A review of management options for vesicourethral anastomotic stenosis and the emergence of robotic reconstruction.

Vesicourethral anastomotic stenosis (VUAS), a sequela of radical prostatectomy, is among the most complex conditions managed by reconstructive urologists. As a distinct entity from bladder neck contracture, VUAS can be managed endoscopically or with reconstruction. There is a paucity of higher-level evidence and head-to-head comparisons between VUAS management options. Interpretation of existing studies is further complicated by variations in diagnostic staging of VUAS, definitions of recurrent VUAS, and criteria for post-procedural success. Multiple endoscopic approaches are available including dilation, transurethral incision, transurethral resection, intralesional injections, and endoscopic urethroplasty. Classically, reconstruction for VUAS is offered after a single failed attempt at endoscopic management. Reconstructive options include transperineal reconstruction, open abdominopelvic reconstruction, and robotic-assisted surgical techniques. In recent years, several advances in reconstruction have developed into minimally invasive techniques using multi- and single-port robotics. Early outcomes of robotic reconstructive surgery demonstrate excellent rates of treatment success and, compared to open approaches, notably lower rates of de novo urinary incontinence. Both endoscopic and surgical treatment of VUAS present significant risks of morbidity including the potential need for urinary diversion, therefore appropriate patient counseling and shared decision-making are critical prior to urologic intervention.