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Salvage Prostatectomy for USF

Salvage prostatectomy in the context of urosymphyseal fistula (USF) repair is a bladder-sparing reconstructive strategy that removes the radiation-damaged prostate (the fistula source), then reconstructs the urinary tract by one of two endpoints:

  • Bladder-neck closure + augmentation cystoplasty + continent catheterizable stoma — pioneered by Pisters, Westney, and colleagues at MD Anderson to address the high incontinence rate of standard salvage RP. Now the preferred reconstruction for USF.[1][2][3]
  • Standard vesicourethral anastomosis (VUA) — direct anastomosis of the tailored bladder neck to the membranous urethra; preserves per-urethral voiding but carries 49.6% any-grade incontinence at 1 yr, 24.6% moderate-severe, and 7–41% anastomotic-stricture rate in the salvage setting[16][17][18]

The choice between endpoints is the principal decision in this operation. Steps 1–2 (pubectomy + salvage RP) are identical; only the urinary-reconstruction step differs. The bulk of this page covers the BNC-closure variant in detail; the VUA variant is treated as a section near the end.

For the broader USF / PPF bladder-sparing decision framework see USF / PPF Bladder-Sparing Approaches. For the cystectomy alternative see male fistula treatment atlas. For technique on the ileal augmentation step, see urinary diversion / augmentation pages under 04b.

Rationale​

The prostate is the epicenter of pathology in radiation-induced USF — radiation has devascularized the prostatic urethra / bladder neck, and subsequent endoscopic procedures have created the fistula tract into the symphysis. Prostatectomy accomplishes four goals simultaneously:

  • Eliminates the fistula origin — excises the diseased prostatic urethra and bladder neck where the tract originates
  • Removes the nidus of chronic infection — necrotic, irradiated prostatic tissue perpetuating pelvic sepsis
  • Facilitates bladder mobilization — bladder can be mobilized superiorly, separating the urinary closure from the infected bone bed[4][5]
  • Enables definitive bladder-neck closure with intestinal-segment interposition, preventing recanalization[5]

Patient Selection​

Feasible in only a minority of irradiated USF patients — ~14% in the Patel 2023 SR, 47% (7/15) in Bugeja 2016.[4][6]

Absolute requirements​

  • Prostate in situ — must not have had prior radical prostatectomy (8/16 patients in Bugeja had prior RP and were therefore not candidates)[4]
  • Adequate bladder function — bladder must retain sufficient compliance and capacity. Patients with end-stage irradiated bladder (severe radiation cystitis, contracted bladder, intractable hematuria) require cystectomy instead[2][4]
  • Patient willingness to perform CIC — bladder neck is closed; voiding occurs exclusively via the catheterizable stoma. Adequate hand dexterity and cognitive function essential[2][3]

Relative considerations​

  • Extent of tissue destruction — extensive cavitation, multiple fistula tracts, or massive necrosis around the prostate favors cystectomy[7]
  • Prior treatment burden — sequential energy sources (EBRT + brachy + cryo / HIFU) create more extensive ischemia; Mundy & Andrich specifically flagged this as conferring "complexity"[7]
  • Nutritional and performance status — operation is > 6 h; patients must tolerate prolonged surgery and recovery

Preoperative Workup​

ModalityRole
MRI pelvisConfirms fistula, characterizes osteomyelitis extent, evaluates prostate and surrounding tissue planes — diagnostic in 95%[6]
CystoscopyBladder mucosa for radiation changes; capacity under anesthesia; fistula orifice
UrodynamicsDetrusor function, compliance, capacity. Preexisting frequency / urgency / urge incontinence supports simultaneous augmentation[2]
CT abdomen/pelvisUrinoma, abscess, upper-tract status
Intraoperative bone cultures95.5% discordance between preoperative urine and intraoperative bone cultures; bone cultures are essential for targeted antibiotics[8]

Surgical Technique​

Midline lower abdominal incision; sequential steps:

Step 1 — Exposure and pubectomy​

  • Enter the retropubic space (typically obliterated by fibrosis, infected tissue, urinoma in USF patients)
  • Expose the pubic symphysis; resect all infected and necrotic bone (pubectomy) using rongeurs and curettes until healthy bleeding bone margins are encountered — active infection in 80% of bone specimens[8]
  • Identify and excise the fistula tract in continuity with the bone debridement

Step 2 — Salvage radical prostatectomy​

Analogous to standard radical prostatectomy, but with critical differences in the irradiated field:

