Abstract
Background:
Vesicourethral anastomotic stenosis (VUAS) remains a challenging sequela of radical prostatectomy (RP).
Objectives:
To evaluate endoscopic outcomes in men with VUAS using a patient-centred composite endpoint of concurrent urethral patency and continence.
Design:
Retrospective, single-centre consecutive case series.
Methods:
We analysed 60 consecutive men treated endoscopically for VUAS (2014–2023). Primary endpoints were urethral patency (passage of a 20F catheter at 6-month follow-up) and continence (0–1 pad/day at last follow-up; for men with an artificial urinary sphincter (AUS), assessed after device activation). Secondary endpoints included AUS implantation and complications. Subgroup comparisons by prior pelvic radiotherapy (RTx) were performed using Fisher's exact and Mann–Whitney tests.
Results:
Median follow-up was 40 months. Patency was achieved in 45/60 (75%). Continence was achieved in 22/60 (36.7%): 5 men remained continent without AUS and 17 became continent after AUS; 4/21 AUS required explant for erosion. Composite success (patency plus continence) occurred in 20/60 (33.3%). Prior RTx was not significantly associated with patency, continence, composite success, or AUS implantation. Three men required urinary diversion for pubic bone fistulation and three were diagnosed with bladder cancer (no AUS implanted). Seventeen patients declined AUS despite persistent stress urinary incontinence.
Conclusion:
Endoscopic treatment restores urethral patency in most men with post-RP VUAS, but the final patient-centred outcome of simultaneous patency and continence is achieved in one-third. These data may support shared decision-making regarding expectations and staged continence surgery.
Trial registration:
Not applicable.
Plain language summary
After prostate removal surgery, some men develop scarring where the bladder joins the urethra. This can narrow or block the urine passage and is often linked with urine leakage. The usual first step is an endoscopic (“keyhole”) procedure that cuts the scar from inside to reopen the passage. We reviewed 60 men treated this way at our centre (2014–2023). We checked, over several follow up visits up to six months, whether the passage stayed open and whether men could control urine (defined as using 0–1 pad per day). We also recorded who needed an artificial urinary sphincter (a small implanted device that helps prevent leakage) and any complications. Results: the urine passage remained open in 45 of 60 men (75%). Good bladder control was achieved in 22 of 60 (37%). Our “final success” combined both goals—an open passage and good control—and was seen in 20 of 60 men (33%). An artificial sphincter was implanted in 21 men (35%); 17 other men chose not to have this device despite ongoing leakage. Four implanted devices later eroded and were removed. Three men needed urinary diversion because of a rare complication (a fistula involving the pubic bone), and three were diagnosed with bladder cancer during follow up. In this study, having had radiotherapy in the past did not clearly change the chances of success. What this means: keyhole treatment usually reopens the passage, but many men will still need an artificial sphincter to be reliably dry. Knowing this helps patients and clinicians plan realistic timelines and next steps after the first procedure. If scarring keeps coming back or the narrowing is severe, early discussion of reconstructive surgery may be appropriate.
Keywords
Introduction
Vesicourethral anastomotic stenosis (VUAS) is a recognised complication after radical prostatectomy (RP) with variable incidence across eras and techniques. Population-based and institutional series suggest that strictures may follow primary prostate cancer therapy and are influenced by surgical approach and patient-level factors.1 –3 Contemporary rates after robot-assisted RP are generally lower than historical open cohorts, but VUAS continues to confer substantial morbidity. 4 Across modern robotic series, VUAS is identified in approximately 0.5%–3% of men, whereas earlier open cohorts reported higher rates (up to ~10%–15%).2,4
Guidelines endorse endoscopic management (dilation, incision or resection) as first-line therapy, reserving reconstruction for recalcitrant disease.5,6 However, most reports define success primarily by anatomic patency, whereas patient-relevant outcomes such as continence-and the gap between anatomic and functional success-are less consistently reported.
