V1-03: Robotic Assisted Laparoscopic Vesicourethral Stricture Excision and Anastomosis
Vesicourethral anastomotic stricture or bladder neck contracture is a well described complication following radical prostatectomy. Minimally invasive approaches such as urethral dilation or direct vision internal urethrotomy are often initially utilized, although they may subject the patient to repeat procedures. Transperineal approaches to repair the vesicourethral anastomotic stricture remains the gold standard, though requires dissection through the external urinary sphincter, resulting in high rates of urinary incontinence. Transperitoneal approaches exposes the patient to increased risk of bowel or vascular injury and has longer postoperative recovery. To date, there have been no reports in the literature regarding robotic assisted laparoscopic management of vesicourethral strictures. This approach is a minimally invasive approach, and may have greater preservation of urinary continence.
Our patient is a 61 year old male with a history of pT2cNxMx prostate adenocarcinoma who underwent robotic assisted laproscopic radical prostatectomy in 2014. Post-operatively, his PSA became undetectable and was able to have erections adequate for intercourse on phosphodiesterase inhibitors, however he developed urinary retention 3 months post op. He underwent several attempts of urethral dilation before a suprapubic tube was placed and he was referred to our center for further management. Evaluation confirmed a vesicourethral anastomotic stricture approximately 1.5 cm proximal to the external urethral sphincter. The patient consented to attempted robotic assisted laparoscopic vesicourethral stricture excision and primary anastomosis, with the understanding that he may require conversion to open transperineal approach.
The patient safely underwent a robotic assisted laparoscopic vesicourethral stricture excision and primary anastomosis. Intraoperative cystoscopy confirmed visual sparring of the external urinary sphincter. He was discharged to home on postoperative day three, though met clinical criteria for discharge by postoperative day one.
Robotic assisted laparoscopic vesicourethral stricture excision and anastomosis is a safe and feasible procedure. Long term outcomes are pending, however improved continence outcomes are expected as a transsphincteric approach was avoided.