  • Obliterated tissue planes from radiation-induced fibrosis. Posterior dissection (between prostate and rectum) is the most challenging portion — risk of rectal injury[9][10]
  • No nerve-sparing — erectile-function recovery is essentially zero (ED 80–100% after salvage RP)[10][11]
  • Divide lateral pedicles; separate prostate from rectum posteriorly and from bladder superiorly
  • Apical dissection to avoid external-sphincter injury, though sphincter preservation is not the primary goal (bladder neck will be closed)[10]
  • Remove prostate en bloc with the fistula tract

Step 3 — Bladder-neck closure with intestinal interposition​

The critical reconstructive step that distinguishes this approach from standard salvage RP:

  • Bladder neck closed in multiple layers — no vesicourethral anastomosis (which has 40–60% incontinence in the salvage setting)[1][2]
  • Intestinal segment interposed at the bladder-neck closure to reinforce healing and prevent recanalization:[5]
    • Ileocecal patch (most commonly used — 4 of 5 in Ullrich/Wessells)
    • Sigmoid segment
    • Ileal segment
  • The interposition serves as a biological buttress of well-vascularized, non-irradiated tissue[5]

Step 4 — Augmentation cystoplasty​

  • Ileal augmentation performed simultaneously to increase capacity reduced by radiation
  • Patients with preexisting storage symptoms (frequency, urgency, urge incontinence) will worsen without augmentation
  • Zafirakis 2010 — simultaneous augmentation required fewer antimuscarinics; none required delayed augmentation (vs historical patients who received catheterizable limbs only)[3]
  • A 15–20 cm segment of ileum is isolated, detubularized, and reconfigured into a patch anastomosed to the bivalved bladder dome

Step 5 — Continent catheterizable stoma​

Three options, in order of preference:

Optionn / total (Zafirakis)Notes
Appendicovesicostomy (Mitrofanoff)6/12Preferred when appendix is available — appendix mobilized on its mesentery, tip anastomosed to augmented bladder, base brought to skin[1][3]
Monti ileovesicostomy4/122–3 cm ileal segment isolated and retubularized perpendicular to its original axis to create a narrow catheterizable channel[3]
Spiral Monti2/12Longer ileal segment spirally reconfigured for patients requiring a longer channel (e.g., obese)[3]

Stoma typically placed in the right lower quadrant or at the umbilicus.[12]

Step 6 — Omentoplasty / tissue interposition​

  • Mobilize omentum on its right gastroepiploic pedicle and bring into the pelvis to fill the dead space created by pubectomy and prostatectomy
  • Omental flap interposed between bladder-neck closure and debrided symphysis — barrier of well-vascularized tissue[4]

Step 7 — Drains and closure​

  • Closed-suction drains in the retropubic space
  • Suprapubic tube and catheterizable-stoma catheter for postoperative drainage
  • Urethra typically left open to drain or oversewn

Postoperative Management​

  • Prolonged catheter drainage — SP tube and stomal catheter remain 3–4 weeks to allow healing of augmentation and bladder-neck closure
  • Cystogram before catheter removal to confirm no leak
  • Culture-directed antibiotics — based on intraoperative bone cultures; typically prolonged course (6–8 weeks IV → PO) for osteomyelitis
  • CIC teaching — patients catheterize via the stoma every 3–6 hours
  • Bladder irrigations — manage mucus production from the intestinal segment
  • Metabolic monitoring — serum electrolytes (hyperchloremic metabolic acidosis from ileal segment), vitamin B12 (if terminal ileum used)

Outcomes​

OutcomePisters 2000 (n = 13)De 2007 (n = 11)Zafirakis 2010 (n = 12)
Follow-upNS32 ± 7.5 mo61 ± 20.5 mo
Continence (dry, no pads)83% (10/12)73% physician / 78% self-report83.3% (10/12)
Pad use17% (2/12)22% (2/9)16.7% (2/12)
CIC interval2–6 hNS3–8 h
Stomal revision rate7.7% (1/13)27% (3/11)33% (4/12)
Patient satisfaction (would repeat)NS77% (7/9)86%
ISI severity / botherNSNS1.86 / 1.0 (minimal)
Intraoperative complications0%NS0%
Surgical deaths1 (7.7%) — small-bowel leak / sepsis00

Continence rates remained stable at long-term follow-up and complications did not increase over time.[3]

