Robot-Assisted Laparoscopic Bladder Neck Reconstruction with Retzius-Sparing Approach for the Treatment of 3 Cases of Refractory Bladder Neck Contracture

Keywords

Bladder Neck Contracture; Retzius-Sparing; Robotic Surgery; Urethral Reconstruction Surgery.

Abstract

We present the preliminary outcomes of robotic-assisted surgical treatment for bladder neck contracture (BNC), using the innovative Robot-Assisted Laparoscopic Retzius-Sparing Bladder Neck Reconstruction (RAL-RSBNR), technique. Between August and October 2024, three adult male patients underwent RAL-RSBNR at our institution. All patients developed BNC following transurethral resection of the prostate (TURP), for benign prostatic hyperplasia (BPH), and had previously undergone multiple urethral dilation procedures. One patient had experienced recurrent TURP interventions. All RAL-RSBNR procedures were performed using a transperitoneal six-port approach with a four-arm robotic system. No significant intraoperative or postoperative complications were observed. At two weeks postoperatively, all three patients successfully had their catheters removed without notable voiding difficulties. Current literature identifies the RAYV technique as the predominant robotic-assisted approach for treating BNC. In contrast, our novel RAL-RSBNR technique addresses BNC at its root, effectively preventing recurrence often associated with endoscopic surgeries, while maintaining a favorable safety profile with no major complications. These preliminary results indicate that RAL-RSBNR holds significant potential as a promising option for BNC treatment. Nevertheless, given the short study period, further clinical data and extended follow-up are required to thoroughly evaluate the long-term outcomes and efficacy of RALRSBNR.

Abstract

We present the preliminary outcomes of robotic-assisted surgical treatment for bladder neck contracture (BNC), using the innovative Robot-Assisted Laparoscopic Retzius-Sparing Bladder Neck Reconstruction (RAL-RSBNR), technique. Between August and October 2024, three adult male patients underwent RAL-RSBNR at our institution. All patients developed BNC following transurethral resection of the prostate (TURP), for benign prostatic hyperplasia (BPH), and had previously undergone multiple urethral dilation procedures. One patient had experienced recurrent TURP interventions. All RAL-RSBNR procedures were performed using a transperitoneal six-port approach with a four-arm robotic system. RSBNR. No significant intraoperative or postoperative complications were observed. At two weeks postoperatively, all three patients successfully had their catheters removed without notable voiding difficulties. Current literature identifies the RAYV technique as the predominant robotic-assisted approach for treating BNC. In contrast, our novel RAL-RSBNR technique addresses BNC at its root, effectively preventing recurrence often associated with endoscopic surgeries, while maintaining a favorable safety profile with no major complications. These preliminary results indicate that RAL-RSBNR holds significant potential as a promising option for BNC treatment. Nevertheless, given the short study period, further clinical data and extended follow-up are required to thoroughly evaluate the long-term outcomes and efficacy of RAL-RSBNR

Keywords

Bladder Neck Contracture; Retzius-Sparing; Robotic Surgery; Urethral Reconstruction Surgery.

Citation

Wu Y, Lu D, Liu J, Wang X, Xiong W, et.al, (2025) Robot-Assisted Laparoscopic Bladder Neck Reconstruction with Retzius-Sparing Approach for the Treatment of 3 Cases of Refractory Bladder Neck Contracture. J Nephrol Kidney Dis 6(1): 5.

INTRODUCTION

Bladder neck contracture (BNC) is a common postoperative complication in urological surgery, particularly after prostate procedures. Its primary symptoms include difficulty urinating, urinary flow obstruction, and even complete urinary retention, which significantly impact patients’ quality of life. Traditional treatment options such as urethral dilation, endoscopic incision, and laser therapy are widely used; however, recurrence of the contracture occurs in approximately half of the case [1]. With the continuous advancements in robotic surgical technology, robot-assisted surgery has gained increasing popularity in the treatment of BNC. Bladder neck Y-V plasty involves creating a Y-shaped incision at the bladder neck and suturing it into a V shape, effectively enlarging the bladder outlet, alleviating urinary obstruction, and reducing the risk of recurrence. However, this technique is associated with a potential risk of postoperative urinary incontinence [2]. The T-plasty approach, on the other hand, involves exposing the bladder neck, excising scar tissue, and performing a T-shaped incision on the anterior bladder wall, which helps to lower the incidence of postoperative urinary incontinence [3]. Meanwhile, urethral repair and reconstruction techniques utilizing the Retzius-sparing approach offer a new treatment option for patients with bladder neck contracture.

