Transperineal reanastomosis for treatment of highly recurrent anastomotic strictures after radical retropubic prostatectomy: extended follow-up

Management of the Devastated Bladder Outlet after Prostate CANCER Treatment

PURPOSE OF REVIEW

Devastating complications of the bladder outlet resulting from prostate cancer treatments are relatively uncommon. However, the combination of the high incidence of prostate cancer and patient longevity after treatment have raised awareness of adverse outcomes deteriorating patients' quality of life. This narrative review discusses the diagnostic work-up and management options for bladder outlet obstruction resulting from prostate cancer treatments, including those that require urinary diversion.

RECENT FINDINGS

The devastated bladder outlet can be a consequence of the treatment of benign conditions, but more frequently from complications of pelvic cancer treatments. Regardless of etiology, the initial treatment ladder involves endoluminal options such as dilation and direct vision internal urethrotomy, with or without intralesional injection of anti-fibrotic agents. If these conservative strategies fail, surgical reconstruction should be considered. Although surgical reconstruction provides the best prospect of durable success, reconstructive procedures are also associated with serious complications. In the worst circumstances, such as prior radiotherapy, failed reconstruction, devastated bladder outlet with end-stage bladders, or patient's severe comorbidities, reconstruction may neither be realistic nor justified. Urinary diversion with or without cystectomy may be the best option for these patients. Thorough patient counseling before treatment selection is of utmost importance. Outcomes and repercussions on quality of life vary extensively with management options. Meticulous preoperative diagnostic evaluation is paramount in selecting the right treatment strategy for each individual patient. The risk of bladder outlet obstruction, and its severest form, devastated bladder outlet, after treatment of prostate cancer is not negligible, especially following radiation. Management includes endoluminal treatment, open or robot-assisted laparoscopic reconstruction, and urinary diversion in the worst circumstances, with varying success rates.

Summarizing the evidence for robotic-assisted bladder neck reconstruction: Systematic review of patency and incontinence outcomes

Objective

Bladder neck contracture and vesicourethral anastomotic stenosis are difficult to manage endoscopically, and open repair is associated with high rates of incontinence. In recent years, there have been increasing reports of robotic-assisted bladder neck reconstruction in the literature. However, existing studies are small, heterogeneous case series. The objective of this study was to perform a systematic review of robotic-assisted bladder neck reconstruction to better evaluate patency and incontinence outcomes.

Methods

We performed a systematic review of PubMed from first available date to May 2023 for all studies evaluating robotic-assisted reconstructive surgery of the bladder neck in adult men. Articles in non-English, author replies, editorials, pediatric-based studies, and reviews were excluded. Outcomes of interest were patency and incontinence rates, which were pooled when appropriate.

Results

After identifying 158 articles on initial search, we included only ten studies that fit all aforementioned criteria for robotic-assisted bladder neck reconstruction. All were case series published from March 2018 to March 2022 ranging from six to 32 men, with the median follow-up of 5-23 months. A total of 119 patients were included in our analysis. A variety of etiologies and surgical techniques were described. Patency rates ranged from 50% to 100%, and pooled patency was 80% (95/119). De novo incontinence rates ranged from 0% to 33%, and pooled incontinence was 17% (8/47). Our findings were limited by small sample sizes, relatively short follow-ups, and heterogeneity between studies.

Conclusion

Despite limitations, current available evidence suggests comparable patency outcomes and improved incontinence outcomes for robotic bladder neck reconstruction compared to open repair. Additional prospective studies with longer-term follow-ups are needed to confirm these findings.

[Urinary diversion with or without simple cystectomy as a salvage option for benign diseases of the lower urinary tract]

Benign diseases of the lower urinary tract can occur as a result of oncological or neurological diseases or their respective therapies (e.g., surgery or radiation treatment) and can significantly reduce the quality of life for affected patients. Urinary diversion serves as a salvage option when all other therapeutic regimens have been carried out and proven unsuccessful. When selecting the suitable urinary diversion, a comprehensive clinical assessment of the patients is required in order to ensure long-term success. In some cases, a cutaneous, catheterizable pouch offers the last and only option for a long-term and definitive treatment of a patient's condition. Overall, a decreasing trend in the establishment of a continent urinary diversion is observed in Germany. Current data on benign indications for urinary diversion are limited. Therefore, further data collection and research are needed.

