Excisional urethroplasty and the abdominoperineal approach to posterior urethral stenosis: surgical techniques and considerations for the radiated patient

Abstract

Pelvic radiation is associated with significant long-term genitourinary toxicity, with a cumulative incidence of urethral stricture following primary prostate radiation of nearly 20%. While there are a variety of techniques for posterior urethral reconstruction in the setting of prior pelvic radiation therapy, excisional urethroplasty remains a mainstay of treatment. Complete scar excision with primary anastomosis (EPA) for posterior stricture below the pelvic floor and a combined abdominoperineal approach for those extending above the pelvic floor are two reconstructive techniques for managing this complex pathology. Reconstructive success, defined as urethral patency on cystourethroscopy, for EPA is between 70–87%; however, the risk of de novo stress urinary incontinence (SUI) approaches 20%. The combined abdominoperineal approach presents one of the more complex techniques for lengthier strictures, involving extensive mobilization of the urethra in order to achieve a tension-free anastomosis. Overall complications, including risk of persistent leak and fistula, are higher with this approach, and there is a greater risk of needing repeat endoscopic intervention for recurrence. Both of these transecting techniques for posterior urethroplasty pose an increased risk of future artificial urinary sphincter erosion, especially in the context of prior radiation therapy. Herein, we describe our standard practice for preoperative evaluation of radiation-induced posterior urethral reconstruction, techniques for excisional urethroplasty, and postoperative pathways.

Highlight box.

Surgical highlights

• Excisional urethroplasty remains a mainstay of treatment of radiation-induced posterior urethral stenosis, with high reconstructive success.

What is conventional and what is novel/modified?

• Excision and primary anastomosis (EPA) is a widely utilized approach for posterior urethral stenosis involving the membranous urethra below the level of the pelvic floor.

• When feasible, a vessel sparing/spongiosal sparing technique should be considered to improve outcomes related to anti-incontinence surgery postoperatively.

• Although less commonly utilized, a combined abdominal and perineal approach can be considered for stenosis extending above the level of the pelvic floor towards the bladder neck; however, the risk of anastomotic leak and stenosis in the radiated population is high.

What is the implication, and what should change now?

• Postoperative stress urinary incontinence remains a challenging condition to manage following excisional urethroplasty, especially in the setting of urethral transection with anastomosis. When feasible, the corpus spongiosum should be spared along with the bulbar urethral arteries to minimize risk of future erosion following artificial urinary sphincter placement.

• Given the high risks of complications associated with extensive urethral mobilization involved in combined abdominal and perineal posterior urethroplasty, a combined endoscopic transluminal and robotic approach should be considered to maintain blood supply and eliminate the risks associated with urethral transection.

Introduction

Cumulative incidence of radiation-induced urethral stricture disease following primary prostate radiation can approach 20% (1), with reconstructive success achieved in up to 80% (2). The psychological and quality of life implications of this disease process, including urinary incontinence, sexual dysfunction, and pelvic pain, make it even more complex to treat (3). Although there are a variety of reconstructive approaches to the management of posterior urethral stricture, recent literature promotes the use of grafts over primary scar excision (4). However, excision and primary anastomosis (EPA) remains a mainstay of treatment at our institution for the radiated patient with isolated bulbomembranous stricture following primary prostate radiotherapy in the absence of prostatectomy.

Reconstructive success following EPA for radiation-induced bulbomembranous stricture is between 70–87%, as reported by several multi-institutional studies (5,6). Risk factors for recurrence include increasing age and length of stricture (5). When the stricture is lengthy and extends well above the pelvic floor involving the prostatic urethra, or bladder neck, the perineal approach alone becomes challenging due to the accessibility of the posterior urethra deep within the narrow confines of the male pelvis. Robotic-assisted techniques have been described for the management of posterior urethral stricture involving the bladder neck, and can be used in conjunction with a perineal approach in order to manage lengthier posterior strictures.

