Robot-assisted reconstruction of posterior urethral stenosis: surgical techniques, graft use, and clinical outcomes

Introduction

Robotic-assisted posterior urethral reconstruction is commonly employed to address damage to the posterior urethra, which comprises the bladder neck (BN), prostatic urethra, and membranous urethra (1). Although endoscopic treatment is more frequently utilized as a first-line option for posterior urethral stenosis (PUS) it has a high failure rate (2). Robotic posterior urethroplasty provides a safe and effective surgical alternative for managing PUS (3). The leading cause of PUS is iatrogenic injury, particularly after endoscopic procedures for benign prostatic obstruction, such as transurethral resection of the prostate (TURP), prostate photovaporization, or holmium laser enucleation of the prostate. These procedures often result in BN contracture, a significant subtype of PUS, which frequently necessitates further surgical intervention. Vesicourethral anastomotic stenosis (VUAS) is a well-recognized complication following radical prostatectomy, leading to PUS due to fibrosis at the vesicourethral anastomosis. Another major cause of posterior damage is trauma, commonly associated with pelvic fracture urethral injuries (PFUI) from high-energy injuries. Such trauma can disrupt the posterior urethra, leading to scarring and narrowing that require reconstructive surgery.

The Société Internationale d’Urologie (SIU)/International Consultation on Urological Diseases (ICUD) committee recommends using anatomical terms for urethral narrowing (1). “Stricture” should refer to narrowing surrounded by corpus spongiosum, while “stenosis” applies to areas without it, such as the BN, prostatic urethra, and membranous urethra (1). PUS includes narrowing from the distal BN to the proximal bulbar urethra (1). Standardized terminology is crucial for accurate diagnosis, treatment planning, and communication. Despite the increased use of robotic approaches to posterior urethral reconstruction guidance, on graft selection and standardized techniques remain limited. This review aims to evaluate the current evidence on graft based-robotic urethral reconstruction and how it can inform patient selection, graft choice, and surgical approach. By examining graft use in robotic PUS repair, this review synthesizes current practice patterns, surgical techniques, and clinical outcomes to guide evidence-based decision-making.

A literature search was performed on 1/30/2025 on MEDLINE, PubMed, Web of Science and Embase databases. Search terms included the following: (‘urethral reconstruction’ OR ‘urethroplasty’) AND (‘posterior urethral stenosis’ OR ‘posterior urethral stricture’) AND (‘vesicourethral anastomotic stricture’) AND (‘graft’ OR ‘grafts’ OR ‘grafting’ OR ‘buccal mucosa graft’ OR ‘tissue-engineered graft’) AND (“adult*” OR “young adult”) NOT (“children” OR “child” OR “pediatric” OR “pediatric” OR “peds” OR “kid*” OR “infant*” OR “neonate*”). Inclusion criteria encompassed studies related to robotic urologic surgery and/or graft use, focusing on original research or systematic reviews, while exclusion criteria included duplicate studies, non-English language publications, lack of full-text availability, descriptions of non-urologic procedures, article commentaries or narrative reviews, and non-human studies. Articles were reviewed for relevance by the authors, who excluded articles based on the title, followed by the abstract, and finally, the full text. Reference lists of included manuscripts were screened. Each reviewer worked independently. The article selection process is depicted in Figures 1,2. This article provides a detailed review of robot-assisted posterior BN reconstruction, focusing on graft types, surgical techniques, and outcomes to optimize reconstruction and patient recovery. Study quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools, with criteria tailored to the specific study design of each included article (5). We present this article in accordance with the SUPER reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-128/rc).

Figure 1 Search criteria and characteristics.

Figure 2 PRISMA search strategy (4).

Preoperative preparations and requirements

The initial management of symptomatic PUS typically involves direct transurethral incision, resection, or office/operating room dilatation. PUS can be managed with mechanical dilation, balloon dilation with or without drug coating, direct visual internal urethrotomy (DVIU), or endoscopic urethroplasty (6-9). For patients who are not surgical candidates, suprapubic tube placement is a viable alternative (10). Surgical interventions for PUS depend on the stenosis’s length, location, and severity, as well as patient-specific anatomical and clinical factors. The posterior urethra’s deep pelvic location complicates access. Reconstruction can be performed in the operating theatre via a transperineal or transabdominal approach, depending upon surgeon’s preference, the exact location within the urethra, and the plan for grafts or flaps. For complex cases, an abdominal approach is required for vesicourethral anastomotic reconstruction (VUAR). When extensive stenosis (>2 cm) and involves the prostate, substitution urethroplasty with tissue excision and graft replacement offers a durable solution, restoring urethral strength and improving symptoms.