Refractory Bladder Neck Contracture (BNC) After Radical Prostatectomy: Prevalence, Impact and Management Challenges

Bladder neck contracture is a recognised complication associated with radical prostatectomy. The management can be challenging, especially when refractory to initial intervention strategies. For the patient, the burden of disease is high and continence status cannot be overlooked. This review serves to provide an overview of the management of this recognised clinical pathology. Consideration needs to be given to minimally invasive approaches such as endoscopic incision, injectables, implantable devices as well as major reconstructive surgery where the condition persists. For the latter, this can involve open and robotic surgery as well as use of grafts and artificial sphincter surgery. These elements underline the need for a tailored and a patient centred approach.

Short- and intermediate-term outcome of robot-assisted inverted YV-plasty for recurrent bladder neck stenosis - a single centre study

OBJECTIVES

To report the technique and preliminary results for extraperitoneal robot-assisted laparoscopic YV-plasty (RAYV) for refractory bladder neck stenosis (BNS) and vesicourethral anastomosis stenosis (VUAS).

MATERIALS AND METHODS

Included were patients with recurrent BNS and VUAS who underwent RAYV at our institution. Primary outcome was short- and intermediate-term functional results measured with urinary peak flow (Qmax), post-void residual urine (PVR) as well as quality of life assessment with the international prostate symptom score (IPSS) and short form health survey (SF-8). Short- and intermediate-term follow-up periods were defined as 1 to 6 months and 6 to 24 months, respectively. Secondary, all patients were reviewed for etiology as well as perioperative data. Treatment success was defined by absence of further treatment and/or need for intermittent or permanent catheterization.

RESULTS

Between March 2016 and October 2020 a total of 30 patients with a median age of 70.8 (64 - 77) years underwent RAYV with a median follow-up of 27 months. Median operative time (skin-skin) was 131 (112 - 145) minutes. The transurethral indwelling catheter was removed after 10 (5 - 16) days. There were no intraoperative complications but two postoperative major complications Clavien-Dindo IIIa and IV, respectively. Short- and intermediate-term results revealed significant improvement of IPS symptom score from 17 (11-24) points to 11 (6-13) points and 6 (3-9) points, respectively. Further thePVR decreased from 90 (5-302) mL to 0 (0-30) mL and 0 (0-90) mL, respectively, and Qmax increased from 7.4 mL/s to 13 (8-16) mL/s and 17 (12-4) mL/s, respectively. Improvement of SF-8 did not reach significance. A total of 5/30 (16.7%) patients had a treatment failure after 24 months whereof 2 had a re-stricture.

CONCLUSION

RAVY-Plasty for recurrent bladder neck stenosis is a safe and effective procedure with good functional short- and median-term outcome.

Current evidence of robotic-assisted surgery use in functional reconstructive and neuro-urology

The use of robot-assisted technology has been widely adopted in urological oncological surgery and its benefits have been well established. In recent years, robotic technology has also been used in several functional reconstructive and neuro-urology (FRNU) procedures. The aim of this review was to evaluate the current evidence in the use of robotic technology in the field of FRNU. We performed a PubMed-based literature search between July and August 2022. The keywords we included were 'robotic assisted', 'ureteric reimplantation', 'cystoplasty', 'ileal conduit', 'neobladder', 'sacrocolpopexy', 'colposuspension', 'artificial urinary sphincter', 'genitourinary fistula' and 'posterior urethral stenoses'. We identified the latest available evidence in the use of robotic technology in specific FRNU procedures such as the reconstruction of the ureters, bladder and urinary sphincter, urinary diversion, and repair of genitourinary prolapse and fistula. We found that there is a lack of prospective studies to assess the robotic-assisted approach in the field of FRNU. Despite this, the advantages that robotic technology can bring to the field of FRNU are evident, including better ergonomics and visual field, less blood loss and shorter hospital stays. There is therefore a need for further prospective studies with larger patient numbers and longer follow-up periods to establish the reproducibility of these results and the long-term efficacy of the procedures, as well as the impact on patient outcomes. Common index procedures and a standardized approach to these procedures should be identified to enhance training.

Transperineal bulbovesical anastomosis for extensive posterior urethral stenoses after treatment of prostatic disease

OBJECTIVES

We report our surgical experience of transperineal bulbovesical anastomosis (BVA) for extensive posterior urethral stenosis (PUS).