In this retrospective, consecutive single-centre series from a reconstructive urology referral centre, we describe endoscopic outcomes for post-RP VUAS and quantify a composite endpoint of concurrent urethral patency and continence to support patient counselling. We also report downstream continence surgery (artificial urinary sphincter (AUS)), complications, and univariable associations with prior pelvic radiotherapy.
Materials and methods
Study population and setting
This retrospective analysis of a prospectively maintained database included 60 consecutive men treated endoscopically for VUAS after RP between January 2014 and August 2023 at a tertiary reconstructive urology referral centre.
Inclusion criteria were: (1) history of RP for prostate cancer; (2) diagnosis of VUAS confirmed by cystoscopy and/or imaging; (3) endoscopic management of VUAS at our institution; and (4) availability of follow-up allowing assessment of the primary endpoints (including the prespecified 6-month patency assessment). Patients managed primarily with open reanastomosis/reconstruction during the study period were excluded from this analysis.
The reporting of this observational study conforms to the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement, 7 and the completed STROBE checklist is provided as Supplemental Material.
Protocol and assessments
Patency was evaluated at 4, 8 and 12 weeks and at 6 months post-procedure by passage of a 20F Foley catheter. For the primary endpoint, urethral patency was adjudicated at the prespecified 6-month visit; earlier checks informed clinical management and triggered imaging when needed, but did not determine endpoint status. Uroflowmetry was not mandated due to limited bladder capacity in many patients; urethrography and urethroscopy were performed if catheter passage failed.
Urinary incontinence was defined as any involuntary leakage of urine and was assessed at baseline and follow-up visits using patient-reported symptoms and daily pad use. When documented in the clinical record, incontinence was categorised as stress, urgency, or mixed based on symptom history; urodynamics were performed when clinically indicated.
Men with stable patency and persistent, bothersome stress-predominant incontinence (typically requiring ⩾ 2 pads/day) were evaluated for AUS implantation (urine culture, urodynamics, cystoscopy). AUS activation occurred 6–8 weeks post-implantation. Continence was defined as 0–1 pad/day (including a safety pad). For the composite endpoint, continence was assessed at the last available follow-up; in AUS recipients, this assessment was performed after device activation.
Treatment algorithm
All men underwent endoscopic treatment (using the deep lateral incision (DLI) technique under direct vision) of the anastomotic stenosis according to local protocol. At the end of the procedure, a 20F transurethral Foley catheter was inserted and left in place for 72 h. Contraindications to AUS included recurrent stenosis, recurrent urinary tract infection, diminished bladder capacity (<200 mL), cognitive impairment, and newly diagnosed bladder cancer. Urinary diversion was considered in the setting of pubic bone fistulation and refractory symptoms.
Statistics
Continuous variables are reported as median (interquartile range, IQR) and categorical variables as n (%). Normality was assessed visually and with the Shapiro–Wilk test. Fisher's exact and chi-squared tests were used for categorical comparisons; Mann–Whitney U for non-parametric continuous data. Subgroup comparisons by prior pelvic radiotherapy after RP were performed as univariable analyses. Given the limited number of composite outcome events, multivariable modelling was not performed, and the analyses should be considered descriptive and hypothesis-generating. Analyses were performed in IBM SPSS Statistics, version 29.0 (IBM Corp., Armonk, NY, USA). Two-sided p < 0.05 was considered significant.
Sample size calculation
No formal a priori sample size calculation was performed. VUAS is an uncommon complication after RP; therefore, we included all consecutive eligible men treated at our institution during the study period to maximise representativeness. The absence of an a priori power calculation is acknowledged as a limitation.
Results
General characteristics are shown in Table 1. Median age was 67 years and BMI 25.1 kg/m2. Time from RP to first endoscopic treatment was 36 months (IQR 24–63). Most men had undergone at least one prior endoscopic intervention (median 1; IQR 1–2).