Step-by-step description

• Access and exposure: 4–5 ports in a fan-shaped distribution across the lower abdomen. Robot is typically docked between the legs for the best pelvic access. Place a catheter if feasible.
• Instrumentation: robotic instruments (curved scissors, needle driver, bipolar forceps) are introduced transvesically.
• Dissection: identify membranous urethra and surrounding scar tissue. The stenotic BN is dissected under combined robotic and cystoscopic guidance. Excise fibrotic urethral tissue until healthy mucosa is reached. Mobilize both proximal and distal urethral ends to ensure length.
• Graft placement: a buccal mucosal graft (BMG) is delivered into the field and sutured at the BN. A 22 Fr Foley catheter calibrates the anastomosis.
• Anastomosis: tension-free mucosa-to-mucosa anastomosis with absorbable sutures.
• Closure: check for hemostasis and watertight closure. Place a pelvic drain if needed.
• Undock robot and close ports. Remove catheter if placed for 2 weeks.

Robotic surgery

When performing transabdominal management of urethral stenosis, the use of the surgical robot provides substantial advantages. Deep pelvic access and improved visualization facilitate complex reconstruction of the posterior urethra and BN. Additionally, indocyanine green (ICG) can be administered intravenously to the patient, which allows for enhanced assessment of tissue viability at the site of the stenosis, ensuring complete excision of the diseased tissue (11). The posterior urethra can be approached transvesically or by accessing through the space of Retzius and can be performed with the single-port or the multiport-robot (3,12).

Surgical considerations

Surgical success in robotic posterior urethroplasty is contingent upon careful consideration of patient anatomy and clinical factors. Candidates with concurrent necrosis, osteonecrosis, small bladder capacity, or cancer recurrence may achieve better outcomes with alternative procedures, such as cystectomy with urinary diversion (10). For patients with poor performance status but without significant necrosis or calcification, chronic suprapubic catheterization may be the most appropriate option. When bladder preservation is not feasible, surgical alternatives include cystectomy with urinary diversion or creating a continent catheterizable stoma. In scenarios where bladder preservation is viable without outlet obliteration, BN closure, bladder augmentation, or ileovesicostomy may be appropriate.

Postoperative considerations and tasks

Posterior urethroplasty is the gold standard for managing PUS, particularly following PFUI when conservative management or endoscopic realignment has failed. Indications include significant urethral defects (>2.5 cm), failed conservative treatments, or complex strictures with extensive fibrosis or prior surgical interventions (13). Complications such as hematomas, infections, and graft rejection can occur; however, meticulous surgical technique and diligent postoperative care significantly reduce these risks. Best practices emphasize preserving the blood supply, minimizing unnecessary mobilization or transection, and maintaining the integrity of the bulbous urethra. These strategies are supported by Anderson et al., highlighting the importance of tailoring interventions to patient-specific factors to optimize outcomes (13).

Biological considerations

Graft selection is influenced by prior surgeries, stricture location/length, and donor site morbidity. Buccal mucosa is preferred for longer bulbar strictures, while lingual mucosa is beneficial for distal urethral strictures (14). Patient-specific considerations, such as oral health and potential donor site complications, are critical for optimizing outcomes (15). Common causes of graft failure include fluid accumulation, such as hematomas or seromas, infection, and shearing of the graft during or after placement (16). Grafts rely on two key processes for survival: imbibition and inosculation (16). During the first 48 hours, imbibition facilitates the exchange of nutrients and waste between the graft and the recipient bed through passive diffusion. From 48 hours to one week, inosculation occurs, where capillary in-growth from the host tissue supports graft integration (17). Reinnervation of the graft takes place over months to years, beginning at the margins and the wound bed, with success largely dependent on the presence of nerve tissue in the recipient site.

Graft types

BMGs are now the standard of care in substitution urethroplasty, especially for managing urethral stricture disease. A survey of Society of Genitourinary Reconstructive Surgeons (GURS) members revealed that 99% favored buccal mucosa as the primary graft source, citing success rates of 80–90% (18). BMGs are harvested from the inner cheek and are preferred for various types of urethral reconstructions, including dorsal and ventral onlay techniques (19). Postoperatively, patients are advised to follow a soft diet and rinse their mouths three times daily for 10 days to promote healing and reduce the risk of infection (20). The included studies evaluating BMG grafts are outlined in Table 1. This method is designed to optimize graft quality while minimizing complications at the donor site and reflects the preferred practice at many institutions.