METHODS

Six male patients who had extensive PUS extending from the bulbomembranous urethra to the bladder neck due to prostatic disease treatment and underwent transperineal BVA between 2014 and 2020 were retrospectively reviewed. BVA was performed according to the elaborate perineal approach for pelvic fracture urethral repair with minor modifications. After confirming the absence of recurrent stenosis 6 months postoperatively, the patients were offered artificial urinary sphincter (AUS) placement for subsequent urinary incontinence (UI).

RESULTS

Median patient age was 68, and the etiology of PUS was radical prostatectomy for prostate cancer in four patients, brachytherapy for prostate cancer in one, and transurethral resection of the prostate for benign prostatic hyperplasia in one. All patients had been previously treated with multiple transurethral procedures such as urethrotomy and dilation. Median operative time and blood loss were 211 min and 154 ml, respectively. Five cases (83.3%) had no recurrent stenosis with a median follow-up of 45 months, but a single direct vision internal urethrotomy was performed in one (16.7%) due to restenosis. Four (66.7%) patients underwent AUS placement via transcorporal approach for subsequent UI, but two had it removed due to urethral erosion.

CONCLUSION

Transperineal BVA could effectively manage extensive PUS after prostatic disease treatment. Staged AUS placement could be a viable option for subsequent UI, but the risk of urethral erosion seemed high.

Devastated Bladder Outlet in Pelvic Cancer Survivors: Issues on Surgical Reconstruction and Quality of Life

Bladder outlet obstruction following treatment of pelvic cancer, predominantly prostate cancer, occurs in 1-8% of patients. The high incidence of prostate cancer combined with the long-life expectancy after treatment has increased concerns with cancer survivorship care. However, despite increased oncological cure rates, these adverse events do occur, compromising patients' quality of life. Non-traumatic obstruction of the posterior urethra and bladder neck include membranous and prostatic urethral stenosis and bladder neck stenosis (also known as contracture). The devastated bladder outlet can result from benign conditions, such as neurogenic dysfunction, trauma, iatrogenic causes, or more frequently from complications of oncologic treatment, such as prostate, bladder and rectum. Most posterior urethral stenoses may respond to endoluminal treatments such as dilatation, direct vision internal urethrotomy, and occasionally urethral stents. Although surgical reconstruction offers the best chance of durable success, these reconstructive options are fraught with severe complications and, therefore, are far from being ideal. In patients with prior RT, failed reconstruction, densely fibrotic and/or necrotic and calcified posterior urethra, refractory incontinence or severe comorbidities, reconstruction may not be either feasible or recommended. In these cases, urinary diversion with or without cystectomy is usually required. This review aims to discuss the diagnostic evaluation and treatment options for patients with bladder outlet obstruction with a special emphasis on patients unsuitable for reconstruction of the posterior urethra and requiring urinary diversion.

Perineoscopic vesicourethral reconstruction: A novel surgical technique for anastomotic stricture following radical prostatectomy

OBJECTIVE

Vesicourethral anastomotic stenosis (VUAS) is frequently seen after prostate surgery because of various operative and postoperative factors. In this study, we aimed to present our results of perineoscopic bladder neck reconstruction, which is a new technique of the perineal approach in the treatment of patients with VUAS after prostate cancer surgery.

MATERIAL AND METHODS

Sixteen consecutive patients who underwent perineoscopic bladder neck reconstruction in our clinic between July 2017 and March 2019 were included in the study. Demographic characteristics, surgical history, postoperative continence status, and additional treatment requirements were recorded. Perineoscopic surgery is defined as the visualization of the surgical site with instruments used in laparoscopy and the surgeon performing the entire operative procedure through the screen.

RESULTS

The mean number of preoperative endoscopic bladder neck resections of the patients was 7±5.1, with a history of suprapubic cystostomy in 7 (43.7%) and radiotherapy in 5 (31.2%) patients before surgery. The mean surgical time was 126.2±13.1 min. The mean follow-up period was 13.2±6.8 months, and the success rate was 81.25%. During follow-up, two (12.5%) patients received perineoscopic re-do reconstruction because of stricture recurrence, and one (6.2%) patient was included in a urethral dilatation program.

CONCLUSION

Improving visualization and ergonomics with the perineoscopic approach can increase the success rate of bladder neck reconstruction in comparison with the standard approach. In addition, the lack of need for expanded dissection (corporal separation, inferior pubectomy) reduces postoperative complication rates.