Complications​

Early (perioperative)​

  • Small-bowel anastomotic leak — the most feared complication. 1 death in original Pisters series (1/13, 7.7%) from sepsis secondary to small-bowel leak[1]
  • Wound dehiscence with disruption of the appendicovesical anastomosis (1 patient)[1]
  • Vesicourethral fistula from the bladder-neck closure — required delayed cystectomy (1 patient)[1]
  • Rectal injury — a known risk of salvage prostatectomy; older series 0–28%, improved in contemporary series. NSQIP: 1.8× increased risk of GI injury vs primary RP[10][13]
  • Urinary leak / fistula — salvage RP carries 3.9× increased risk vs primary RP (NSQIP)[13]

Late​

  • Stomal stenosis — most common late complication, 27–33% at mean 24–39 mo. Managed with stomal revision or dilation[2][3]
  • Stomal relocation — required in 2/12 in the long-term series[3]
  • Bladder stones — from mucus accumulation in the augmented bladder
  • Augmented-bladder rupture — rare, reported (1 case Ullrich/Wessells)[5]
  • Metabolic acidosis — hyperchloremic from chloride reabsorption by the ileal segment

Variant: Vesicourethral Anastomosis Instead of Bladder-Neck Closure​

The VUA variant preserves per-urethral voiding by directly anastomosing the tailored bladder neck to the membranous urethra. Steps 1–2 (pubectomy + salvage RP) are identical; Steps 3–6 are replaced by:

  1. Bladder-neck tailoring — reconstruct the bladder neck to approximate the membranous urethral diameter (24–26 Fr); mucosal eversion when possible. Irradiated, fibrotic tissue makes tailoring harder than in primary RP.[16]
  2. Vesicourethral anastomosis — interrupted (open) or running barbed / absorbable (robotic) sutures over an 18–22 Fr urethral catheter. Often under tension in the salvage setting due to retropubic scarring.
  3. Tissue interposition / omentoplasty between the VUA and the debrided symphyseal bone bed (still critical).
  4. Prolonged catheter — typically 2–3 weeks (longer than primary RP) due to impaired healing.

Why VUA was largely abandoned for USF​

The Pisters / Westney group explicitly developed bladder-neck closure + augmentation + catheterizable stoma because VUA after salvage RP yields unacceptable continence in the irradiated field. De 2007 — "the postoperative continence rate appears superior to that in the literature for salvage prostatectomy with vesicourethral anastomosis."[2][3]

Functional outcomes — VUA in the salvage setting​

Pooled data from the salvage RP-for-cancer-recurrence literature (tissue conditions are identical or worse in USF):[16][17][18]

OutcomeRate
Any-grade incontinence (≥ 1 pad/d)49.6% at 1 yr[17]
Moderate-severe incontinence (≥ 2 pads/d)24.6% at 1 yr[17]
Severe incontinence (≥ 3 pads/d)17.8%[17]
Erectile dysfunction73.2%[17]
Stephenson MSK 5-yr completely dry39%; 68% ≤ 1 pad/d; 23% required AUS[16]
Gotto MSK 3-yr continence recovery30%[9]
Chade SR continence range21–90% (wide variability)[10]

Anastomotic stricture — VUAS​

  • 30% in Stephenson MSK (n = 100)[16]
  • 7–41% across the systematic review[10]
  • > 40% after salvage RP per SIU / ICUD consultation on posterior urethral stenosis[19]
  • Radiation independent risk factor — Massouh 2026 HR 7.3 for 5-yr VUAS (RT vs no RT)[20]
  • When VUAS develops, recurrent stenosis after BNI occurs in 50% of irradiated patients vs 12% after primary RP alone[21]

The vicious-cycle concern in USF: VUA stricture → endoscopic treatment → urinary leak through devascularized tissue → potential recurrent USF (the same cascade that caused the original fistula).[22] Matsushita — median interval from primary endoscopic BNC treatment to development of pubovesical fistula was 35.9 mo.[22]

VUA disruption / leak — uniquely high in the salvage setting​

Ogaya-Pinies 2018:[23]

  • Salvage RARP with standard VUA (no graft): 35.5% (16/45) clinically significant disruption; median catheter time 17.4 d
  • Salvage RARP with UB-ECM scaffold bolstering the VUA: 6.7% (1/15) leak (P = 0.045); catheter time 11.2 d
  • Primary RARP (control): 0% leaks; catheter time 6.3 d

Filipas 2023 — excessive VUA leak after RP leads to epithelialized vesicourethral cavity formation in 0.56%, with 11.5% developing symphysitis — essentially creating the conditions for a new USF.[24]

