Hypothesis / aims of study
Vesicourethral anastomotic stenosis (VUAS) and bladder neck stenosis (BNS) are uncommon but significant complications following surgery for prostate pathology. Endoscopic treatments are first-line but show higher recurrence and reintervention rates in complex cases. Failure may require robotic or open reconstruction, typically associated with increased morbidity.
To address this gap, we developed an endo-laparoscopic reconstructive technique (1). During this procedure, a GelPOINT® Mini (Applied Medical) is placed transvesically, the stenosis is resected, and a buccal mucosal graft is positioned with transvesical fixation and, if needed, endoscopic transurethral suturing. This approach may serve as an intermediate step between endoscopic treatment and more extensive salvage surgery.
This study reports mid-term functional outcomes of the first patients treated with this novel technique for refractory VUAS and complex bladder neck stenosis.
Study design, materials and methods
This retrospective study provides a descriptive analysis of nine patients who underwent endolaparoscopic buccal mucosal graft reconstruction for VUAS, complex bladder neck stenosis, and proximal urethral strictures. All patients had a minimum follow-up of four months.
The primary endpoint was freedom from reintervention for recurrent stenosis during follow-up.
Secondary endpoints included assessment of functional outcomes and patient-reported outcome measures.
Results
Nine male patients were included, with a median follow-up of 29 months (range 4–74). All cases involved complex stenosis: eight patients had undergone multiple prior endoscopic procedures, three had a history of radiotherapy, and three were on intermittent self-dilatation.
Preoperatively, 7/9 patients (78%) had urinary incontinence. Consequently, endolaparoscopic reconstruction was performed as the first stage of a planned reconstructive pathway the majority of patients (67%), followed by artificial urinary sphincter (AUS) implantation.
No patient required reintervention for recurrent stenosis during follow-up.
Five patients underwent AUS implantation, of which four devices had been activated at the time of analysis. Two patients achieved complete continence, while the remaining two showed significant improvement, requiring one pad per day. All pre-implantation cystoscopies confirmed urethral and bladder neck patency. No AUS erosions were observed during follow-up.
Seven of nine patients completed the ICIQ-MLUTS, ICIQ-LUTSqol, and PGI-I questionnaires postoperatively. Median ICIQ-MLUTS voiding and incontinence subscores were both 7 (ranges 0–15 and 0–14, respectively), noting that not all patients had an activated AUS at the time of assessment. The median ICIQ-LUTSqol global bother score (Q21) was 3 (range 0–9).
Despite variability in symptom severity, all patients reported improvement on the PGI-I scale, with 57.1% (4/7) rating their condition as “much improved” or “very much improved” (PGI-I 1–2).
Interpretation of results
No stricture recurrence was observed during follow-up, despite the high clinical complexity of the cohort. In comparable high-risk populations with prior radiotherapy or repeated surgical failure, recurrence rates of up to 40% have been reported (2).
Following catheter removal, an immediate increase in Qmax was observed and sustained throughout follow-up (Fig. 1).
The median postoperative ICIQ-MLUTS score was 16, corresponding to a moderate symptom burden according to Ito et al. Postoperative continence outcomes were largely determined by pre-existing sphincter dysfunction, often necessitating artificial urinary sphincter (AUS) implantation.
The endolaparoscopic approach allows preservation of periurethral tissue integrity and vascularity prior to device implantation, which may contribute to the low observed erosion rates.