Successful treatment by gasless single-port robot-assisted perineal secondary urethrectomy combined with adjuvant therapy for urethral recurrence after radical cystectomy: a case report of an elderly male patient with 16-month follow-up

Abstract

Background

Secondary urethrectomy is recommended for managing the recurrence of invasive tumor after radical cystectomy. The anatomical changes (such as adhesions around the urethral stump, the direct contact between urethral stump and intestine, etc.) influence the procedure, which is more complex in males than in females. There are several methods available for performing secondary urethrectomy. In this report, we present a case in which a gasless single-port (SP) robotic perineal approach was used to resect the proximal portion of the urethra for an elderly male.

Case Description

The case involved a male patient who had undergone transurethral resection of bladder tumor followed by laparoscopic radical cystectomy with Bricker intracorporeal ileal conduit urinary diversion in 2018, with six cycles of an adjuvant gemcitabine-cisplatin (GC) regimen being administered. The patient experienced urethral bleeding in January 2025, which was diagnosed by urethroscopy and imaging as tumor recurrence in the anterior urethra. On February 18, 2025, a secondary urethrectomy of the proximal urethra was conducted through the use of a SP robotic system via a gasless perineal approach. The operation was completed successfully, and the patient was discharged 5 days after the surgery, with no severe complications, except a dull pain in the perineum. Pathological test results indicated muscle-invasive high-grade urothelial carcinoma (pT2), with a positive proximal margin, negative distal margin, and intravascular tumoral thrombus. After one cycle of adjuvant GC therapy, the patient was switched to immunotherapy (toripalimab), and no recurrence was found on imaging after a follow-up of 16 months.

Conclusions

The gasless SP robot-assisted perineal approach may be a technically feasible option for secondary urethrectomy in selected patients. However, further study is needed to confirm its advantages and disadvantages.

Highlight box.

Key findings

• During secondary urethrectomy after radical cystectomy, robots [such as SHURUI single-port (SP) flexible robot] can be used to mobilize the proximal portion of urethra and dissect adhesions until the urethral stump is exposed and resected.

What is known and what is new?

• Typically, urethrectomy is conducted entirely via an open approach.

• In secondary urethrectomy after radical cystectomy, the proximal portion of the urethra can be dissected with a gasless technique through a perineal incision via the SHURUI SP flexible robot.

What is the implication, and what should change now?

• Gasless SP robot-assisted perineal secondary urethrectomy may be a feasible option in selected patients after radical cystectomy.

Introduction

According to the European Association of Urology, the incidence of new urethral tumors after radical cystectomy is 4.4% (1.3–13.7%). For urethral carcinoma in situ of the urethra, instillation of Bacillus Calmette-Guérin into the urinary tract is the recommended treatment; meanwhile, for invasive disease, urethrectomy is recommended if the urethra is the only site of disease, while in cases of distant metastasis, systemic chemotherapy is indicated (1). Urethrectomy is more complex in males than in females. Simultaneous urethrectomy with radical cystoprostatectomy can be completed through several approaches, including the open perineal approach (2), open prepubic approach (3), and laparoscopic/robotic transperitoneal (dissection of membranous urethra) combined with an open perineal access. However, few options are available for secondary urethrectomy.

Secondary urethrectomy is more complicated than simultaneous urethrectomy due to the post-cystoprostatectomy pelvic adhesions around the urethral stump, the direct contact between urethral stump and intestine, the local invasion of peri-urethral tissues after recurrence of urethral tumors, etc. Thus, these anatomical changes will influence the secondary urethrectomy procedure and the dissection should be executed cautiously to avoid intestinal damage. For this reason, the traditional approach for secondary urethrectomy is conducted via an open perineal access.

However, the secondary urethrectomy procedure in males is even more complicated than in females, because of the anatomical structures. The proximal portion of urethra is deeply located in the perineal and pelvic structures, that limits the field of vision and the operation during the surgery. Therefore, the dissection of proximal portion of urethra from the adhesions and the bowl in males is difficult through the open perineal approach. New technique is needed.

As the urethral stump can be dissected with robotic assistance through the transperitoneal approach for simultaneous urethrectomy with cystoprostatectomy, we speculated that this technique could be feasibly used with a perineal approach to perform secondary urethrectomy and complete management of the urethral stump. In this report, we describe our initial experience of removing the proximal portion of urethra in secondary urethrectomy via a gasless single-port (SP) robot-assisted perineal approach using the SHURUI SP surgical robotic system (Beijing Surgerii Robotics Company Ltd., Beijing, China). The SHURUI SP platform involves a dual-continuum mechanism and the core nitinol arm technology (4,5). In the dual-continuum mechanism, the proximal structures segmentally control the distal structures through guiding cannula to drive the flexible manipulator with multiple degrees of freedom. Moreover, through visual feedback and based on the orientation and position of the manipulator’s tip, a shape reconstruction algorithm, a compliant motion controller, and a force estimation method can be applied (6). This technology has been used for urological surgeries (7,8) but not urethrectomy. To our knowledge, this is the first report on the use of robot-assisted urethrectomy in this context. We present this article in accordance with the CARE reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-0500/rc).