Baseline characteristics of the cohort.
IQR, interquartile range; PP, pelvic pain; RP, radical prostatectomy; VUAS, vesicourethral anastomotic stenosis.
Baseline continence status was as follows: 55/60 (92.7%) men reported urinary incontinence and 5/60 (7.3%) were continent (0–1 pad/day). Incontinence onset was most commonly after RP (38/55, 69.1%); a smaller proportion developed incontinence after post-RP radiotherapy (6/55, 10.9%) or only after previous VUAS treatment (12/55, 21.8%). Among those with post-RP incontinence, worsening was reported after radiotherapy in 1/38 (2.6%) and after VUAS treatment in 5/38 (13.2%).
Thirty-two (53.3%) had received pelvic radiotherapy after RP. Median follow-up was 40 months.
Treatment outcomes are summarised in Table 2. Urethral patency was restored in 45/60 (75%). Overall continence after completion of the treatment pathway was achieved in 22/60 (36.7%). The composite endpoint – simultaneous patency and continence – was met by 20/60 (33.3%). AUS was implanted in 21/60 (35.0%) after a median of 9 months (IQR 8–13) from index endoscopy; four devices were removed for erosion after a median time of 14 (1–28) months. Three men (5.0%) underwent urinary diversion for pubic bone fistulation. Three men (5.0%) were diagnosed with bladder cancer; none received an AUS. Seventeen additional men explicitly declined AUS despite persistent stress incontinence. Among the five men continent at baseline, four remained free of recurrence and one was managed by intermittent self-dilatation.
Outcomes and timelines.
AUS, artificial urinary sphincter; IQR, interquartile range.
In univariable comparisons, prior radiotherapy was not significantly associated with outcomes (Table 3).
Outcomes stratified by prior radiotherapy.
AUS, artificial urinary sphincter; RP, radical prostatectomy; RTx, radiotherapy.
Discussion
This retrospective, consecutive single-centre series reports outcomes of endoscopic treatment for post-RP VUAS using a composite endpoint of simultaneous urethral patency and continence. Although combined or functional endpoints have been discussed in the VUAS literature, they are less consistently reported in endoscopic series; therefore, we aimed to quantify the gap between anatomic success (75% patency) and patient-relevant success (33% composite). Two aspects make these results particularly informative for counselling: we explicitly account for downstream decisions (17 men declined AUS despite persistent stress urinary incontinence) and report events that preclude AUS or mandate diversion (newly diagnosed bladder cancer, pubic bone fistulation). Consecutive accrual, complete follow-up, and prespecified outcome definitions allow benchmarking against other series.
Our patency aligns with contemporary endoscopic series but highlights the gap to patient-centred success. Using the DLI technique, Shinchi et al. reported overall success around 80% while noting that post-incision incontinence is not uncommon and may require staged continence surgery. 8 In a RARP-based cohort, Veerman et al. 9 found low recurrence and low severe incontinence after bladder neck incision in non-irradiated men, with outcomes adversely influenced by prior radiotherapy. A multi-institutional analysis by Pfalzgraf et al. 10 underscored that recurrences tend to occur early (within months) and that repeat endoscopic procedures are common; prior radiotherapy often portends a more complex course. In irradiated, previously instrumented pelvises, urosymphyseal fistula has been described and was reflected in our series by three diversions. 11
Several U.S. groups advocate a single vertical 12 o’clock incision, often combined with transverse mucosal realignment. The anatomic rationale is to maximise distance from the lateral external sphincter while re-epithelialising the incised tract to mitigate restenosis. Early series report high success after one procedure with favourable continence profiles, and the technique is compatible with subsequent AUS placement.5,12,13
