Treatment of posterior urethral obstruction (PUO), including vesicourethral anastomotic stenosis (VUAS) and bladder neck stenosis (BNS), remains challenging to reconstructive urologists. The AUA guidelines recommend use of endoscopic management including dilation, incision, or resection as first-line for uncomplicated cases, whereas surgical reconstruction is reserved for more complex, recalcitrant obstructions.¹ Other societies (European Association of Urology and Société Internationale d’Urologie) share similar stepwise approaches to management, starting with endoscopic techniques.²

Historically, definitive reconstruction involved a technically challenging combined open abdomino-perineal approach. More recently, a robotic-assisted approach has emerged as an alternative with improved visualization and more ergonomic advantages. While the robotic approach is a reasonable alternative with lower morbidity when compared to open repair, it confers increased cost and operative time. In a review of treatment options for PUOs, endoscopic management including incision/resection +/− mitomycin C had a lower success rate (23%–83%) compared to robotic YV-plasty (75%–100%) and open approaches (60%–100%).³ To enhance operative success without incurring morbidity of abdominal or perineal incisions, we sought to develop an endoscopic technique that replicates the principles of open or robotic repairs. Herein, we detail the operative steps of what we refer as TUITMR (transurethral incision with transverse mucosal realignment). We will also discuss lessons learned from our updated series.

Our experience with TUITMR for PUO has been previously described and outcomes reported on our initial 19 patients.⁴ Over the subsequent treatment course of an additional 48 patients, we made several modifications to the technique. The procedure begins as previously described: using the 27Fr continuous flow cystourethroscope with a visual obturator (Olympus Surgical, Southborough, Massachusetts), and the level of obstruction is visualized. If we cannot safely incise the narrowing, a 0.35 inch wire is passed through the lumen and it is balloon dilated. A needle tip electrode is used to incise the 3 and 9 o’clock at the level of the stenosis. In the setting of VUAS we aim to open the stricture to 30Fr and ensure the incision does not encroach upon the membranous urethra. In the setting of BNS we open wide until healthy fat. Hemostasis is aggressively obtained. Having incised the stricture, we turn our attention to mucosal reapproximation.

Our technical modifications begin with a novel sheath (JNW Urtrac, LSI Solutions, Rochester, New York) which allows us to better visualize the suturing steps described below. The cystourethroscope is removed and the JNW Urtrac sheath is inserted into the bladder using the blind obturator. The 8.5Fr FLEX-X^C digital flexible ureteroscope (KARL STORZ Endoscopy-America, Inc.) is then placed through the upper visualization port and the RD-180 (LSI Solutions) through the lower working channel. Fluid is passed alongside the ureteroscope, or via the ureteroscope under pressure (Figure 1). The RD-180 is used to grasp the mid aspect of the proximal edge of bladder mucosa using a 2-0 Monoglide suture (LSI Solutions), and a second throw is made through the midpoint of the distal urethral mucosa. The suture tails externally are then threaded through the Ti Knot (LSI Solutions) and the Ti Knot is passed into the urethra to the site to be approximated. The suture is pulled tight externally, advancing the bladder mucosa distally to realign to the urethral mucosa (Figure 2). Pulling the handle of the Ti Knot both cuts the suture internally and secures it with the titanium knot. This is repeated on the opposite side, completing the procedure.

The catheter is left in place for 1 week. All patients must undergo a cystoscopy, which we perform at 4 months to ensure the absorbable suture has dissolved and the titanium knot has passed.

Success is determined by ability to pass a 17Fr cystoscope through the repair. We now have 67 patients with more than 6 months of follow-up. Forty-nine (73%) patients had failed prior endoscopic interventions, and 3 (5%) had previous YV robotic procedures. Most (55% [37/67]) patients had VUAS, and of those 73% (27/37) were radiated. Of those radiated VUAS patients, 62% (23/37) had pre- and postoperative incontinence. There were no cases of de novo incontinence including in the 45% (30/67) of BNS patients after benign prostate procedures. 64/67 (95%) of patients had successful treatment. All 3 failures were in the BNS cohort. Seven percent of the titanium clips required removal at 4 months (15% of patients). This is easily performed using stent grasping forceps.

There are some important patient selection considerations. We do not offer this operation for membranous urethral stenosis as we prefer urethroplasty in this setting. Likewise, we do not offer the procedure to patients with obliterative PUO, necrosis (Figure 3), or significant calcifications within the prostate bed as we prefer diversion or robotic revision of anastomosis in these cases. Therefore, we prefer to perform the preoperative cystoscopy ourselves or have video of the cystoscopy to ensure there is no membranous urethral involvement, and no significant calcification or necrosis. Delay of postoperative cystoscopy until 4 months allows the absorbable suture to dissolve and the titanium clips to be urinated out. Our 3 treatment failures were early in the series in patients with enlarged prostates. In these cases, suture tore through residual adenoma near the apex of the prostate. We now loop out any residual apical tissue to the level of the prostate capsule and anchor the suture to the capsule. This adjustment has averted further treatment failures.

The authors are often asked why we don’t use an offset nephroscope for these cases. After extensive explorations, the authors can confidently confirm that no true 5 mm offset scopes (that will accommodate 5 mm laparoscopic instruments) exist in the U.S. market. That said, the JNW Urtrac sheath makes this procedure possible using widely available flexible ureteroscopes.

Our early results are encouraging. This minimally invasive technique preserves principles of open surgery, and is effective with decreased morbidity, cost, and time expenditure compared to open and robotic approaches. We are accruing more patients over many sites to ensure the outcomes are reproducible.