New perspectives on the surgical treatment of posterior urethral obstruction

PURPOSE OF REVIEW

Posterior urethral obstruction (PUO) from prostate surgery for benign and malignant conditions poses a significant reconstructive challenge. Endoscopic management demonstrates only modest success and often definitive reconstructive solutions are necessary to limit morbidity and firmly establish posterior urethral continuity. This often demands a combined abdominoperineal approach, pubic bone resection, and even sacrifice of the external urinary sphincter and anterior urethral blood supply. Recently, a robotic-assisted approach has been described. Enhanced instrument dexterity, magnified visualization, and adjunctive measures to assess tissue quality may enable the reconstructive surgeon to engage posterior strictures deep within the confines of the narrow male pelvis and optimize functional outcomes. The purpose of this review is to review the literature regarding endoscopic, open, and robotic management outcomes for the treatment of PUO, and provide an updated treatment algorithm based upon location and complexity of the stricture.

RECENT FINDINGS

Contingent upon etiology, small case series suggest that robotic bladder neck reconstruction has durable reconstructive outcomes with acceptable rates of incontinence in carefully selected patients.

SUMMARY

Initial reports suggest that robotic bladder neck reconstruction for recalcitrant PUO may offer novel reconstructive solutions and durable function outcomes in select patients.

[Urethro-vesical anastomosis reconstruction using extra-peritoneal robot-assisted laparoscopy for anastomotic stenosis after radical prostatectomy]

INTRODUCTION

Urethro-vesical anastomosis stenosis following radical prostatectomy is a rare complication but represents a challenging situation. While the first-line treatment is endoscopic, recurrences after urethrotomies require a radical approach. We present the updated results of our patient's cohort treated by pure robotic anastomosis refection.

MATERIAL AND METHODS

This is a retrospective, single-center study focusing on one surgeon's experience. Patients presented an urethro-vesical stricture following a radical prostatectomy. Each patient received at least one endoscopic treatment. The procedure consisted of a circumferential resection of the stenosis, followed by a re-anastomosis with well-vascularized tissue. We reviewed the outcomes in terms of symptomatic recurrences and continence after the reconstructive surgery.

RESULTS

From April 2013 to May 2020, 8 patients underwent this procedure. Half of the patients had previously been treated with salvage radio-hormonotherapy. The median age was 70 years (64-76). The mean operative time was 109minutes (60-180) and blood loss was 120cc (50-250). One patient had an early postoperative complication, with vesico-pubic fistula. The average length of stay was 4.6 days (3-8). Mean follow-up was 24.25 months (1-66). Half of the patients experienced a recurrence at a median time of 8.25 months (6-11) after surgery. Five patients experienced incontinence of which 3 required an artificial urinary sphincter implantation.

CONCLUSION

Extra-peritoneal robot-assisted urethro-vesical reconstruction is feasible and safe to manage bladder neck stricture after radical prostatectomy. The risk of postoperative incontinence is high, justifying preoperative information.

LEVEL OF EVIDENCE

III.

Contemporary Management of Vesico-Urethral Anastomotic Stenosis After Radical Prostatectomy

Vesico-urethral anastomotic stenosis is a well-known sequela after radical prostatectomy for prostate cancer and has significant impact on quality of life. This review aims to summarize contemporary therapeutical approaches and to give an overview of the available evidence regarding endoscopic interventions and open reconstruction. Initial treatment may include dilation, incision or transurethral resection. In treatment-refractory stenoses, open reconstruction via an abdominal (retropubic), transperineal or combined abdominoperineal approach is a viable option with high success rates. All of the open surgical procedures are generally accompanied by a high risk of developing de novo incontinence and patients may need further interventions. In such cases, subsequent artificial urinary sphincter implantation is the most common treatment option with the best available evidence.

[Anastomosis stenosis after radical prostatectomy and bladder neck stenosis after benign prostate hyperplasia treatment: reconstructive options]

Bladder neck stenosis (BNS) after simple prostatectomy and vesicourethral anastomosis stenosis (VUAS) after radical prostatectomy for prostate cancer are common sequelae. However, the two entities differ in their pathology, anatomy and their surgical results. VUAS has an incidence of 0.2-28%. Commonly, VUAS occurs within the first 2 years after surgery. Initial therapy should be performed endourologically: dilatation, (laser) incision or resection. After three unsuccessful treatment attempts, open reconstruction should be considered. Different surgical approaches (abdominal, perineal, abdominoperineal) have been described. All are associated with good success rates. However, they are accompanied by high rates of urinary incontinence. Incontinence can be treated safely by implantation of an artificial urinary sphincter. The incidence of BNS is around 5% for all types of surgery for benign prostate hyperplasia. It occurs within the first 2 years after surgery. Initial treatment should be performed endourologically. In case of recalcitrant BNS, open reconstruction is indicated. The YV-plasty is an established procedure, and the T‑plasty represents a modification. Success rates of both procedures are high. Robot-assisted reconstructive procedures have been described for both VUAS and BNS.

