Robotic Post Radical Prostatectomy bladder neck stenosis

Posterior Lower Urinary tract issues should be divided in 2 categories as per etiology :

Traumatic and non traumatic.
Non Traumatic Issues:
Post radical prostatectomy bladder neck contracture is known.First line of treatment is to perform bladder neck incisions either with cold or hot knife and laser.For recurrent stenosis when lumen is present one may need open/robotic YV pasty or BMG inserted posteriorly.Obliterative and recurrent bladder neck stenosis requires a redo Vesico-Urethral anastomosis.

[Robotic urethral reconstruction: redefining the paradigm of posterior urethroplasty .Timothy C. Boswell, Kevin J. Hebert, Matthew K. Tollefson, Boyd R. Viers Transl Androl Urol 2020;9(1):121-131 |

The redo anastomosis is challenging due to previous surgery and/or radiation.Robotic repair abdominally is now getting popularity. Ocassionally one may need perineal mobilisation of the bulbar urethra and abdominal (Robotic) anastomosis. These  patients will be incontinent and may need an artificial sphincter.

Trauma as etiology  :
Few anecdotal reports of use of robot in posterior urethroplasty have been available.
The patients in our subcontinent merit perineal approach  and anastomosis from perineum.
Rarely abdominal approach is needed.
Even in robotic posterior urethroplasty,the perineal approach still remains standard to  mobilise bulbar urethra, crural separation,inferior pubectomy. This cannot be done by a Robot abdominally.

I would divide Membranous Urethra in 2 half,Proximal and distal.
Stenosis of proximal side (Post Prostatectomy) merit Robotic approach. 
Stenosis of distal side (Pelvic Fracture Urethral Injury) merits perineal approach .

Please see the attached image of management of Non traumatic conditions.

Open Perineal approach with bulbar mobilisation,crural separation ,inferior pubectomy will stay as the main approach for majority of posterior pelvic fracture urethral injuries.
Robot is indicated in management of bladder neck issues and redo vesicle urethral anastomosis arising out of treatment of prostate cancer.

Robotic Post Radical Prostatectomy bladder neck stenosis


  • Dr. Anil Takvani
    Dr. Anil Takvani
    22 Feb 2020 11:17:30 AM

    Sir, Thank you very much for posting approaches for posterior urethral strictures.

    Can some one highlight on incidence of bladder neck stenosis following radical prostectomy?
    And any difference in incidence with robot assisted radical prostectomy?

  • Venugopal P
    Venugopal P
    24 Feb 2020 09:36:52 AM

    Dear All,

    I even now believe that a stricture of urethra due to whatever cause needs lifelong attention and whatever methods at treatment that we adopt is at best temporary in alleviating the problem. Even a well done urethroplasty, even with experienced hands, produce recurrence in many and need probably repeat surgical interventions. The quoted figures in literature vary with very few studies mentioning long term outcomes. Hence it is apt to say even today that ‘once a stricture always a stricture’. I am sure many in our group may not like this factual statement. If a stricture can be effectively cured by the treatment adopted, then there should be no need for relook and suggesting self catheterisation etc.

    Posterior Urethral Strictures are often more complex and need Expertise to tackle the problem.

    No surgery has ever been described without its inherent complications. But as surgeons, we tend to underplay complications and quite often keep it to ourselves. We harp on our successes. It needs courage to talk on complications.

    In the article mentioned by Sanjay on Bladder Neck Stenosis (Stricture), it is obvious that posterior urethral strictures can occur with most of the treatments that we adopt for Prostatic cancer and even for benign conditions. Cindolo et al (2017) reported that 10% of patients develop bladder neck contracture (BNC) after outlet procedures for benign prostatic hyperplasia. Breyer and Cowan et al (2010) found that Lap RP and RARP have developed vesicourethral anastomotic stenosis (VUAS) in 3%. Browne and Vanni (2017) found that up to one-third of men undergoing pelvic radiation ultimately develop prostatic urethral stenosis. With advent of Focal therapies for P Ca, it is possible that the incidence of such complications could increase.

    Sanjay has provide the flow chart as given by Timothy C Boswell, Boyd R Viers* et al (2020). This could help us to plan the treatment option if and when we encounter such a complication. Sanjay has mentioned that in India, Perineal approach with Inferior Pubectomy could still be the preferred approach. What I would like to know is how feasible it is in a postoperative situation where there could be considerable postop fibrosis. I do not know whether RALP causes less fibrosis than other techniques of RP. No doubt posterior Urethroplasties are done in a milieu of fibrosis.

    It is important for us to discuss on complications associated with surgeries for the many who are less experienced at present but could be leading lights in the future to know.

    I must compliment Sanjay for the write up he has provided.

    With warm regards,



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