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.
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.
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
The videos are age-restricted on YouTube, so you need to be signed in to watch them.
Obliterated segment: retropubic excision and primary anastomosis
Obliterated with poor mobility: Tanagho flap
Robotic VUA after disruption with a Tanagho flap (NARUS 2025). Upload in progress.
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
Further reading and viewing
- How to start tackling bladder neck reconstruction, NARUS 2021 lecture
- Lee M, Lesgart M, McPartland C, Lee R, Eun DD. Robotic transvesical bladder neck reconstruction: a novel approach to managing vesicourethral anastomotic stenosis. Eur Urol. 2025;88(5):519-524. PubMed 40393860
- My bladder neck papers