Robotic urethral reconstruction: redefining the paradigm of posterior urethroplasty

Outlet procedures for benign prostatic hypertrophy, prostate cancer therapy, and trauma can result in stenosis of the posterior urethra, a complex reconstructive problem that often fails conservative endoscopic management, necessitating more aggressive and definitive reconstructive solutions. This is typically done with an open technique which may require a combined abdominoperineal approach, pubectomy, and/or flap interposition. Implementation of a robot-assisted platform affords several potential advantages including smaller incisions, magnified field of vision, near-infrared fluorescence (NIRF) imaging to characterize tissue integrity, enhanced dexterity within the deep and narrow confines of the male pelvis, sparing of the perineal planes, and shorter convalescence. Herein, we describe important surgical considerations for robotic posterior urethral reconstruction.

Vesicourethral Anastomotic Stenosis After Open or Robot-assisted Laparoscopic Retropubic Prostatectomy-Results from the Laparoscopic Prostatectomy Robot Open Trial

BACKGROUND

Vesicourethral anastomotic stenosis is a well-known late complication after open radical retropubic prostatectomy (RRP) with previously reported incidences of 2.7-15%. There are few reports of the incidence after robot-assisted laparoscopic radical prostatectomy (RALP) compared with RRP.

OBJECTIVE

The aim was to compare the risk of developing symptomatic stenosis after RRP and RALP, and to explore potential risk factors and the influence of stenosis on the risk of urinary incontinence.

DESIGN, SETTING, AND PARTICIPANTS

Between 2008 and 2011, 4003 men were included in a prospective trial comparing RRP and RALP at 14 Swedish centres. Clinical data and patient questionnaires were collected before, during, and after surgery.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Stenosis was identified by either patients' reports in questionnaires or case report forms. The primary endpoint is reported as unadjusted as well as adjusted relative risks (RRs), calculated with log-binomial regression models. Data on incontinence were analysed by means of a log-binomial regression model, with stenosis as an independent and incontinence as a dependent variable.

RESULTS AND LIMITATIONS

Symptomatic stenosis developed in 1.9% of 3706 evaluable men within 24 mo. The risk was 2.2 times higher after RRP than after RALP (RR 2.21, 95% confidence interval [CI] 1.38-3.53). Overall, urinary incontinence was twice as common in patients who had stenosis (RR 2.01, 95% CI 1.43-2.64).

CONCLUSIONS

This large prospective study found an overall low rate of vesicourethral anastomotic stenosis after radical prostatectomy, but the rate was significantly lower after robot-assisted prostatectomy. The risk of stenosis seems to be associated with the number of sutures/takes in the anastomosis, but this was statistically significant only in the RALP group.

PATIENT SUMMARY

We investigated the risk of developing vesicourethral anastomotic stenosis after open and robot-assisted radical prostatectomy. We found that the risk was generally lower than previously reported and lower after robot-assisted radical prostatectomy than after radical retropubic prostatectomy. Urinary incontinence was twice as common in patients with stenosis.

Extraperitoneal Robot-Assisted Vesicourethral Reconstruction to Manage Anastomotic Stricture Following Radical Prostatectomy

OBJECTIVE

To demonstrate the feasibility of robot-assisted vesicourethral reconstruction. Vesicourethral anastomotic stricture following radical prostatectomy is a real challenge for reconstructive surgery when facing several endoscopic management failures.

MATERIAL AND METHODS

This is a case series of robot-assisted vesicourethral reconstruction for anastomotic stricture failing endoscopic management. The procedure was performed with an extraperitoneal approach. The fibrotic anastomotic region was resected and a new vesicourethral running suture was performed with well-vascularized tissue. Bladder catheter was removed after 7 days.