Adjuncts and selection may further shape outcomes. Paclitaxel drug-coated balloon (DCB) dilation was not used in our cohort; evidence specific to VUAS is still limited. Randomised data in anterior strictures (ROBUST III) demonstrate higher anatomic success for DCB versus standard endoscopic therapy at 1–2 years,14,15 and a recent real-world comparative cohort that included posterior anastomotic stenoses (VUAS/BNC) suggested improved recurrence-free survival without worsening continence. 16 Given the anatomic and vascular particularities of the vesicourethral anastomosis-especially after radiotherapy-we consider DCB investigational for VUAS and best reserved for trials or carefully selected cases. Advanced imaging can refine selection and planning; dynamic MR urethrography shows excellent agreement with intra-operative findings and may help preserve vascularity during urethroplasty. 17 When endoscopic therapy fails or stenosis is obliterative, reconstruction offers durable patency. Open transperineal reanastomosis achieves high patency at the expense of near-universal sphincteric incontinence, often requiring AUS, whereas contemporary robotic reconstruction reports patency ~75%–90% with markedly lower de novo incontinence (≈10%–25%).18 –20 Our institutional experience with salvage transperineal reanastomosis has been reported separately and complements the present endoscopic series. 21
Urinary incontinence remains a critical determinant of patient-centred success. Most VUAS cohorts report high baseline incontinence (approximately 60%–85%), and persistent or de novo incontinence after endoscopy is frequently in the 30%–60% range depending on technique and definitions.2,9,10 In our cohort, incontinence prevalence was 92.7% at baseline and 63.3% at last follow-up-an absolute reduction of approximately 29 percentage points-driven predominantly by staged AUS (17/55, 30.9%). Among the small subset of men who were continent at baseline (n = 5), we did not observe new incontinence; however, this finding should be interpreted cautiously given the small numbers and retrospective assessment. Notably, AUS erosion occurred in 4/21 recipients (19%), underscoring the need for careful patient selection, counselling, and follow-up in this high-risk population. After reconstruction, de novo incontinence is expected after open reanastomosis, whereas contemporary robotic series report lower rates (approximately 10%–25%).18 –20
Limitations
This study should be interpreted in light of several limitations. First, the design is retrospective and descriptive, without a control group or comparison of alternative endoscopic techniques. Second, the long inclusion period (2014–2023) may introduce temporal confounding because surgical practice, radiotherapy approaches, AUS devices, and patient selection can evolve over time. Third, our outcome definitions were pragmatic: patency was assessed by the ability to pass a 20F catheter at 6 months and does not capture all functional voiding outcomes; continence was assessed by pad count (0–1 pad/day) without validated patient-reported quality-of-life instruments. Continence assessment may also be influenced by staged AUS implantation and patient preference (including men who declined AUS despite persistent incontinence). Fourth, radiotherapy was analysed as a binary exposure and detailed radiotherapy parameters (dose, timing, modality) were not uniformly available. Finally, because only 20 composite outcome events occurred, multivariable modelling was not performed, and the study is not powered to detect modest predictor effects. Prospective, multi-centre studies with standardised continence phenotyping and patient-reported outcomes are needed to validate these findings.
Conclusion
In this retrospective consecutive series of men with post-RP VUAS managed endoscopically, urethral patency was achieved in most patients; however, only one-third attained the combined patient-relevant outcome of patency and continence. These findings can help frame counselling and shared decision-making, including expectations for staged continence surgery, while highlighting the need for prospective studies incorporating validated patient-reported outcomes.
Supplemental Material
sj-docx-1-tau-10.1177_17562872261449901 – Supplemental material for Endoscopic management of vesicourethral anastomotic stenosis after radical prostatectomy: final outcomes defined by urethral patency and continence
Supplemental material, sj-docx-1-tau-10.1177_17562872261449901 for Endoscopic management of vesicourethral anastomotic stenosis after radical prostatectomy: final outcomes defined by urethral patency and continence by Skrzypczyk Michał Andrzej, Białek Łukasz, Rydzińska Marta, Gwara Piotr and Dobruch Jakub in Therapeutic Advances in Urology
Footnotes
References
Supplementary Material
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