Perineal and robot-assisted vesico-urethral reconstruction for anastomotic strictures after RP

Vesico-urethral anastomotic stricture (VUAS) following radical prostatectomy is a rare clinical condition in the robot-assisted procedure era, due to the improved magnification of the surgical field and the perfect knowledge of the anatomic structures deputed to maintaining the mechanisms for urinary continence. Improvements in surgical technique such as muco-mucosal apposition, tension-free anastomosis, water-tight vesico-urethral suture, have been recognized as significant contributors to precise vesico-urethral reconstruction. Conversely, excessive intraoperative blood loss, urinary extravasation and previous history of trans-urethral prostatectomy have been commonly cited as predisposing factors for the development of postoperative scars. Terminology used in the definition of VUAS distinguishes the condition from bladder neck contracture (BNC) and identifies the exact site of the contracture/stenosis/stricture. The majority of cases involves the bladder neck and bulbo-membranous urethra mainly in patients who received radical prostatectomy plus adjuvant radiotherapy. Diagnosis of VUAS is mainly based on symptoms and retrograde urethro-cystogram imaging to identify whether or not the sphincter mechanism is involved and the length of the strictured segment, although delineation of the precise anatomy is often complex. Stricture length is a significant factor for prognosis and correlates with probability of recurrence after reparative surgeries such as urethral dilation, trans-urethral scar incision or resection and perineal urethral buccal mucosa repair. Results obtained via different surgical techniques are amply described, with the hindrance of VUAS and BNC often not being properly distinguished in the reported series of patients treated. Notwithstanding, a 0 to 69% success rate has been reported for patients with bladder neck stricture after urethral dilation and/or cold-knife incision and/or holmium laser incision and/or trans urethral resection, while a 60 to 93% success rate was obtained for patients treated via an abdominal and/or perineal approach. Repair of a long-length urethral stricture often implies the complete loss of urinary continence, whilst it does not appear to have significant impact on sexual potency if previously preserved. The risk of developing VUAS/BNC as a complication after radical prostatectomy falls from 30% of patients treated by Retropubic Radical Prostatectomy (RRP) to less than 5% of patients who received Robotic Assisted Radical Prostatectomy (RARP). Subjects with a histological diagnosis of T3 cancer, positive surgical margins and/or Gleason score >7 and treated by RARP who required early adjuvant radiotherapy, reported an overall 8.4% rate of VUAS. Lavollè et al. treated six patients with anastomotic stricture who had previously undergone radical prostatectomy by extraperitoneal robot-assisted vesico-urethral reconstruction obtaining a 50% success rate. Dinerman et al. presented a case report on a patient with long-length post prostatectomy vesico-urethral stricture by combining robotic-abdominal and open-perineal surgical procedure. The combined abdomino-perineal approach allows to provide “complete” scar removal and a new vesico-urethral anastomosis at a lower risk of developing subsequent recurrences of the stricture also in patients with long-length strictures. An extensive dissection of the bladder neck and bulbo-membranous urethra does imply the complete loss of urinary continence, that can however be recovered through subsequent or concomitant artificial sphincter implant. This novel combined technique was adopted on a series of three patients of whom two previously treated by RARP and one by RRP.