Herein, we aim to outline our diagnostic approach for posterior urethral stricture as well as surgical techniques for excisional urethroplasty, including both perineal and combination abdominoperineal approaches in men with radiation induced posterior urethral stricture disease following primary prostate radiation. We present this article in accordance with the SUPER reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-281/rc).

Preoperative preparations and requirements

The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board (IRB No. 18-01205) and informed consent was obtained from all individual participants. The initial patient encounter involves a thorough history and physical examination. It is important to identify prior cancer treatments, specifically prostate cancer, history of pelvic radiation therapy, and any prior treatments for urethral stricture. Adequate urethral rest is important to allow for more precise characterization of the extent of urethral stricture (7). Therefore, any patient performing intermittent catheterization or dilation to maintain patency is recommended to have a suprapubic catheter placed 4–6 weeks prior to undergoing further diagnostic evaluation.

Our standard preoperative diagnostic evaluation includes fluoroscopic imaging such as retrograde urethrogram (RUG) and voiding cystourethrogram (VCUG) in order to achieve adequate staging of the urethral stricture and confirm the presence of a competent bladder neck. Laboratory evaluation includes a prostate-specific antigen (PSA) in patients with history of prostate cancer, and urinalysis and urine culture. Cystourethroscopy is routinely performed to better characterize the degree of stricture and tissue integrity, specifically characterizing the location of the scar relative to the urinary sphincter complex. Direct visualization of the tissue is especially important when evaluating radiation injury, which can involve extensive tissue necrosis, dystrophic calcifications, and radiation cystitis. Not only do the presence of the above findings influence the surgical approach, but also identify patients who may benefit from preoperative hyperbaric oxygen therapy (HBOT) to improve tissue quality and wound healing (8-11).

Pelvic magnetic resonance imaging (MRI) is increasingly utilized in our practice to better delineate the extent of scar as well as proximity to adjacent anatomy, such as the pubic bone anteriorly and rectum posteriorly. A more detailed understanding of the location of the scar with respect to the pelvic floor is important in determining surgical approach, including perineal, abdominal, or combined abdominoperineal. Incidental findings such as fistulae, abscesses, osteomyelitis, or areas concerning for cancer recurrence have also been identified on preoperative MRI, ultimately impacting the surgical plan.

It is important to set appropriate expectations for patients in their postoperative recovery, particularly related to pain control, catheter care, and potential for complications such as need for prolonged catheterization, risk of urinary incontinence, and changes to sexual function. At our institution, our dedicated nursing team provides catheter education and reviews the standard narcotic free pathway for postoperative pain control (12). In patients with stenoses extending through the pelvic floor, we provide careful counseling regarding the risk for postoperative urinary incontinence and strategies for managing incontinence, including the timeline for future surgical intervention. Sexual side effects of treatment, including erectile dysfunction and ejaculatory dysfunction, are also discussed in the context of the patient’s anatomy and surgical approach.

Finally, alternatives to urethral reconstruction and their relative success rates and lifestyle considerations should always be discussed. In addition to continuing with chronic catheterization, patients are also offered more invasive alternatives such as supravesical urinary diversion.

Step-by-step description

Isolated membranous urethral stricture

The preferred surgical approach for membranous urethral stricture in men with prostate in situ is through a perineal incision using a circumferential EPA with or without sparing of the bulbar arteries.

The patient is positioned in high lithotomy, taking care to appropriately pad all pressure points. Flexible cystourethroscopy is performed, and a wire is placed through the lumen of the stricture when applicable. The two types of incisions include either a vertical midline incision extending from the base of the scrotum to the anal verge or a lambda type incision, with the apex of the perineal flap extending from the base of the scrotum towards the ischial tuberosities bilaterally. Choice of incision varies based on the patient’s body habitus and the proximal extent of the stricture. The lambda incision provides improved exposure to the posterior urethra, and is our preferred incision for posterior urethroplasty; however, care must be taken to ensure a broad based well vascularized flap to mitigate risk of wound related complications.

