Robotic bladder neck reconstruction using a double-faced buccal mucosal graft - A novel approach to complete bladder neck obliteration

Abstract

Objective

Bladder neck contractures (BNCs) are a well-documented, but acceptably uncommon late adverse outcome of surgical treatment for benign prostatic hyperplasia. Urologists successfully manage short segment contractures with endoscopic approaches, but recurrence rates are significant. When two endoscopic attempts fail, or in the case of long segment contractures and complete obliteration of the bladder neck, reconstruction and grafting are the mainstay. In this submission we aim to describe a new surgical solution to the completely obliterated bladder neck and prostatic fossa - a robot assisted laparoscopic (RAL) bladder neck reconstruction using an anterior and posterior buccal mucosal graft to create a double-faced repair.

Methods and Surgical Procedure

A 70-year-old male with a history of BPH presented with recurrent bladder neck contractures after an initial TURP. Being recalcitrant to four attempts at endoscopic correction, he was dependant on a suprapubic catheter (SPC) for 18 months. Retrograde urethrogram and SPC-gram confirmed a complete obliteration of the bladder neck and prostatic fossa. The patient underwent a RAL bladder neck reconstruction with a double face buccal mucosal graft. There were no perioperative complications.

Results

The patient was discharged on day 2 without perioperative complications. His IDC was removed and SPC clamped at 3 weeks, and the patient was voiding spontaneously without incontinence. At his 7-month follow-up the patient remained continent with a Qmax of 23 ml/s where he previously had no flow at all. His residual bladder volume was 125 ml. He has had no change in his erectile function. His postoperative IPSS was 3, and his quality of life “delighted”.

Conclusions

We present a new surgical alternative to treat an obliterated bladder neck whereby we completely reconstruct the defect with a double-faced buccal mucosal graft. Significant morbidity is avoided by the robot assisted transvesical approach, especially in regard to continence and erectile function. As technology becomes more readily available, this procedure will be easily replicated by adequately trained Urologists.