The success of urethral reconstruction using grafts is determined by both technical and clinical criteria. From a technical standpoint, a successful procedure results in a patent and functional urethra with adequate graft integration, minimal intraoperative complications, and no significant stricture recurrence. Clinically, success is defined by the resolution of obstructive voiding symptoms, low recurrence rates, high patient satisfaction, and an acceptable length of hospital stay. Conversely, failure is characterized by stricture recurrence requiring further intervention, graft contracture or poor integration, fistula formation, persistent or recurrent symptoms, infection, functional impairment, or the need for revision surgery.

Our group was the first to utilize buccal mucosa for BN reconstruction, a significant advancement in the field. Avallone and Flynn published the first video documentation of BN reconstruction using BMG, highlighting the technique’s feasibility and success (Figure 3) (19). This pioneering work underscores the importance of emphasizing the buccal mucosa’s role in BN reconstruction, particularly for managing complications related to benign prostatic hyperplasia (BPH) treatments.

Figure 3 Performance of laparoscopic transvesical bladder neck reconstruction with buccal mucosal grafting. Exposure and access: a laparoscopic transvesical approach is used with a midline cystotomy at the space of Retzius, sparing the fascia. Stay sutures maintain exposure, and a guidewire helps identify the bladder neck. (A) Incision and resection: a Y-shaped incision is made in the fibrotic bladder, extending toward the ureteral orifices and prostatic contracture. Fibrotic tissue is resected until healthy tissue is reached, extending distally to the urethral stenosis. (B, C) Graft placement and closure: a trigonal buccal mucosal graft is harvested and introduced via the assistant port. (D) The graft is sutured to the bladder and urethral mucosa with 4-0 PDS sutures, ensuring a watertight closure . A suprapubic tube and Foley catheter are placed, and the cystotomy is closed in two layers with a running V-lock suture. PDS, polydioxanone.

Labial tissue grafts are harvested from the inner surface of the lower lip. They are a versatile option for urethral reconstruction, particularly when buccal mucosa is not available or suitable. Labial mucosa grafts have been shown to be effective (21). Complications can include donor site morbidity such as pain, swelling, and infection, but these are generally manageable (22). The American Urological Association (AUA) guidelines recognize both lingual and labial mucosa as viable options for substitution urethroplasty, with the choice of graft material often depending on the specific clinical scenario and surgeon preference (23). While labial mucosa can be an alternative, especially when buccal mucosa is unavailable or unsuitable, it is essential to consider the specific clinical scenario and the surgeon’s expertise.

These grafts are harvested from the sublingual area (Figure 4) and are considered equivalent to BMGs in terms of success rates and outcomes (15,24). LMGs may offer advantages in certain cases due to their thinner epithelium and submucosa, which can reduce the risk of urethral lumen restriction (25). The harvested LMG is then tailored to match the length and width of the urethrotomy and is sutured to the edges using fine, absorbable sutures. Postoperatively, the catheter is left in place for 2–3 weeks to facilitate healing, with monitoring for complications such as infection, graft contracture, or stricture recurrence. This technique has been validated by studies highlighting its efficacy and safety in urethral reconstruction, with success rates comparable to other graft materials and minimal donor site morbidity (26).

Figure 4 Harvest of lingual mucosa for grafting includes the following steps: 1) Marking the graft site: the lateral mucosa of the tongue, typically from the posterior part, is selected as the donor site. as demonstrated in the figure. 2) Incision and harvesting: an incision is made at the marked site, and the mucosal graft is carefully dissected, ensuring uniform thickness (4–6 cm long, 2.5 cm wide). 3) Hemostasis and closure: the donor site is closed with continuous 4-0 polyglactin sutures to control bleeding.

Tips & pearls

Graft selection

The choice of graft material should be tailored to the patient’s needs, ensuring the best possible outcomes. BMGs are preferred for anterior urethral strictures due to their robust vascular supply, ease of harvest, and high success rates (~90%). However, complications like oral numbness and swelling may occur (17). BMGs are rarely used for VUAS primarily due to the high risk of complications, recurrence, and the challenging nature of these strictures (20). However, BMG is consistently utilized in BN reconstruction for complications related to BPH treatments, demonstrating its effectiveness in this specific context despite its limited role in VUAS (22). LTGs are an alternative when buccal or lingual mucosa is unavailable or unsuitable. They are effective for anterior and posterior urethral strictures but are associated with donor-site morbidities such as pain and swelling. LMGs are suitable for distal urethral and meatal reconstructions and offer comparable success rates to BMGs but carry risks of postoperative speech difficulties and tongue protrusion. Factors influencing graft selection include prior surgeries, stricture location, length, and donor site morbidity, with buccal mucosa often preferred for longer bulbar strictures and lingual mucosa advantageous for distal urethral strictures (23). Patient-specific considerations, such as oral health and potential donor site complications, are critical for optimizing outcomes.

