Surgical management of vesicourethral anastomotic stenosis

Vesicourethral anastomotic stenosis (VUAS) is a challenging complication following radical prostatectomy with incidence ranging between, and sometimes exceeding, 1.4%-4.8%. While endoscopic management remains the first-line approach, refractory cases often necessitate open or robotic reconstruction. This review examines contemporary surgical options, including newer reconstructive techniques and salvage procedures for recalcitrant stenoses. A comprehensive review of all relevant literature was conducted to evaluate surgical options for VUAS. Techniques assessed included endoscopic procedures, YV- and T-plasty, transvesical reconstruction, robotic-assisted approaches, and salvage techniques such as bladder flaps and intestinal substitution. A novel endoscopic procedure, the transurethral incision with transverse mucosal realignment, may offer higher success with decreased morbidity. Open and robotic techniques are often utilized in recalcitrant stenosis. The most comprehensive cohort to date looking at robotic repair of refractory VUAS by the TURNS (Trauma and Urologic Reconstructive Network of Surgeons) demonstrated a 75% success rate at 3 months. Patients with a history of radiation may suffer from higher complication rates. Salvage options, including intestinal substitution for extensive stenoses, have been described but remain a last resort due to potential for greater morbidity. Urinary diversion is an option for patients with refractory disease, often leading to improved quality of life despite initial hesitancy. The management of VUAS requires an individualized approach based on degree of stenosis, prior treatments, and patient goals. While newer techniques such as robotic reconstruction show promise, long-term studies are needed to determine their efficacy and complication rates. Continued advancements will refine treatment algorithms for this complex condition.