New perspectives on the surgical treatment of posterior urethral obstruction

Robotic-assisted Posterior Urethroplasty: Outcomes From 105 Men in a Single-center Experience

OBJECTIVE

To determine surgical outcomes in a large of cohort men undergoing robotic-assisted posterior urethroplasty (RPU), which has been described in small series as a viable option.

MATERIALS AND METHODS

We performed a retrospective review of all 105 men who underwent RPU from October 2014 to August 2022 at a single institution. We evaluated postoperative outcomes, including complications; surgical success defined as no need for reintervention; and incontinence requiring artificial urinary sphincter placement. We performed descriptive statistics and chi-square testing to determine if outcomes were associated with certain posterior urethral disease etiologies.

RESULTS

Mean follow-up time was 18.7months. Over half of patients (57.1%) received prior pelvic radiation. The most common reconstructive techniques were excision and primary anastomosis (n = 45, 30.0%), resitting of the bladder neck (n = 26, 24.8%), Y-V plasty (n = 21, 20.0%), and buccal mucosal graft urethroplasty (n = 14, 13.3%). Forty-one patients (39.0%) required a combined abdominoperineal approach. Seven patients (6.7%) had ≥CD grade 3 complications within 30days. Thirty patients (28.6%) developed incontinence with subsequent artificial urinary sphincter placement. One-quarter (24.8%) of patients required at least one subsequent surgical reintervention.

CONCLUSION

In the largest RPU cohort to date, surgical success rates were similar and continence rates were improved compared to open surgery and align with existing robotic series, adding to the growing body of evidence demonstrating advantages of RPU.

Robotic Urethral Reconstruction Outcomes in Men with Posterior Urethral Stenosis

OBJECTIVE

To evaluate surgical outcomes stratified by posterior urethral obstruction (PUO) etiology in men undergoing definitive robotic posterior urethral reconstruction.

METHODS

A retrospective, single surgeon, review of men undergoing robotic posterior urethral reconstruction between 2018 and 2020 was performed. Differences in complications, reconstructive success (no further intervention), and urinary continence by PUO etiology were assessed.

RESULTS

Robotic posterior urethral reconstruction was performed in 21 men. PUO etiology included BPH treatment in 5 (24%), prostatectomy in 10 (48%), radiation in 5 (24%), and trauma in 1 (5%). Median number of prior endoscopic treatments was 3 (BPH), 3 (prostatectomy), and 2 (radiation) with an average time between obstruction and reconstruction of 9, 12, and 15 months (p=0.52). Median length of stay after reconstruction was 2, 1, and 2 days (p=0.45). 30-day complications occurred in 0%, 20%, 40% (p =0.19). Post-reconstruction re-intervention was necessary in 0%, 10%, 80% (p =0.004). Ultimately, anatomic success was achieved in 100%, 90%, 80% (p=0.63), with functional success rates of 100%, 100%, 60% (p=0.035). Median postoperative pad/day usage was 0,0, 10.5 (p<0.001), and ultimately 0%, 30%, 80% (p=0.013) underwent artificial urinary sphincter placement.

CONCLUSION

Endoscopic treatment of posterior urethral obstruction (PUO) secondary to benign and malignant prostate conditions is associated with a high incidence of treatment failure. Robotic posterior urethral reconstruction is a safe and effective surgical solution for men with PUO in the absence of pelvic radiation. Men with pelvic radiation appear to be at increased risk of complications, PUO recurrence, and clinically significant stress urinary incontinence.