Case presentation

Case history and examination

A 77-year-old male patient without a remarkable medical, family, or psycho-social history underwent transurethral resection of bladder tumor in our hospital in July 2018. Multiple lesions were observed in the bladder during the surgery, the largest of which was 4 cm in diameter, and could not be completely removed. Pathological testing revealed invasive high-grade urothelial carcinoma without muscle invasion (pT1). Laparoscopic radical cystectomy with Bricker intracorporeal ileal conduit urinary diversion was performed in November 2018. Postoperative pathological testing indicated invasive high-grade urothelial carcinoma, with submucosa infiltration (pT1). Six cycles of standard-dose gemcitabine-cisplatin (GC) chemotherapy [1,000 mg/m² of gemcitabine, d1+8; 70 mg/m² of cisplatin, d2, every 3 weeks (q3w)] were administered.

Beginning in early January of 2025, the patient experienced bleeding from the urethral orifice without any obvious cause. He did not take any anticoagulant. The physical examination showed no abnormalities in the genitalia. Urethroscopy showed multiple neoplasms located in the proximal and middle section of the anterior urethra, suggesting malignant tumors (Figure 1A,1B). Tumor markers, including carcinoembryonic antigen (CEA), alpha-fetoprotein (AFP), cancer antigen (CA)125, CA199, squamous cell carcinoma (SCC), CA724, and CA242, were normal (9). No pelvic recurrence or metastasis was found on thoracic and abdominal computed tomography (CT) scans except for a mass in the proximal and middle section of the anterior urethra (Figure 1C). Secondary urethrectomy was considered necessary. Because of the prior cystoprostatectomy, careful dissection of the urethral stump from the pelvic floor and adherent bowel (Figure 1D) was a critical operative concern. After obtaining informed consent from the patient and completing intestinal preparation, a gasless SP robot-assisted secondary urethrectomy was performed via a perineal access on February 18, 2025.

Figure 1.

Preoperative examination. (A) The urethral tumor in urethroscopy. (B) Distal edge of the urethral tumor indicated via urethroscopic illumination (white arrow). (C) The urethral tumor on enhanced CT (red circle). (D) Possible adhesion of the urethral stump to the intestine (yellow circle). CT, computed tomography.

All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.

Therapeutic intervention

The operation was conducted in the lithotomy position with a perineal median vertical incision being applied. A 16-Fr Foley catheter was inserted into the urethra until the urogenital diaphragm to serve as a guide. The anterior urethra was dissected from the penis, and the urethral meatus was closed via absorbable suture. During the phase of excision of the proximal urethral stump (Figure 2), two robotic manipulators were used (one with dissecting forceps and the other with scissors). The bulbospongiosus muscle was vertically incised and separated to expose the corpus spongiosum of the bulbar urethra, and the urethral stump was then carefully dissected. The adhesions between the urethral stump and intestinal wall were separated with the cold scissors, and the residual urethra was entirely resected (Figure 3A), after which the surgical area was washed with distilled water. The perineal membrane was sutured with a 3-0 V-Loc (Medtronic, Minneapolis, MA, USA) via the robotic system, and after a wash with iodophor and withdrawal of the robot, the perineal incision was closed. No drainage tube was installed. The operation time was 153 minutes, and the robotic operative time was 97 minutes. The estimated bleeding amount was approximately 100 mL, and no transfusion was used.

Figure 2.

SP robot-assisted perineal urethrectomy (two robotic arms). (A) Separation of the urethra and the bulbospongiosus muscle. (B) Detachment of the urethra from the adhesive tissue of the pelvic floor. (C) Further excision of the proximal urethra. (D) Suturing of the pelvic floor tissue. (E) The assistant seated with access to the patient’s perineal region. (F) Perineal incision. SP, single-port.

Figure 3.

The pathology of the urethral specimen. (A) Urethral specimen. The left side is the pelvic stump, while the right side is the orifice. (B) Hematoxylin and eosin staining of histopathological sections (40×) showed that the tumor cells were arranged in a nest-like pattern, with obvious cellular atypia and visible nucleoli in some cells. The muscle layer was invaded. (C) Histopathological sections stained with hematoxylin and eosin (100×). (D) Tumor cells arranged in a nest-like pattern (hematoxylin and eosin staining, 200×).

