Lee C. Zhao, MD

For referring physicians

Bladder neck reconstruction: how I choose the operation

Bladder neck contracture after TURP or HoLEP, vesicourethral anastomotic stenosis after prostatectomy, and the same problems after radiation. These are the questions I ask, in order, with a video for each operation.

Bladder neck contracture or VUAS?

The two often go by the same name. They are different problems. Bladder neck contracture is scar at the bladder neck in a man who still has his prostate, usually after TURP, HoLEP or simple prostatectomy. Vesicourethral anastomotic stenosis, VUAS, is scar at the join between the bladder and the membranous urethra after radical prostatectomy.

What separates them is the distance to the external sphincter. With the prostate in place, the scar sits a prostate length above the sphincter. After prostatectomy, the anastomosis sits right on it, so any repair puts continence at risk. Before I operate on a continent man with VUAS, he needs to understand that he may leak afterward, and that incontinence has treatments. Radiation can come on top of either problem.

Bladder neck contracture, prostate in place Schematic frontal view. Scar narrows the bladder neck above the prostate. The TURP cavity lies below it, and the external sphincter sits below the prostate, a prostate length away from the scar. distance to sphincter Bladder Scar at the bladder neck Prostate with TURP cavity External sphincter Bulbar urethra
Bladder neck contracture. The prostate is still there. The scar sits at the bladder neck, a prostate length above the external sphincter.
Vesicourethral anastomotic stenosis after radical prostatectomy Schematic frontal view. The prostate has been removed and the bladder is sewn to the membranous urethra. Scar narrows the anastomosis, which sits directly on the external sphincter. almost no distance Bladder No prostate. The bladder is sewn to the membranous urethra. Scar at the anastomosis External sphincter Bulbar urethra
Vesicourethral anastomotic stenosis. The prostate is gone. The scar sits at the anastomosis, directly on the external sphincter.

Schematic frontal views, not to scale.

Where is it?

The external sphincter decides the approach. Disease below it is perineal, disease spanning it is abdominoperineal, and disease above it is abdominal.

Is there a lumen?

Above the sphincter, the lumen decides the operation. An obliterated segment, usually an anastomosis that pulled apart after RARP, gets retropubic excision and primary anastomosis, with a Tanagho flap if the bladder neck won't mobilize. A lumen that is only too narrow goes transvesical.

Y-V or buccal?

Transvesically, the choice depends on how the Y-V flap looks. In a radiated patient the tip of the Y-V is radiated too, and a leak from the tip can go to the bone. So radiated patients mostly get a buccal graft, and non-radiated patients get the Y-V.

After TURP or HoLEP

With the prostate in place I do more Y-V. If the prostatic fossa is part of the problem, I do a Y-V or mobilize the mucosa down transvesically.

See the outlet after TURP in 3D

Where Optilume fits

Optilume is fine for patients who really don't want surgery. I don't use it much in non-radiated patients, because the bladder neck repair there is easy. In radiated patients, I think it absolutely makes sense.

Radiation, endoscopy and the sphincter

Radiated patients still get one endoscopic attempt, then repair. I never put in the artificial urinary sphincter at the same sitting. I wait three months minimum, six if radiated, and the cystoscopy decides. The single-port robot helps for transvesical work, but you don't need it; a multiport robot does it too.

When you read endoscopic success rates, ask how many of those men are self-dilating.

Videos by operation

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Obliterated segment: retropubic excision and primary anastomosis

Obliterated with poor mobility: Tanagho flap

Narrow lumen, radiated: transvesical buccal graft

Narrow lumen, not radiated: Y-V plasty or T-plasty

Prostate in situ, after TURP or HoLEP: Y-V plasty

Bladder flaps and bladder rotation

Radiated posterior urethra: excision, abdominoperineal and free-flap repair

Papers

  1. 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 TURNS experience. Urology. 2018. PubMed 29777787
  2. Shakir NA, Alsikafi NF, Buesser JF, et al. Durable treatment of refractory vesicourethral anastomotic stenosis via robotic-assisted reconstruction: a TURNS study. Eur Urol. 2021. PubMed 34521553
  3. Granieri MA, Weinberg AC, Sun JY, Stifelman MD, Zhao LC. Robotic Y-V plasty for recalcitrant bladder neck contracture. Urology. 2018. PubMed 29729365
  4. Viegas V, Freton L, Richard C, et al. Robotic YV plasty outcomes for bladder neck contracture vs. vesico-urethral anastomotic stricture. World J Urol. 2024. PubMed 38506927
  5. Zhang TR, Alford A, Zhao LC. Summarizing the evidence for robotic-assisted bladder neck reconstruction: systematic review of patency and incontinence outcomes. Asian J Urol. 2023. PubMed 39139537
  6. Zhang TR, Alford A, Wang A, Zhao LC. Robotic-assisted posterior urethroplasty: outcomes from 105 men in a single-center experience. Urology. 2023. PubMed 37543119
  7. Liu W, Shakir N, Zhao LC. Single-port robotic posterior urethroplasty using buccal mucosa grafts: technique and outcomes. Urology. 2021. PubMed 34624362
  8. Cavallo JA, Vanni AJ, Dy GW, et al. Clinical outcomes of a combined robotic, transabdominal, and open transperineal approach for anastomotic posterior urethroplasty. J Endourol. 2021. PubMed 33820448
  9. Voelzke BB, Leddy LS, Myers JB, et al. Multi-institutional outcomes and associations after excision and primary anastomosis for radiotherapy-associated bulbomembranous urethral stenoses following prostate cancer treatment. Urology. 2021. PubMed 33556448
  10. Sorenson TJ, Elbakry AA, Ratanapornsompong W, et al. Posterior urethral reconstruction with ileal chimeric free flap: a novel approach for management of radiation-induced devastated bladder outlet. Urology. 2025. PubMed 41106522
  11. Nabavizadeh B, Blum KA, Zhong J, et al. Comparative outcomes and management of vesicourethral anastomotic stenosis after contemporary standard and pelvic-fascia-sparing robotic-assisted radical prostatectomy techniques. JU Open Plus. 2026. PubMed 42369976
  12. Bhatt N, Peyronnet B, Zhao L. Re: Robotic transvesical bladder neck reconstruction: a novel approach to managing vesicourethral anastomotic stenosis. Eur Urol. 2025. PubMed 41402145
  13. Ramirez D, Zhao LC, Bagrodia A, et al. Deep lateral transurethral incisions for recurrent bladder neck contracture: promising 5-year experience using a standardized approach. Urology. 2013. PubMed 24054130

All my bladder neck and vesicourethral papers

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