Innovations to improve VUA outcomes​

  • UB-ECM scaffold bolstering — Ogaya-Pinies 35.5% → 6.7% disruption[23]
  • Robotic platform — Zhou meta-analysis: moderate-severe incontinence 31.4% (robotic) vs 43.4% (open), P = 0.001[17]
  • Anterior bladder flap (Boari-type) — bridges short urethral stump / fibrotic bladder neck (TURNS robotic VUAS reconstruction)[25]
  • Dorsal onlay BMG urethroplasty (D-BMGU) — Sterling 2024 for post-RP / post-RT anastomotic stenosis (n = 45) — no de novo incontinence; 86.6% satisfaction (manages stenosis after it develops, not initial reconstruction)[26]

Mundy & Andrich URF + USF cascade​

In 8/17 salvage RP patients for URF, all URF were cured but the cascade was substantial: BNC in 2 (1 dilation, 1 VUA revision); 8 patients required AUS implantation for sphincter weakness incontinence. Mundy & Andrich explicitly stated that "the role of salvage radical prostatectomy in patients with a fistula who still have a prostate, needs to be defined."[7]

Head-to-head: VUA vs BNC closure + augmentation + stoma​

ParameterSalvage RP + VUASalvage RP + BNC closure + augmentation + stoma
Continence (completely dry)30–39% at 3–5 yr[16][9]83% at 61 mo[3]
Any-grade incontinence (≥ 1 pad/d)49.6% at 1 yr[17]17% at 61 mo[3]
Moderate-severe incontinence (≥ 2 pads/d)24.6% at 1 yrVery low[3]
AUS placement required23%[16]0%
Anastomotic stricture7–41%[10]N/A (no VUA)
VUA disruption (no scaffold)35.5%[23]N/A
Stomal stenosisN/A27–33%[3]
Voiding mechanismPer-urethral (spontaneous)CIC via stoma q 3–8 h
Preserves per-urethral voidingYesNo
Bowel surgery requiredNoYes (augmentation + stoma)
Operative complexity / timeLowerHigher
Patient satisfaction (would repeat)NR86%[3]

When VUA might still be reasonable for USF​

  1. Patient strongly desires per-urethral voiding and is unwilling to accept lifelong CIC
  2. Patient not a candidate for CIC — cognitive impairment, severe hand-dexterity limitations, no social support
  3. Adequate preoperative sphincter function — was continent before the fistula developed; sphincter not damaged by prior endoscopic procedures
  4. Willingness to accept staged AUS placement — informed about ~23% AUS rate post-salvage-RP
  5. Surgeon experience disproportionately greater with VUA than with continent catheterizable stoma creation

In all cases, counsel patients extensively about the cascade risk: VUA → 30% stricture → endoscopic treatment → potential recurrent USF.

Comparison vs Cystectomy for USF​

ParameterSalvage RP + augmentationCystectomy + ileal conduit
Proportion of irradiated USF~14%~86%[6]
Bladder preservationYesNo
Voiding mechanismCIC via stoma q 3–8 hExternal appliance (stoma bag)
Continence83%N/A (incontinent diversion)
Pain resolution~100%~100%[4]
Major complications (≥ Grade III)~30%~32%[14]
Reoperation for pelvic abscessNS37.9%[14]
Patient satisfaction (would repeat)86%NS[3]

TURNS multicenter (Osterberg 2017) — cystectomy n = 19 vs bladder-sparing n = 12: no significant complication-rate difference; 84% pain resolution at 6 mo; only 1 fistula recurrence in the bladder-sparing group.[15]

Special Considerations​

Salvage prostatectomy in URF with concurrent USF​

Mundy & Andrich performed salvage RP in 8/17 post-irradiation URF patients — specifically those "in whom a discrete prostate still existed." They emphasized that the role of salvage RP when a fistula coexists with a prostate "needs to be defined," and that complexity is conferred by cavitation, BNC, and extensive ischemia from serial energy sources.[7]

Robotic approach​

Robotic salvage RP for cancer recurrence is increasingly performed (moderate-severe incontinence 31.4% vs 43.4% vs open).[11] The robotic approach for USF-specific salvage prostatectomy with augmentation and pubectomy has not been well described — the pubectomy + bowel work (augmentation, stoma) make a purely robotic approach challenging.

Operative time and complexity​

Patients with prostatic fistula undergoing urinary diversion had significantly longer OR times — 515.7 vs 414.2 min (P = 0.017) — vs localized radiation injury alone.[14] Combined salvage RP + pubectomy + augmentation + stoma creation is among the most complex operations in reconstructive urology.