RESULTS

Six procedures were performed from April 2013 to May 2018 at our department. One patient had a robot-assisted radical prostatectomy at our department; the 5 others were referred from other institutions after receiving open prostatectomies. Three patients had salvage radiation therapy before reconstruction. Mean age was of 73.8 years (68-82). There was no peroperative complication. Mean operative time was of 108 minutes (60-180)], with a mean estimated blood loss of 130 mL (50-300). After surgery, 3 patients presented recurrences managed endoscopically without recurrence after 3, 5, and 11 months. Three patients presented incontinence treated with artificial sphincter implantation. One patient had no residual symptom after 5 years of follow-up.

CONCLUSIONS

Robot-assisted vesicourethral reconstruction is a safe procedure. It is an option to consider when facing recurring anastomotic stricture following radical prostatectomy. It is an alternative to the perineal approach and an option before urinary diversion. Patients should be informed of the risks of incontinence and recurrence before surgery especially if they had radiation therapy.

Safety and effectiveness evaluation of open reanastomosis for obliterative or recalcitrant anastomotic stricture after radical retropubic prostatectomy

Purpose:

To evaluate safety, efficacy and functional outcomes after open vesicourethral re - anastomosis using different approaches based on previous urinary continence.

Materials and Methods:

Retrospective study of patients treated from 2002 to 2017 due to vesicourethral anastomosis stricture (VUAS) post radical prostatectomy (RP) who failed endoscopic treatment with at least 3 months of follow-up. Continent and incontinent patients post RP were assigned to abdominal (AA) or perineal approach (PA), respectively. Demographic and perioperative variables were registered. Follow-up was completed with clinical interview, uroflowmetry and cystoscopy every 4 months. Success was defined as asymptomatic patients with urethral lumen that allows a 14 French flexible cystoscope.

Results:

Twenty patients underwent open re-anastomosis for VUAS after RP between 2002 and 2017. Mean age was 63.7 years (standard deviation 1.4) and median follow-up was 10 months (range 3 – 112). The approach distribution was PA 10 patients (50%) and AA 10 patients (50%). The mean surgery time and median hospital time were 246.2 ± 35.8 minutes and 4 days (range 2 – 10), respectively with no differences between approaches. No significant complication rate was found. Three patients in the AA group had gait disorder with favorable evolution and no sequels.

Estimated 2 years primary success rate was 80%. After primary procedures 89.9% remained stenosis - free. All PA patients remained incontinent, and 90% AA remained continent during follow-up.

Conclusion:

Open vesicourethral re - anastomosis treatment is a reasonable treatment option for recurrent VUAS after RP. All patients with perineal approach remained incontinent while incontinence rate in abdominal approach was rather low.

Patency and Incontinence Rates After Robotic Bladder Neck Reconstruction for Vesicourethral Anastomotic Stenosis and Recalcitrant Bladder Neck Contractures: The Trauma and Urologic Reconstructive Network of Surgeons Experience

OBJECTIVE

To review a robotic approach to recalcitrant bladder neck obstruction and to assess success and incontinence rates.

MATERIALS AND METHODS

Patients with a recalcitrant bladder neck contracture or vesicourethral anastomotic stenosis who underwent robotic bladder neck reconstruction (RBNR) were identified. We reviewed patient demographics, medical history, etiology, previous endoscopic management, cystoscopic and symptomatic outcomes, urinary continence, and complications. Stricture success was anatomic and functional based upon atraumatic passage of a 17 Fr flexible cystoscope or uroflowmetry rate >15 ml/s. Incontinence was defined as the use of >1 pad per day or procedures for incontinence.

RESULTS

Between 2015 and 2017, 12 patients were identified who met study criteria and underwent RBNR. Etiology of obstruction was endoscopic prostate procedure in 7 and radical prostatectomy in 5. The mean operative time was 216 minutes (range 120-390 minutes), with a mean estimated blood loss of 85 cc (range 5-200 cc). Median length of stay was 1 day (range 1-5 days). Three of 12 patients had recurrence of obstruction for a 75% success rate. Additionally, 82% of patients without preoperative incontinence were continent with a median follow-up of 13.5 months (range 5-30 months). There was 1 Clavien IIIb complication of osteitis pubis and pubovesical fistula that required vesicopubic fistula repair with pubic bone debridement.

CONCLUSION

RBNR is a viable surgical option with high patency rates and favorable continence outcomes. This is in contrast to perineal reconstruction, which has high incontinence rates. If future incontinence procedures are needed, outcomes may be improved given lack of previous perineal dissection.