At the AUA Plenary session this year we were asked to present a panel on bladder neck contractures (BNCs) and vesicourethral anastomotic stricture (VUAS). We presented numerous different types of management options: 2 endoscopic techniques and 2 robotic techniques. No one form of management will always prevail. The session started off by clearly delineating the difference between a BNC and a VUAS. BNCs are more straightforward, usually do not involve the external urinary sphincter (EUS; risk of incontinence is minimal to zero), are not radiated, and respond well to advanced techniques if primary dilation or incision fails. Dr Alex Vanni from the Lahey Clinic demonstrated the value of antifibrotic agents (mitomycin C) as an adjunctive to direct vision internal urethrotomy alone with excellent results for the treatment of BNC (>90%) and very good results for radiated VUAS (∼75%) after 2 treatments.^1-3 He noted the dosing of mitomycin C was very important and should be used as described at 0.4 mg/mL and avoided at 12 and 6 o’clock. Dr Nick Warner from the Mayo Clinic introduced the technique of a transurethral vertical incision and transverse mucosal realignment suture closure using a newly developed transurethral device.⁴ He reported results greater than 90% in BNC and VUAS proximal to the external urinary sphincter (EUS). He noted this is not for transmembranous strictures, obliterations, or radiation calcification. This is an exciting new technique to successfully manage BNC/VUAS.

In the robotic space, Dr Ziho Lee from Northwestern described robotic-assisted BNC reconstruction using a YV plasty for short >10F contractures and a complete excision and anastomosis for <10F contractures. Robotic series such as those from TURNS, which include BNC and the more challenging VUAS and radiated VUAS, showed a >75% success.⁵ For those studies focused exclusively on BNC, robotic repair success rates are higher, at >90%-100%.⁶ The key difference is, although obliterated or recurrent, BNC tissue is relatively healthy and free of the additional wound healing complication associated with radiation. Dr Boyd Viers from the Mayo Clinic spoke on VUAS, the most challenging of the group, especially the radiated VUAS, and demonstrated how robotic-assisted surgery is the most effective technique in terms of visualization, magnification, and surgical repair. He emphasized the preoperative assessment which includes retrograde urethrography, cystoscopy, and an MRI in complex posterior stenosis/VUAS (distraction injury). Benefits of the robotic abdominal approach include preserving the EUS when stenosis is proximal to this area and patency outcomes >75% or greater depending on if the tissue has been radiated or not.^7-9

Patients can be cured from refractory BNC and VUAS (radiation-induced included) using the various techniques described above. What is fantastic to see is the various treatment options that are tailored to the patient. With direct comparative studies, we will be able to compare technique to technique, assessing outcomes, side effects, cost, patient experience and recovery, and overall health care resource utilization. With many new and improved techniques over historical dilation or urethral incision alone, our ability to treat and cure these challenging conditions has grown exponentially and changed patients’ lives for the better.