Follow-up and outcomes

The patient was discharged 5 days after the surgery, with no scrotal/penile hematoma, laceration, infection, etc. (3). He experienced perineal pain, which was gradually relieved.

Pathological testing revealed muscle-invasive high-grade urothelial carcinoma (pT2; Figure 3B-3D), with a positive proximal margin, a negative distal margin, and intravascular tumoral thrombus, indicating that the lesion extent was greater than that was suggested by imaging. The immunohistochemical results showed that human epidermal growth factor receptor 2 (HER2) was moderately positive (2+), and programmed death-ligand 1 (PD-L1) had a combined positive score of about 30. A pelvic magnetic resonance plain scan conducted on March 20, 2025 showed no obvious residual tumor.

On March 26, 2025, the patient started with split-dose GC chemotherapy (1,000 mg/mg² of gemcitabine, d1+8; 35 mg/m² of cisplatin, d1+8, q3w) (10), which is recommended as first-line therapy for patients with recurrent and metastatic tumor (11). But the patient could not tolerate it well, experiencing significant fatigue and poor appetite, and required prolonged rest to recover. Furthermore, after one cycle of therapy, the CA199 level increased to 160.8 U/mL, but there was no abnormality in the enhanced abdominal CT scan on April 23, 2025. The patient declined positron emission tomography-CT. According to our previous study on upper tract urothelial carcinoma, elevation in the level of routine tumor markers, such as CEA, AFP, SCC, CA199, CA242, CA724, and CA125, might indicate disease progression (9). Given the positive proximal margin and intravascular tumoral thrombus, a more optimized treatment was considered. It has been recently reported that the combination therapy of programmed cell death protein 1 (PD-1) and antibody-drug conjugate has good efficacy in patients with urothelial carcinoma who are HER2 positive, improving overall survival (11). After careful discussion with the patient, the GC regimen was switched to immunotherapy (240 mg of toripalimab q3w), which was currently being applied. On May 12, 2025, the levels of tumor markers returned to normal and had remained stable thus far. The follow-up imaging examinations were recommended every 4 cycles of toripalimab. The enhanced abdominal and pelvic CT scan on February 5, 2026 showed no recurrence and metastasis, and all the biochemical indicators and the tumor markers on May 27, 2026 were basically normal (the timeline of treatment is shown in Figure 4). The dull pain in the perineum had been alleviated.

Figure 4.

Timeline of treatment for a patient with bladder cancer and urethral cancer. CT, computed tomography; GC, gemcitabine-cisplatin; q3w, every 3 weeks; TURBT, transurethral resection of bladder tumor.

Discussion

The incidence of urethral recurrence after cystectomy is between 1.3% and 13.7% (1), with recurrence appearing a median of 18.5 months after cystectomy (12,13). In one study on urethras removed preventively during cystourethrectomy, about 12.5% were found to contain previously unsuspected carcinoma in situ or marked atypia (13). This condition can lead to a worse prognosis, especially if prostatic invasion is also present. The primary risk factor for urethral recurrence is the spread of the bladder carcinoma into the prostatic urethra, especially if the prostate stroma is invaded (2). Clark et al. (12) reported that the majority of patients with urethral recurrence have overt symptoms (e.g., bloody urethral discharge, pain, or a palpable mass), but 31% of patients are asymptomatic, with abnormal cytology (12,13). CT of the chest, abdomen and pelvis for staging, including CT urography for urothelial evaluation is recommended. Magnetic resonance imaging can also be utilized to evaluate tumor location and size, as well as local tumor extent and presence of regional LN metastases (14). The median survival of patients with urethral urothelial carcinoma after radical cystectomy is only 28 months after diagnosis, with the most important predictor of overall survival being the stage of urethral carcinoma (12).

For females, urethrectomy is among the approaches available for standard radical cystectomy (10). In a previous study, urethral involvement was present in 17% cases, 26.5% of patients were alive with disease, 62 (20.8%) in the urethrectomy group and 14 (28.6%) in the non-urethrectomy group (15). For males, prophylactic urethrectomy at the time of radical cystectomy can provide survival benefit in patients with multiple tumors and/or concomitant carcinoma in situ, particularly those who do not receive neoadjuvant chemotherapy (16). However, prophylactic urethrectomy is not associated with survival in patients with bladder cancer undergoing radical cystectomy (regardless of urethral recurrence-associated factors) and is associated with unfavorable perioperative outcomes (blood loss, deep vein thrombosis, and severe postoperative surgical complications of Clavien-Dindo grade 3 or higher) (17,18). Thus, prophylactic urethrectomy is not a routine procedure during cystectomy in males (2). It has also been reported that urethrectomy can be safely deferred in both male and female patients without clear urethral disease (19). Therefore, reversely, the secondary urethrectomy seems to be a routine procedure for the patients who have local recurrence of tumor in the urethra after cystoprostatectomy, and in that case, secondary urethrectomy is necessary.