Dissection is carried out through subcutaneous tissues down to the bulbospongiosus muscle, which is divided at the midline. Either a self-retaining Lonestar retractor or perineal Bookwalter is placed to retract the muscle and expose the urethra. Circumferential mobilization of the urethra from the penoscrotal junction distally to the strictured segment proximally is then carried out in order to gain adequate mobility for a tension free anastomosis. If the patient has a suprapubic catheter in place, the flexible cystoscope is placed in an antegrade fashion to delineate the proximal extent of scar and ensure dissection has been carried out through this segment.

Dorsal nontransecting anastomotic urethroplasty

For focal (<1 cm), non-obliterative stenoses immediately distal to the membranous urethra, without evidence of significant surrounding fibrosis, we prefer a dorsal nontransecting approach as previously described by Andrich and Mundy (13). A dorsal urethrotomy is made either under direct visualization using the flexible cystoscope and an angled beaver blade or directly overlying a urethral sound or catheter. The urethrotomy is carried out to expose at least 5 mm of healthy urethral segment both proximal and distal to the scar. The urethra is sounded to 26 Fr using bougie dilators. For focal, thin strictures, we do not routinely excise diseased ventral mucosa. Otherwise, we will perform a ventral mucosectomy of diseased mucosa, and reapproximate the healthy edges using a 4-0 polyglactin suture. Prior to the mucosectomy, evenly spaced 5-0 polydioxanone sutures are placed proximally and secured on the self retaining retractor. Once the ventral plate has been approximated, the proximal sutures are then thrown through their corresponding locations along the distal dorsal urethrotomy. A 16 Fr urethral catheter is placed across the anastomosis. Tunical edges of the spongiosum that protrude out laterally from our anastomosis are oversewn with 5-0 polydioxanone suture for hemostasis.

EPA

For longer strictures involving the membranous urethra/pelvic floor (most common), those associated with complete obliteration, or presence of significant surrounding fibrosis, our preferred approach is complete excision of the diseased segment with primary anastomosis. The bulbar arteries are spared when possible. In select patients with prostate in situ, we will perform a spongiosal (vessel) sparing anastomotic posterior urethroplasty (14,15). When appropriate, incision and excision of the intercrural septum can be deployed to improve proximal exposure and mobility for the anastomosis. After adequate proximal and distal mobilization has been achieved, the urethra is separated from the corpora spongiosum using a right angle with sparing of the bulbar arteries, and vessel loops is placed to facilitate urethral retraction (Figure 1). The urethra is then sharply transected at the level of the scar distally, and remaining proximal scar is circumferentially excised proximally until healthy urethra and supple surrounding pelvic floor are encountered. The proximal and distal segments are sounded to 26 Fr using bougie dilators. The proximal urethra is spatulated ventrally and the distal urethra is spatulated dorsally. We then place twelve evenly spaced 5-0 polydioxanone sutures proximally (Figure 2). A Turner-Warwick needle driver is often helpful in placing these proximal sutures. We then throw these proximal sutures through their corresponding location on the distal urethra, starting with the ventral sutures, working our way dorsally. A laparoscopic knot pusher can be used to facilitate securing the knots along ventral anastomosis when a vessel sparing/spongiosal sparing approach is used.

Figure 1.

Dissection of membranous urethra off the corpora spongiosum in a spongiosal sparing nontransecting posterior urethroplasty. The left vessel loop is around the bulbar urethra. The right vessel loop is around the membranous urethra. Light of cystoscope can be appreciated at the proximal aspect of the stricture on the right side of the image.

Figure 2.

Circumferential placement of evenly spaced sutures on the proximal urethra for spongiosal sparing nontransecting posterior urethroplasty (A,B).