Key Takeaways​

  • Bladder-sparing reconstructive strategy for select irradiated USF patients with prostate in situ and adequate bladder function. Two urinary-reconstruction endpoints; the choice is the principal decision in this operation.
  • Preferred endpoint — BNC closure + augmentation + continent catheterizable stoma (Pisters / Westney): six-step operation; 83% dry on CIC at 61 mo, stable; 86% would choose surgery again; 27–33% stomal revision rate; requires CIC willingness.
  • VUA alternative: preserves per-urethral voiding but inferior continence (49.6% any-grade / 24.6% moderate-severe incontinence at 1 yr; 23% require AUS; 7–41% anastomotic-stricture rate; 35.5% disruption without scaffold). Reserve for patients unwilling / unable to perform CIC, with the explicit cascade risk: VUA stricture → endoscopic treatment → potential recurrent USF.
  • Main morbidity: stomal stenosis (27–33% requiring revision), small-bowel anastomotic leak (1 death in original series), rectal injury risk inherent to salvage prostatectomy.
  • The technique that distinguishes this from standard salvage RP — bladder-neck closure + intestinal-segment interposition + augmentation + catheterizable stoma rather than vesicourethral anastomosis — addresses the very high salvage-RP incontinence rate (40–60%) by eliminating per-urethral voiding entirely.

References​

1. Pisters LL, English SF, Scott SM, et al. "Salvage prostatectomy with continent catheterizable urinary reconstruction: a novel approach to recurrent prostate cancer after radiation therapy." J Urol. 2000;163(6):1771–1774. doi:10.1016/s0022-5347(05)67539-8

2. De E, Pisters LL, Pettaway CA, Scott S, Westney OL. "Salvage prostatectomy with bladder neck closure, continent catheterizable stoma and bladder augmentation: feasibility and patient reported continence outcomes at 32 months." J Urol. 2007;177(6):2200–2204. doi:10.1016/j.juro.2007.01.151

3. Zafirakis H, De EJ, Pisters LL, Pettaway C, Westney OL. "Long-term outcomes and patient satisfaction of continent catheterizable limb and augmentation cystoplasty simultaneous with salvage prostatectomy." Neurourol Urodyn. 2010;29 Suppl 1:S51–S56. doi:10.1002/nau.20898

4. Bugeja S, Andrich DE, Mundy AR. "Fistulation into the pubic symphysis after treatment of prostate cancer: an important and surgically correctable complication." J Urol. 2016;195(2):391–398. doi:10.1016/j.juro.2015.08.074

5. Ullrich NF, Wessells H. "A technique of bladder neck closure combining prostatectomy and intestinal interposition for unsalvageable urethral disease." J Urol. 2002;167(2 Pt 1):634–636. doi:10.1016/S0022-5347(01)69101-8

6. Patel N, Mehawed G, Dunglison N, et al. "Uro-symphyseal fistula: a systematic review to inform a contemporary, evidence-based management framework." Urology. 2023;178:1–8. doi:10.1016/j.urology.2023.05.002

7. Mundy AR, Andrich DE. "Urorectal fistulae following the treatment of prostate cancer." BJU Int. 2011;107(8):1298–1303. doi:10.1111/j.1464-410X.2010.09686.x

8. Andrews JR, Hebert KJ, Boswell TC, et al. "Pubectomy and urinary reconstruction provides definitive treatment of urosymphyseal fistula following prostate cancer treatment." BJU Int. 2021;128(4):460–467. doi:10.1111/bju.15333

9. Gotto GT, Yunis LH, Vora K, et al. "Impact of prior prostate radiation on complications after radical prostatectomy." J Urol. 2010;184(1):136–142. doi:10.1016/j.juro.2010.03.031

10. Chade DC, Eastham J, Graefen M, et al. "Cancer control and functional outcomes of salvage radical prostatectomy for radiation-recurrent prostate cancer: a systematic review of the literature." Eur Urol. 2012;61(5):961–971. doi:10.1016/j.eururo.2012.01.022

11. Zhou Y, He X, Yu Q, Zhong Q. "Functional outcomes and complications following salvage radical prostatectomy for post radiotherapy recurrent prostate cancer: a meta-analysis." Medicine (Baltimore). 2025;104(39):e44440. doi:10.1097/MD.0000000000044440

