Refractory bladder neck contracture (BNC) and complete prostatic urethral obliteration represent significant clinical challenges following benign prostatic hyperplasia (BPH) surgery or radical prostatectomy. While endoscopic management remains the first-line treatment, it is associated with high recurrence rates in complex cases. Robotic-assisted reconstruction has emerged as a durable alternative, providing superior visualization and precision within the deep, narrow male pelvis. This abstract details the application of a double-faced or combined graft technique for complex bladder neck reconstruction using robotic-assisted platforms.
Objective: To report out case of minimally invasive robotic approach for the reconstruction of recalcitrant BNC/prostatic urethral obliteration using  double on-lay  buccal mucosal graft (BMG) to improve long-term patency and maintain urinary continence.

The patient is a 68-year-old male presenting with a total obliteration of the bladder neck, secondary to previous open radical prostatectomy performed five years prior., followed by radiotherapy. Patient presented with recurrent UTI , High PVR. Conventional management, including repeated cold-knife urethrotomies, resulted in rapid recurrence. Given the patient’s history of radiation and extensive fibrotic narrowing, we elected for a robotic-assisted reconstruction to provide superior visualization and precision within the pelvic floor.
Surgical Technique:
The procedure was performed using Davinci system. Following cystoscopic identification of the obliterated segment, the patient was placed in the Trendelenburg position. A transvesical approach was utilized to excise the fibrotic tissue, creating a wide, healthy vascularized urethral bed. A double onlay Buccal Mucosal Graft harvested from the patient's inner cheek—was utilized to augment the caliber of the bladder neck. The  robotic arms provided optimal ergonomic positioning, allowing for the precise circumferential suturing of the grafts onto the posterior and anterior aspects of the urethral plate. This double onlay technique ensures maximum graft-to-bed contact, reducing the risk of contracture recurrence and promoting stable epithelization. The procedure concluded with the placement of a Foley catheter as a stent.

The operation was completed successfully without intraoperative complications.
 The docking time was 7 minutes accommodating the patient’s unique pelvic anatomy. 
Post-operatively, patient was discharged Day 5 post operative with FC and Suprapubic catheter.
 Histopathology of resected fibrosis showed no malignancy.
After 6 weeks Foleys catheter and suprapubic catheters were removed, the patient showed significant improvement in uroflowmetry, with a Qmax of 22 mL/s at the three-month follow-up. 
Cystoscopic evaluation revealed a patent, well-epithelialized bladder neck without signs of re-stenosis.

Robotic-assisted bladder neck reconstruction using BMGs, complemented by tissue advancement techniques, represents a viable, minimally invasive solution for refractory BNC. This approach offers a favorable balance between low perioperative morbidity and the durability of formal reconstructive principles. As robotic platforms continue to evolve, this technique is positioned to become a standard of care for complex, recurrent lower urinary tract obstructions.

The T-plasty: a modified YV-plasty for highly recurrent bladder neck contracture after transurethral surgery for benign hyperplasia of the prostate: clinical outcome and patient satisfaction October 2016World Journal of Urology 34(10) DOI:10.1007/s00345-016-1779-5
Robotic Y-V Plasty for Recalcitrant Bladder Neck Contracture May 2018Urology 117 DOI:10.1016/j.urology.2018.04.017
Robotic-Assisted Laparoscopic Sub-trigonal Inlay of Buccal Mucosal Graft for Treatment of Refractory Bladder Neck Contracture May 2019Urology 130 DOI:10.1016/j.urology.2019.02.048