In the setting of radiation-induced membranous strictures or lengthier posterior stenoses where a vessel sparing approach is not feasible, we proceed with a transecting approach. The corpora spongiosum is divided at distal extent of the scar, often in the setting of extensive spongiofibrosis and the diseased segment is circumferentially excised proximally until healthy mucosa is visualized. In a similar fashion as described above, the proximal urethra is spatulated ventrally and the distal urethra is spatulated dorsally. The urethral segments are sounded to 26 Fr. The anastomosis is also completed in a similar manner; however, sutures are thrown through the distal ventral urethra using partial thickness bites and full thickness along the dorsal segment. The anastomosis is then brought together over a 16 Fr urethral catheter in a parachuting fashion (Figure 3). A ventral tunica plasty securing the distal bulbar tunica to the pelvic floor is performed using 5-0 polydioxanone suture for hemostasis.

Figure 3.

Anastomotic suture placement for posterior urethral excision and primary anastomosis technique via perineal approach. (A) Circumferential placement of evenly spaced sutures on the proximal urethra for transecting posterior urethroplasty. (B) View of both the distal urethral segment with catheter in place and proximal urethral segment with sutures in place.

We often place an absorbable hemostatic agent such as Surgicel™ Fibrillar™ around our anastomosis deep to the bulbospongiosus muscle. The incision is then closed in multiple layers including bulbospongiosus muscle, Colles’ fascia, and skin.

Stricture involving urethral segments both above and below the pelvic floor

Posterior urethral stricture extending both above and below the pelvic floor can be approached through a combined abdominoperineal approach. This surgical technique is illustrated in Video 1.

Video 1.

Download video file ^{(18.2MB, mp4)}

Combined robotic-assisted laparoscopic and perineal approach to complex posterior urethral reconstruction.

Patients are positioned synchronously in stirrups to allow for repositioning of the legs to accommodate high lithotomy for the perineal dissection and a low lithotomy for transabdominal dissection. Although an open abdominal approach is reasonable, we prefer a robotic-assisted laparoscopic approach given the improved visualization and dissection for deep pelvic surgery. When feasible, two surgeons can operate simultaneously transperineal and transabdominally in order to reduce operative time. The perineal dissection is carried out as described above, and the urethra is transected distally at the level of scar.

For the robotic-assisted abdominal approach, Veress access is achieved either at the level of the umbilicus or in the left upper quadrant, two finger breadths below the costal margin along the midclavicular line. The abdomen is insufflated and robotic trocars are placed in a pelvic orientation similar to a prostatectomy. We typically start with a posterior dissection to separate the bladder and prostate away from the rectum. The posterior peritoneum is incised at the level of the vas deferens bilaterally in order to develop this plane, and dissection is carried out below the rectoprostatic fascia. This dissection is carried down to the rectourethralis muscle when feasible. Once the posterior dissection is complete, we proceed with the anterior mobilization of the bladder to develop the retropubic space of Retzius. If a suprapubic catheter is encountered, we keep the catheter in place and instead dissect the bladder free from the abdominal wall in this location.

In patients with a prostate in situ and a history of radiation with a lengthy obliterative stricture, a prostatectomy may be necessary. This can either be performed through an anterior approach or a combination of posterior and anterior approaches as described above. When feasible, neurovascular bundle preservation can be performed.

The distal urethral segment is then passed through the perineum into the pelvis. It is important to ensure adequate distal urethral mobilization to facilitate a tension free anastomosis. The bladder can also be mobilized further when needed. The urethra is spatulated dorsally, and we perform a running anastomosis with a barb absorbable 3-0 monofilament suture. The bladder is approximated to the abdominal wall both immediately distal to our anastomosis and around the site of the suprapubic catheter tract to prevent any tension on the anastomosis.

Tissue flap advancement can be considered to fill the radiated space and reinforce the anastomosis. One consideration is the use of a peritoneal flap, including the urachus, to reinforce the anterior aspect of the anastomosis. Alternatively, omentum can be mobilized and used for coverage. Rarely have muscle flaps such as gracilis or vertical rectus abdominis muscle (VRAM) been needed for interposition in these cases.