12. Spahn M, Kocot A, Loeser A, Kneitz B, Riedmiller H. "Last resort in devastated bladder outlet: bladder neck closure and continent vesicostomy — long-term results and comparison of different techniques." Urology. 2010;75(5):1185–1192. doi:10.1016/j.urology.2009.11.070

13. Mundra V, Titus RS, Luna E, et al. "Morbidity and mortality of salvage radical prostatectomy for prostate cancer: an analysis of the National Surgical Quality Improvement Program targeted prostatectomy database." Urol Oncol. 2025. doi:10.1016/j.urolonc.2025.07.019

14. Myers JB, Hernandez BS, McCormick B, et al. "Comparison of urinary diversion in patients with prostatic fistula to those with localized radiation injury after radiotherapy for the treatment of prostate cancer." Urology. 2024;183:256–263. doi:10.1016/j.urology.2023.11.006

15. Osterberg EC, Vanni AJ, Gaither TW, et al. "Radiation-induced complex anterior urinary fistulation for prostate cancer: a retrospective multicenter study from the Trauma and Urologic Reconstruction Network of Surgeons (TURNS)." World J Urol. 2017;35(7):1037–1043. doi:10.1007/s00345-016-1983-3

16. Stephenson AJ, Scardino PT, Bianco FJ, et al. "Morbidity and functional outcomes of salvage radical prostatectomy for locally recurrent prostate cancer after radiation therapy." J Urol. 2004;172(6 Pt 1):2239–2243. doi:10.1097/01.ju.0000140960.63108.39

17. Zhou Y, He X, Yu Q, Zhong Q. "Functional outcomes and complications following salvage radical prostatectomy for post radiotherapy recurrent prostate cancer: a meta-analysis." Medicine (Baltimore). 2025;104(39):e44440. doi:10.1097/MD.0000000000044440

18. Chade DC, Eastham J, Graefen M, et al. "Cancer control and functional outcomes of salvage radical prostatectomy for radiation-recurrent prostate cancer: a systematic review of the literature." Eur Urol. 2012;61(5):961–971. doi:10.1016/j.eururo.2012.01.022

19. Herschorn S, Elliott S, Coburn M, Wessells H, Zinman L. "SIU/ICUD consultation on urethral strictures: posterior urethral stenosis after treatment of prostate cancer." Urology. 2014;83(3 Suppl):S59–S70. doi:10.1016/j.urology.2013.08.036

20. Massouh K, Leucht K, Leistritz L, Grimm MO. "Retrospective analysis of vesicourethral-anastomosis stricture / urethral stricture after robotic-assisted laparoscopic radical prostatectomy with and without radiotherapy." Int J Urol. 2026;33(1):e70339. doi:10.1111/iju.70339

21. Veerman H, Vis AN, Hagens MJ, et al. "Surgical and functional outcomes of bladder neck incision for primary vesico-urethral anastomosis stricture after robot-assisted radical prostatectomy are influenced by the presence of pre- or postoperative radiotherapy." Urology. 2022;166:216–222. doi:10.1016/j.urology.2022.03.015

22. Matsushita K, Ginsburg L, Mian BM, et al. "Pubovesical fistula: a rare complication after treatment of prostate cancer." Urology. 2012;80(2):446–451. doi:10.1016/j.urology.2012.04.036

23. Ogaya-Pinies G, Kadakia Y, Palayapalayam-Ganapathi H, et al. "Use of scaffolding tissue biografts to bolster vesicourethral anastomosis during salvage robot-assisted prostatectomy reduces leak rates and catheter times." Eur Urol. 2018;74(1):92–98. doi:10.1016/j.eururo.2016.10.004

24. Filipas DK, Graefen M, Fisch M, et al. "Outcome of patients with epithelialized cavity formation after excessive vesicourethral anastomotic leak post radical prostatectomy." World J Urol. 2023;41(9):2327–2333. doi:10.1007/s00345-023-04479-9

25. Shakir NA, Alsikafi NF, Buesser JF, et al. "Durable treatment of refractory vesicourethral anastomotic stenosis via robotic-assisted reconstruction: a TURNS study." Eur Urol. 2022;81(2):176–183. doi:10.1016/j.eururo.2021.08.013

26. Sterling J, Simhan J, Flynn BJ, et al. "Multi-institutional outcomes of dorsal onlay buccal mucosal graft urethroplasty in patients with postprostatectomy, postradiation anastomotic stenosis." J Urol. 2024;211(4):596–604. doi:10.1097/JU.0000000000003848