationale. Combines the advantages of the transvesical approach (avoiding the space of Retzius, direct mucosal visualization) with the tissue augmentation principle of buccal mucosal grafting, which is well-established in anterior urethral stricture surgery but novel in the posterior urethra/bladder neck. See the dedicated Subtrigonal Inlay (BMG family) page for the broader BMG framework.

Transvesical Robotic-Assisted Radical Prostatectomy (TvRARP) for Recalcitrant BNC​

A more radical transvesical approach described by Yu et al. (World Journal of Urology, 2025) specifically for recalcitrant BNC after HoLEP.[5]

Surgical technique​

  • Transvesical robotic-assisted radical prostatectomy — the residual prostate tissue (the source of recurrent contracture) is completely excised via a transvesical route.
  • A new vesicourethral anastomosis is then created.

Outcomes (n=8)[5]​

  • 100% treatment success (all patients passed 17 Fr cystoscope or had Qmax > 15 mL/s).
  • Qmax improved from 4.15 → 17.7 mL/s.
  • PVR decreased from 190 → 17.5 mL.
  • IPSS improved from 31 → 10.5.
  • All patients continent at 3 months.
  • Median operative time 123 min; median EBL 50 mL.
  • Minimum 6-month follow-up.

This approach is conceptually different — it removes the entire prostate as the definitive solution to recurrent BNC, rather than reconstructing around the contracture. It is closely related to salvage prostatectomy in the reconstructive setting.

Comparison: Transvesical vs. Standard Retropubic Robotic Approaches​

FeatureRTV-BNR (Transvesical)[1]Standard Retropubic (TURNS)[2][3]
AccessPosterior, through bladderAnterior, space of Retzius
Scar excisionCircumferential, from withinCircumferential, from outside
ReconstructionMucosa-to-mucosa directPrimary anastomosis or anterior bladder flap
Success rate91% (n=11)75% (n=32)
De novo SUI0%15%
Median follow-up22 mo12 mo
Radiation history18%50%
Obliterative stenosisNot specified47%
Median OR time189 min~216 min (TURNS-1)
Median EBL100 mL85 cc (TURNS-1)

Caveats. The TURNS cohort had a much higher proportion of radiated patients (50% vs 18%) and nearly half had obliterative VUAS, both of which are known to worsen outcomes. Direct comparison is therefore limited.[1][2]

Limitations and Current Evidence Level​

The transvesical approach remains at an early stage of evidence (Grade C per AUA classification):

  • Small sample sizes — 11 patients for RTV-BNR, 1 case report for subtrigonal BMG, 8 patients for TvRARP.
  • Single-institution, retrospective design for all studies.
  • No direct comparative studies against retropubic or Y-V plasty approaches.
  • Short-to-intermediate follow-up — durability beyond 2 years is not yet established.
  • The technique requires advanced robotic skills and familiarity with intravesical robotic surgery, limiting generalizability.

The AUA Urethral Stricture Disease Guideline (2023 Amendment) provides a conditional recommendation that surgeons may perform robotic or open reconstruction for recalcitrant BNC/VUAS but does not yet specifically address the transvesical approach, as the Lee et al. data postdates the guideline.[6]

References​

1. 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

2. 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

3. 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

4. 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

5. Yu C, Zhang Q, Quan J, Zhang D, Wang S. "Transvesical Robot-Assisted Radical Prostatectomy for Recalcitrant Bladder Neck Contracture After Holmium Laser Enucleation of Prostate: Initial Experience and Clinical Outcomes." World Journal of Urology. 2025;43(1):117. doi:10.1007/s00345-025-05494-8

6. 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