Postoperative considerations and tasks

Perineal posterior urethroplasty is performed as an outpatient surgery. When a combined abdominoperineal approach is performed, patients typically spend one night in the hospital for observation. Our standard perioperative pain regimen has been previously described and has been shown to significantly reduce the need for postoperative narcotic prescriptions (12,16). In summary, acetaminophen and ibuprofen are used on an alternating schedule every 6 hours for the first few days after surgery, when applicable based on preoperative renal and hepatic function, and patients are instructed to take extended-release oxybutynin 10 mg once daily while the catheter is in place. It is important to counsel patients on aggressive management of postoperative constipation to avoid any exacerbation of bladder spasms or straining with bowel movements that would put additional tension on the urethral anastomosis. The urethral catheter is secured to the lower abdomen using a StatLock to avoid any tension on the catheter with movement. In patients who had a preoperative suprapubic catheter, decision to remove versus exchange at the time of surgery is dependent on the complexity of the reconstruction and radiation history. In complex cases or those with significant radiation history, we elect to exchange the suprapubic catheter.

Diagnostic imaging and catheter follow-up

A VCUG is performed at 3–4 weeks postoperatively to ensure a patent anastomosis without evidence of extravasation of contrast prior to removal of the urethral catheter. In patients who have a history of radiation, a VCUG is performed 4 weeks postoperatively. If extravasation is present, a smaller, 14 Fr urethral catheter is replaced with another 4 weeks for repeat VCUG at that time. If extravasation is still present on follow-up imaging, the urethral catheter is removed, and a suprapubic catheter is placed for an additional 4 weeks. However, if a patient had a concurrent suprapubic and urethral catheter, it is our preference to remove the urethral catheter and keep the suprapubic catheter to gravity drainage if extravasation is present on the first 4-week postoperative VCUG.

Following a combined abdominopelvic approach, a CT cystogram is performed to evaluate for extravasation. If negative, the urethral catheter is removed and the suprapubic catheter is capped for an additional week to ensure the patient is able to void and empty to completion. Some patients prefer to maintain the suprapubic catheter until their future AUS surgery to help control urinary incontinence, whereas others elect to remove the suprapubic catheter.

Long-term follow-up

Following urethral catheter removal and confirmation of no extravasation on postoperative imaging, patients are followed with uroflowmetry with postvoid residual (PVR) at 3 months and annually thereafter in conjunction with an American Urological Association Symptom Score (AUA-SS) and International Index of Erectile Function (IIEF). Cystoscopy is only performed if the patient endorses obstructive voiding symptoms with or without evidence of weakened stream or elevated PVR on uroflowmetry.

We recommend delaying any anti-incontinence surgery for 6 months following perineal urethroplasty. Patients are re-evaluated with a cystoscopy to ensure urethral patency prior to surgery. Both the history of radiation and prior urethroplasty are independent risk factors for earlier time to AUS cuff erosion, and therefore patients should be counseled appropriately (17).

Tips and pearls

Preoperative MRI

We stress the value of obtaining a preoperative pelvic MRI in the more complex patients presenting with posterior urethral stricture, including those with a history of radiation and prostatectomy or those presenting with cystoscopic findings of radionecrotic debris or calcifications. Not only does the spatial understanding of surrounding structures aid in surgical approach and intraoperative decision making, but imaging may also unmask incidental findings such as fistulae or contained abscesses. In some scenarios, findings on preoperative MRI have changed our surgical decision-making to proceed with urinary diversion over urethral reconstruction.