PATIENTS AND METHODS

From July to October 2024, three patients with refractory bladder neck contracture (BNC) underwent robot-assisted laparoscopic Retzius sparing bladder neck reconstruction (RAL-RSBNR), at our institution. All cases of BNC occurred following transurethral plasmakinetic resection of the prostate (TURP) for benign prostatic hyperplasia (BPH). Of these, two patients showed no improvement despite multiple endoscopic resection attempts. Patient histories, surgical details, postoperative courses, and follow up data were retrospectively collected and analyzed using medical records and patient questionnaires. The questionnaire included the International Prostate Symptom Score (IPSS), which aligns with the American Urological Association Symptom Index (AUA-SI). All patients were fully informed of the procedure and provided written consent. Postoperative complications were documented and classified according to the Clavien-Dindo grading system.

SURGICAL TECHNIQUE

All procedures were performed by an experienced robotic urologist using the da Vinci surgical robotic system. A transperitoneal six-port approach was utilized, with patients positioned in a lithotomy setup and a 30° Trendelenburg tilt. The surgery commenced with cystoscopy to assess the anatomical relationship between the bladder neck and the urethral sphincter. The robotic system was then employed to access the bladder through a posterior approach, dissecting along the pelvic wall, Denonvilliers’ fascia, and the lateral walls of the prostate down to its apex. At the bladder neck, a transverse incision was made on the posterior bladder neck at the junction of the prostate and bladder. After opening the posterior bladder neck, traction was applied to expose the anterior bladder neck, which was subsequently incised. Bladder neck reconstruction involved creating a fish-mouth-shaped configuration. A double-layer continuous anastomosis was performed using 3-0 absorbable barbed sutures (5/8 curved needle) to seamlessly connect the urethra to the bladder neck opening.

RESULTS

The patient characteristics and perioperative outcomes are summarized in Table 1. No major intraoperative or postoperative complications occurred in any of the patients. The follow-up period ranged from 1 to 4 months. During this time, all three patients successfully had their catheters removed between 14 and 15 days postoperatively, with no cases of urinary incontinence. All patients regained satisfactory voiding function. The median International Prostate Symptom Score (IPSS) during follow-up was 4.6, indicating that all patients experienced only mild urinary symptoms. 

Abbreviations

BMI: Body Mass Index, BNC: Bladder Neck Contracture, CCI: Charlson Comorbidity Index, IPSS: International Prostate Symptom Score,RAL- RSBNR:Robot-Assisted Laparoscopic Retzius-Sparing Bladder Neck Reconstruction

Figure 1: Transperitoneal Six-Port Approach (Four-Arm Robotic Setup).The patient is positioned in a Trendelenburg lithotomy position. RP: Robotic Ports, CP: Camera Port, AP: Assistant Port.

Figure 2: Intraoperative cystoscopy was performed to examine the condition of the bladder neck.

Figure 3: Radical prostatectomy via a transvesical posterior approach.(a) Resection of the prostatic base.(b) Resection of the prostatic apex

Figure 4: Reconstruction of the bladder neck using a 3-0 barbed absorbable suture with double needles.

DISCUSSION

Transurethral resection of the prostate (TURP) is one of the earliest and most widely used minimally invasive procedures for treating benign prostatic hyperplasia (BPH). However, bladder neck contracture (BNC) occurs in approximately 2.2% to 9.8% of patients following TURP, with some studies suggesting an incidence as high as 15.8%. This complication significantly reduces postoperative quality of life [2-6]. The primary treatment for BNC is surgical intervention, where complete excision of scar tissue and full incision of the contracture ring are essential for success. Despite this, recurrence rates remain high. Transurethral bladder neck incision is the standard treatment for BPH related BNC. However, Kranz [7]reported that while the success rate for the initial bladder neck incision is 65%, it drops to just 25% for patients undergoing three or more repeat procedures.