Because of the anatomical changes, such as the post-cystoprostatectomy pelvic adhesions around the urethral stump and the intestine, the direct contact between urethral stump and intestine, the local invasion of peri-urethral tissues after recurrence of urethral tumors, the secondary urethrectomy is more complicated than simultaneous urethrectomy. The intestinal injury is the most concerning aspect of this procedure, which needs a bowel preparation before the surgery and a cautious dissection during the surgery. And the most widely used approach for secondary urethrectomy is conducted via an open perineal access.

However, in males, the proximal portion of urethra is deeply located in the perineal and pelvic structures. Thus, the dissection of proximal portion of urethra from the adhesions and the bowl in males is difficult through the open perineal approach due to the limited field of vision and operation during the open perineal surgery.

Furthermore, residuals of the bulbomembranous urethra are associated with a high risk of recurrence (2). Therefore, in line with Morizane et al. (20), we suggest that during cystoprostatectomy, a circular incision of the perineal membrane around the urethra should be made, and, after a resection of the membranous urethra with the bladder, the perineal membrane should be sutured closed so that the urethral stump can be embedded outside the pelvic cavity. In this way, the likelihood that subsequent urethral resection damages the intestinal damage is reduced. In fact, in cystoprostatectomy simultaneous with urethrectomy, this technique can be performed during the laparoscopic or robotic stage to facilitate rapid release of the urethral stump in the secondary urethrectomy.

During cystoprostatectomy, some surgeons prefer to use a Hem-o-Lok to close the urethral stump, while others prefer suturing. The Hem-o-Lok could be an indicator of the extremity of the urethral stump in the secondary urethrectomy. In our case, the patient did not accept preventative removal of the urethral stump, and the stump was also closed via suturing.

This leads to a reliance on digital palpation, blunt separation, and guided sharp separation, which cannot guarantee the complete removal of the urethral stump while the integrity of the adherent intestinal wall is maintained. But a more advanced technique, which could help to clearly expose the surgical area and entirely resect the urethral stump without intestine injury, is needed.

Secondary perineal urethrectomy comprises two stages: (I) removal of the proximal section and (II) the removal of the distal section. The open approach appears to be the most suitable method for completing the second stage, but for the first stage, several options may be used. Robotic systems could be used to perform perineal surgeries. For instance, one study reported that the da Vinci Xi surgical system was used to complete nerve-sparing radical perineal prostatectomy, with a median operation time of 246 [interquartile range (IQR), 230–268] minutes (21). CO₂ sufflation was applied in that procedure, with a pressure of 15 mmHg. In another study, the da Vinci XI system was used to perform gasless robot-assisted perineal radical prostatectomy, with an operative duration of 130 minutes (22). A meta-analysis concluded that the perineal approach may be useful for SP robot-assisted radical prostatectomy (23). Studies have also reported the use of the da Vinci SP system for a transperineal approach in cystoprostatectomy with intracorporeal ileal conduit urinary diversion and lymph node dissection in male cadavers (24,25); meanwhile, others have used the da Vinci Xi system for gasless urethral reconstruction. Thus, robotic systems, including SP types, are capable of performing perineal surgeries. Furthermore, research suggests that robot-assisted surgery for the transperineal approach—albeit challenging—may be an effective, feasible, and safe minimally invasive procedure for selected patients (21,22).

In our case, we used the SHURUI SP flexible-arm robot to perform urethral stump resection via a perineal access. During the robotic surgery, as the robot could expand its field of vision, the surgical area was more clearly exposed than through the open approach. The robot provided a more precise operation, and the urethral stump was carefully dissected from the adhesions. Of course, a proficient operation requires a certain learning curve.

The SHURUI SP surgical robot has a large bending angle (approximately 135°) for each manipulator (7) and requires a large space to release its lateral range due to continuous deformation (7). For a perineal incision in urethrectomy, the more deeply the robotic arms are inserted, the greater their deflection. For our case, due to the narrow space, we had to limit the lateral range of the manipulators by reducing the bending angle.

Patient perspective

The patient described his postoperative recovery in written form. There was no local hematoma or infection. He only experienced perineal pain and scrotal pain, which improved gradually in the 3 months after the operation.

Conclusions

Gasless SP robot-assisted perineal secondary urethrectomy may be a feasible and viable option for secondary urethrectomy after radical cystectomy. Nonetheless, its relative benefits and drawbacks remain to be confirmed in further research.

Supplementary

The article’s supplementary files as

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. All procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patient for the publication of this case report and accompanying images. A copy of the written consent is available for review by the editorial office of this journal.