HBOT

When radionecrosis, calcifications, or radiation cystitis are observed on preoperative cystourethroscopy, we recommend the patient receive 15–20 sessions of HBOT preoperatively followed by 10–20 sessions of HBOT postoperatively. Certain cardiopulmonary conditions, such as chronic obstructive pulmonary disease, history of spontaneous pneumothorax, and heart failure, are contraindications to HBOT, and therefore all patients are referred to hyperbaric medicine for evaluation and clearance to proceed with treatment. Anecdotally, we have observed improved tissue quality of the necrotic or calcified bed on repeat preoperative cystoscopy. There is a paucity of data surrounding the utility of HBOT in post-radiation urethral reconstruction. A retrospective review of patients undergoing breast reconstruction following chest wall radiation for breast cancer did not identify a difference in operative time or complications in the patients treated with preoperative HBOT versus not, however they did find a shorter ischemia time for flaps in the HBOT group that did not reach statistical significance (18). Despite the lack of statistical significance, the hypothesis surrounding this difference was that shorter ischemia times could be associated with less complexity of the dissection or reconstruction. In a retrospective study of reoperative hypospadias cases, patients treated with postoperative HBOT and vasodilators had fewer complications including breakdown and fistulae compared to patients without these interventions (11). More robust prospective randomized studies are needed to further our understanding of the utility of perioperative HBOT in reconstructive surgery.

Proximal suture placement in perineal approach

Due to the location of the posterior urethra deep in the male pelvis, access to the proximal urethrotomy for suture placement can be quite challenging. The Turner Warwick needle driver facilitates throwing needles at difficult angles deep within the perineum, however manipulation of the needle is occasionally needed. For more difficult throws along the dorsal urethral plate, we will often reduce the curve of the needle by “skiing” it or less commonly increasing the curve to make it similar to a fish hook. Despite these modifications, finding the appropriate angle to pass the needle through the tissue can still be challenging. In this scenario where needle modifications are unsuccessful, use of the RD-180 laparoscopic suturing device (LSI Solutions, Rochester, NY, USA) and 2-0 Monoglide suture (LSI Solutions) can simplify these throws, as previously described by Balzano et al. (19).

Discussion

Posterior urethral reconstruction, particularly in the setting of prior radiotherapy, remains a technically challenging endeavor. Despite the increasing popularity in use of substitution grafts, excisional urethroplasty remains the most commonly used approach for managing radiation induced bulbomembranous stricture. Although surgical success is modest compared to reconstruction within the anterior urethra, more recent multiinstitutional data with nearly 3-year follow-up suggest recurrence-free survival as high as 87% (5). A review of a single surgeon urethroplasty database at our institution identified 18 men with radiation-induced bulbomembranous stricture and prostate in situ. In the patients with at least 3-month follow-up, urethral patency without need for intervention was observed in 14/14 (100%) patients at a median follow-up of 1.6 years (interquartile range, 0.52–3.2). A summary of results from our institutional data compared to other multi-institutional series is shown in Table 1. The combined abdominoperineal approach is a rare entity in our practice, with only 3 patients undergoing this operation since 2017. At a mean follow-up of 2.8 years (range, 0.6–5.7 years), 2/3 (67%) required a dilation of dense 14–16 Fr anastomotic stenosis either at the time of or prior to AUS placement. These results are consistent with other reports in the literature citing a need for repeat endoscopic intervention in up to 50% of patients following robotic posterior urethroplasty in the setting of post-prostatectomy, post-radiation urethral stenosis (20). However, there is no consensus on how to define “success” following urethral reconstruction, with some groups using objective measures of urethral patency on cystourethroscopy or improvement in flowrate, and others focused on subjective measures of symptomatic improvement on questionnaires (21,22). Another definition used is freedom from reintervention, which can be problematic as avoidance of another procedure may be related to dissatisfaction related to prior surgery or complications (21). While urethral patency is an important functional outcome of posterior urethroplasty, it often comes with either de novo or persistent urinary incontinence postoperatively.

Table 1. Comparison of Mayo Clinic patients undergoing EPA for radiation induced bulbomembranous stricture to other series in the literature.

