Management of vesicourethral anastomotic stenosis

Vesicourethral anastomotic stenosis (VUAS) is a complication of radical prostatectomy characterized by fibrotic narrowing at the surgical connection of bladder and urethra. It is distinct from bladder neck contractures (BNC) as BNC occur with prostate in situ and VUAS occurs after a surgical anastomosis is created after removal of the prostate. Clinically, VUAS may present with obstructive lower urinary tract symptoms, fistula, urine leak, or paradoxically improving continence due to the narrowing of the vesicoureteral junction. There are multiple risk factors for VUAS from preoperative, intraoperative, and postoperative considerations. These include comorbidities and technical considerations as well as necessary adjuvant treatments. Diagnostics including imaging and cystoscopy are crucial to the identification of VUAS. Management focuses on restoration of stable, unobstructed urinary flow while minimizing treatment-related stress urinary incontinence. Endoscopic techniques remain the firstline treatments for non-obliterated VUAS, while refractory or complex cases may require formal bladder neck reconstruction. Urinary diversion, via ileal conduit or Indiana pouch, is a last resort for the most severe VUAS. For patients with VUAS that are not surgical candidates, catheterization via clean intermittent catheterization (CIC) or suprapubic tube (SPT) remains a viable option. VUAS remains a challenging condition with a wide spectrum of therapeutic options. Selection of intervention must be tailored to the severity of the stenosis, presence of complicating factors, and patient goals.