For refractory BNC, open reconstructive surgeries such as abdominoperineal bladder neck resection with anastomosis or bladder neck Y-V plasty are considered effective options. Nevertheless, these open surgeries require extensive midline abdominal incisions to expose the surgical field, posing significant risks to pelvic floor function. Robotic-assisted laparoscopic approaches, by contrast, offer greater precision in anatomical localization and bladder neck dissection, reducing trauma and complications compared to open surgery. Currently, minimally invasive robotic surgeries for refractory BNC typically employ Y-V plasty or modified T-plasty techniques. However, recurrence rates for these methods remain at 20% to 30%. Additionally, the disruption of the Retzius space during these procedures often compromises postoperative urinary continence [8]. In our case series, the RAL-RSBNR technique proved feasible and demonstrated potential as an effective treatment for BNC. The minimally invasive nature of this approach resulted in no major intraoperative or postoperative complications. Crucially, the preservation of the Retzius space minimized disruption to bladder neck support structures, safeguarding urinary continence and reducing the risk of pelvic nerve damage. This preservation also significantly decreased the likelihood of sexual dysfunction and urinary incontinence [9]. Among the three patients in our study, no BNC recurrence was observed within three months postoperatively. While the absence of cystoscopic evaluation prevents us from ruling out subclinical recurrence entirely, the median IPSS score of 4 suggests favorable outcomes. All patients expressed willingness to undergo RAL-RSBNR again if necessary. In summary, our preliminary follow-up results indicate that RAL RSBNR is as effective as well-established open surgeries for the treatment of BNC. Furthermore, it may offer advantages over the current mainstream RAYV approach in specific aspects, particularly in reducing complications and preserving pelvic function.

CONCLUSION

Reports on the application of RAL-RSBNR for treating refractory bladder neck contracture (BNC) remain scarce. However, robot-assisted laparoscopic Retzius-sparing urethral repair and reconstruction has shown promising efficacy, particularly in managing recurrent and treatment-resistant cases. This technique significantly reduces the risk of postoperative complications, preserves the Retzius space to minimize urinary incontinence, and facilitates the recovery of urinary continence. The robotic surgical system’s high-definition 3D visualization and stable mechanical arms improve the precision of fibrotic tissue excision and urethral suturing while minimizing disruption to surrounding tissues. This leads to faster postoperative recovery, shorter hospital stays, and an overall enhancement in quality of life for patients. In our case series, RAL-RSBNR was successfully performed on all patients without major intraoperative or postoperative complications. However, given the limited study duration, further clinical data and extended follow-up are required to validate the long-term efficacy and safety of RAL-RSBNR. As robotic surgical technology continues to evolve and become more accessible, this approach has the potential to establish itself as the standard treatment for bladder neck contracture in the future.

REFERENCES

1. Ramirez D, Simhan J, Hudak SJ, Morey AF. Standardized approach for the treatment of refractory bladder neck contractures. Urol Clin North Am. 2013; 40: 371-380.
2. Kurtzman JT, Blum R, Brandes SB. Lower Urinary Tract Stenosis Following Surgery for Benign Prostatic Hyperplasia. Curr Urol Rep. 2021; 22: 55.
3. Reiss CP, Rosenbaum CM, Becker A, Schriefer P, Ludwig TA, Engel O, et al. The T-plasty: a modified YV-plasty for highly recurrent bladder neck contracture after transurethral surgery for benign hyperplasia of the prostate: clinical outcome and patient satisfaction. World J Urol. 2016; 34: 1437-1442.
4. Sekar H, Palaniyandi V, Krishnamoorthy S, Kumaresan N. Post- transurethral resection of prostate urethral strictures: Are they often underreported? A single-center retrospective observational cohort study. Urol Ann. 2021; 13: 329-335.
5. Li J, Ruan J, Hong S. Analysis and prevention of urethral stricture after transurethral resection of the prostate. Clinical Medicine. 2007; 27: 29-30
6. Castellani D, Wroclawski ML, Pirola GM, Gauhar V, Rubilotta E, Chan VW, et al. Bladder neck stenosis after transurethral prostate surgery: a systematic review and meta-analysis. World J Urol. 2021; 39: 4073-4083.
7. Kranz J, Reiss PC, Salomon G, Steffens J, Fisch M, Rosenbaum CM. Differences in Recurrence Rate and De Novo Incontinence after Endoscopic Treatment of Vesicourethral Stenosis and Bladder Neck Stenosis. Front Surg. 2017; 4: 44.
8. Zhang TR, Alford A, Zhao LC. Summarizing the evidence for robotic- assisted bladder neck reconstruction: Systematic review of patency and incontinence outcomes. Asian J Urol. 2024; 11: 341-347.
9. Lei PENG, Jinze LI, Dandan TANG, Tangqiang WEL, Yunxiang LI. Safety and efficacy of Retzius-sparing robot-assisted laparoscopic radical prostatectomy: meta-analysis. J Clin Urol. 2020; 35: 516-522.

Citation

Wu Y, Lu D, Liu J, Wang X, Xiong W, et.al, (2025) Robot-Assisted Laparoscopic Bladder Neck Reconstruction with Retzius-Sparing Approach for the Treatment of 3 Cases of Refractory Bladder Neck Contracture. J Nephrol Kidney Dis 6(1): 5.