Demographic and clinical factors	Mayo Clinic EPA (N=14)	Voelzke et al. (N=137) (5)	Hofer et al. (N=66) (6)
Median age (years)	70 (60–77)	69 (50–86)	–
Median stricture length (cm)	2.5 (1–3)	2.3 (1–5)	2.3 (1–6)
Radiation type
EBRT	5 [36]	52 [38]	28 [42.4]
Proton beam	5 [36]	1 [0.7]	1 [1.5]
Brachytherapy	1 [7]	60 [43.8]	28 [42.4]
Combination	2 [14]	13 [9.5]	9 [13.6]
Unknown	2 [14]	–	–
Anastomotic leak on VCUG	3 [21]	–	–
90-day complications	3 [21]	22 [16.1]	–
Clavien 1–2	2 [14]	20 [14.6]
Clavien 3	1 [7]	1 [0.7]
Clavien 4	0 [0]	1 [0.7]
Success	14 [100]	119 [87]	46 [69.7]
Definition of success	Freedom from re-intervention	Able to pass 17 Fr cystoscope	Able to pass 17 Fr cystoscope
Postoperative SUI	7 [50]	44 [32.1]	22 [33.8]
De novo	5 [36]	–	12 [18.5]
Mild (≤2 ppd)	4	–	–
Moderate (3–5 ppd)	1	–	–
Surgical intervention for SUI	0 [0]	30 [21.9]	9 [15.5]
AUS erosion	–	5/30 (16.7)	–
Median follow-up (months)	19 (6–38)	32 (12–118)	37

Categorical variables are presented as n or n [%]. Continuous variables are presented as median (interquartile range). AUS, artificial urinary sphincter; EBRT, external beam radiation therapy; EPA, excision and primary anastomosis; SUI, stress urinary incontinence; VCUG, voiding cystourethrogram.

Due to the location of the scar in relation to the external sphincter complex, de novo stress urinary incontinence (SUI) is a notable side effect of treatment, occurring in up to 20% of patients (5,6). However, many patients have pre-existing incontinence prior to surgery as a result of either prostate surgery or radiation therapy, which can be exacerbated following urethroplasty. In a survey of 87 patients with membranous urethral stricture following primary radiotherapy for prostate cancer, nearly 2/3^rd reported frequent or total urinary incontinence requiring daily pad use (3). Artificial urinary sphincter placement is the gold standard for management of SUI in the setting of prior radiation therapy. However, both radiation and prior urethral reconstruction are risk factors for urethral erosion following AUS placement (17). In a multi-institutional cohort of 137 men undergoing EPA for radiation-induced posterior urethral stricture, Voelzke et al. reported a urethral erosion rate of 16.7% (5). In our series of EPA for radiation-induced posterior stricture, incidence of de novo SUI was 5/12 (41%), including 4 (29%) mild (≤2 ppd) and 1 (7%) moderate (3–5 ppd). However, none underwent surgical intervention during the median 1.6-year follow-up period. Incontinence following combined abdominoperineal posterior urethroplasty was observed in 3/3 (100%) patients, with AUS placement involving adjunctive maneuvers including gracilis muscle flap, corporal wrapping, and transcorporal cuff placements. While we did not observe any cuff erosions during the follow-up period in our cohort, these patients are at a higher risk given their prior urethral mobilization and reconstruction as well as radiation history (17). However, in a single center experience using a vessel-sparing nontransecting anastomotic approach to posterior urethral reconstruction, none of the patients experienced an AUS erosion at a median follow-up of 36 months (15). Therefore, when feasible, this nontransecting technique should be considered given the reduced risk of future AUS cuff erosion.

Sexual side effects, such as erectile dysfunction, are the most commonly reported functional outcome of prostate cancer treatment, between both radical prostatectomy and radiation therapy alike (23). At a median 5-year follow-up following excisional urethroplasty in the bulbar urethra, Barbagli et al. reported sexual side effects including ejaculatory dysfunction (23%), erectile dysfunction (12%), and changes to glans sensitivity (18%) (24). However, in a cohort of 66 men with radiation-induced membranous strictures, incidence of new onset erectile dysfunction after EPA was 7% and there was no significant difference in rates of pre- and postoperative erectile dysfunction (45.6% vs. 50.9%) (6). While sexual function is an important quality of life outcome, urethroplasty may not have a significant impact on the post radiation patient population.

