There is no clear consensus regarding the management of recurrent post-prostatectomy vesicourethral anastomosis stenosis (VUAS) after failure of endoscopic treatments. Robotic YV plasty has been reported in that setting but in case of long stricture extending to the bulbar urethra, a purely robotic abdominal approach does not allow to treat the whole stricture. The purpose of this video was to describe a technique of YV urethroplasty by combined robotic and perineal approach for VUAS with concomitant artificial urinary sphincter (AUS) implantation.

We present the case of  a 76-year-old man who had prostate cancer treated with radiation therapy in 2008 and then salvage prostatectomy in 2014. He then developed vesico-urethral anastomosis stenosis treated with endoscopic dilation and then intermittent self-dilatations. He had major stress urinary incontinence treated with a penis clamp with significant leakage (3-4 pads per day) upon clamp removal. He had no post-void residual. The urodynamic assessment showed an uninhibited detrusor contractions at 190mL and the cystoscopy confirmed the anastomotic stenosis.

The procedure is performed under general anesthesia in Trendelenburg position. We use the Xi robot with 5 ports and a transperitoneal approach. The Retzius space is opened and dissected down to the bladder neck. A bulbo-membranous dissection by perineal approach is performed by the second operator. The dissections from the perineal and robotic abdominal approach meet below the pubic bone to free anterior part of the anastomosis. The stenosis is opened longitudinally. A bladder V-flap is moved down on the urethral opening using a barbed suture with the needle being passed below the pubic bone from the robotic to the perineal surgeon who performs the distal sutures of the anastomosis. The upper sutures of the anastomosis on each side of the bladder V-flap are then performed by the robotic surgeon. As the bulbar urethra has been dissected extensively, the AUS is implanted concomitantly. The patient was dicharged on day 3. The bladder catheter was removed on day 7 and of suprapubic tube at week 3. There were no postoperative complications. At 9 months there is no recurrence of stenosis and the patient is completely dry.

Combined robotic and perineal YV plasty for long VUAS involving the bulbar urethra is a feasible technique that can provide satisfactory results . A concomitant AUS implantation may be of interest although the possible increased risk of AUS erosion/infection compared to a staged approach should be further evaluated.

Continence 2S2 (2022) 100482
DOI: 10.1016/j.cont.2022.100482