A less common, yet significant complication that can occur following excisional posterior urethroplasty in radiated patients includes fistula. Overall, 90-day complication rate following EPA for radiated posterior stricture was observed in 16.1% (22/126) of patients, with perineal fistula observed in 1 patient, managed with prolonged catheter drainage (5). In our series, 3/14 (21%) had prolonged suprapubic catheter drainage due to persistent leak. Of these, 2 healed 1 month and 1 required 8 months of drainage due to persistent urethroperineal fistula. In our single-institution series of robotic posterior urethral reconstruction, Bearrick et al. reported the highest complication rate in the radiated vesicourethral anastomotic stenosis cohort, with 2/5 (40%) experiencing a 30-day complication of urosepsis from partial anastomotic dehiscence (n=1) and urosymphyseal fistula (n=1) (25). In our combined abdominoperineal urethroplasty cohort, 2/3 (67%) required prolonged catheterization of 1 month due to persistent leak; however, both healed without progression to perineal or urosymphyseal fistulae.

Future directions

The radiated post-prostatectomy posterior urethral stricture population remains the most challenging to manage due to the inherent risks associated with urethral transection and extensive mobilization through the pelvic floor. Our practice has now shifted from a combined abdominoperineal approach to a hybrid transluminal endoscopic and robotic transvesical approach to resect scar and deploy buccal mucosal graft (BMG) in an inlay fashion. In this novel approach, we modify the technique described by Ungerer et al. for endoscopic BMG urethroplasty for membranous urethral stricture by also using the robot to assist with proximal scar incision and approximation of the graft (26). Following transurethral resection of scar, with or without combination robotic scar excision through a transvesical approach, the Urtrac sheath, RD-180 laparoscopic suturing device, and Ti Knot (LSI Solutions) are used to secure the graft distally. Using this novel sheath and laparoscopic suturing devices facilitates distal graft fixation in a transluminal fashion, without the need for transection. Additionally, distal graft fixation can be more challenging to accomplish robotically, particularly if the scar extends below the pelvic floor. For complete obliteration, a combination of ventral and dorsal inlay grafting is utilized for resurfacing. However, if a lumen is present, we proceed with a ventral inlay technique. Following proximal suturing of the graft robotically, the Secure Strap (Ethicon, Cincinnati, OH, USA) fixation device is used to quilt the graft along its length. An example of preoperative VCUG/RUG and 1 month postoperative VCUG is shown in Figure 4. While long-term follow-up is ongoing, we believe that a hybrid combination of endoscopic and robotic approaches for posterior urethral reconstruction is broadly reproducible and provides technically superior graft fixation which may reduce complications associated with urethral transection and extensive mobilization and improve reconstructive outcomes, especially in highly complex patients with radiated post-prostatectomy vesicourethral anastomotic stenosis.

Figure 4.

Preoperative and postoperative imaging of a patient undergoing combination transluminal endoscopic and robotic-assisted abdominal posterior urethroplasty with buccal mucosal graft. (A) Preoperative VCUG and RUG, demonstrating posterior urethral stenosis extending from the bladder neck to the bulbomembranous junction. (B) Postoperative VCUG demonstrating widely patent posterior urethra without evidence of extravasation. RUG, retrograde urethrogram; VCUG, voiding cystourethrogram.

Conclusions

Excisional urethroplasty for radiation induced posterior urethral stricture remains a mainstay of treatment. Outcomes related to patency are overall favorable and durable; however, urinary incontinence remains a significant postoperative concern that presents with unique challenges for future management. Careful preoperative counseling regarding this risk is necessary to set the stage for the pathway of full functional recovery after their urethral reconstruction. While a vessel-sparing anastomotic urethroplasty remains an excellent reconstructive solution for isolated radiation induced bulbomembranous stricture, the use of a combined abdominopelvic approach is falling out of favor with the advances in endoscopic and laparoscopic techniques.

Supplementary

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board (IRB No. 18-01205) and informed consent was obtained from all individual participants.