Single port versus multiport

Selection of the single-port versus the multiport robot depends upon robot availability, surgeon preference, and patient characteristics (3). When the multiport robot is used, ports are typically placed like those of a prostatectomy, and access is transperitoneal. Many urologists are familiar with the multiport robot, and these systems are widely available, so the multiport robot is commonly used for posterior urethral repair. The single-port robot can be advantageous if the patient is anticipated to have a hostile abdomen. In this case, transvesical access can entirely avoid the peritoneum, reducing the risk of bowel injury or other intraabdominal complications.

Anastomotic tension

Tension on a urethral repair increases the likelihood of failure (27). Although Dr. Kulkarni’s study was performed using the open transperineal approach and focused on PFUI, these principles apply to all stenotic diseases of the posterior urethra regardless of the mechanism of injury or repair approach. When the stricture or injured urethral segment is long, multiple maneuvers may be employed to achieve a tension-free repair (27). These include mobilizing the posterior urethra, inferior or posterior pubectomy, and rerouting the urethra to be subcrural (28). These maneuvers increase the likelihood that two urethral ends will reach each other in the case of excision and primary anastomosis (27). These maneuvers can be performed using the robot or via a combined transabdominal and transperineal approach. Quilting sutures are often employed to ensure the graft is evenly spread and securely attached to the underlying tissue. The graft is further secured in place over an 18 F silicone catheter, which supports the graft and maintains urethral patency during the initial healing phase (29).

Use of tissue flaps and bioengineered scaffolds

Because urethral repairs, especially when grafts are used, require both structural support and local nutrient supply, flap placement is often used to augment the repair. Several flaps have been described. One standard flap is the omentum, which can be mobilized and stitched into place using the robot (3). A gracilis muscle flap can be harvested and passed transperineally, after which it can be secured in place robotically (3). Harvesting this flap can be performed simultaneously with the repair if a second surgeon performs the harvest (3). Finally, the rectus muscle can be used as a flap, which can be harvested and placed robotically (3). Furthermore, bioengineered scaffolds can be used to support the repair (30).

Discussion

Advantages & disadvantages of the robotic-assisted approach

Novel approaches using the DaVinci Robot have improved surgical access into narrow spaces while ensuring surgeon ergonomics (31). The three-dimensional, high-definition view allows for precise dissection and suturing, which is crucial for complex procedures. Robotic systems provide a greater range of motion through articulated instruments that mimic wrist movements. This enhanced precision allows surgeons to perform challenging tasks with laparoscopic or open techniques. Robotics has revolutionized reconstructive surgery. Furthermore, the robotic approach is associated with reduced morbidity and shorter hospital stays compared to open surgery (32). These benefits have contributed to the increasing adoption of the robotic approach in posterior urethral reconstruction.

Robotic surgical systems like the Da Vinci Surgical System involve significant financial and operational investments. The initial acquisition cost of these systems exceeds $2 million, with annual maintenance expenses ranging from $100,000 to $200,000 (33). Additionally, operating these systems demands substantial technical expertise and involves a steep learning curve. Surgeons must complete specialized training programs and typically perform 20–40 cases to achieve proficiency in robotic techniques (33). The complexity of robotic-assisted procedures requires advanced skills, particularly in tasks such as suturing and graft placement. These are crucial for successful outcomes in procedures like BMG urethroplasty. The high level of required expertise can hinder the widespread adoption of robotic systems, especially in smaller or less specialized centers (32).

Advantages & disadvantages of graft use

Incorporating graft materials in reconstructive procedures complements the precision of robotic techniques. Grafts provide structural support, enable tissue augmentation, and facilitate healing in complex reconstructions. The choice of graft type, buccal, lingual, or labial, allows customization based on patient-specific needs. Nevertheless, the use of grafts is not without risks. Complications such as infection, rejection, or graft failure remain significant concerns, potentially compromising surgical outcomes (22,25).

Additionally, concerns at the harvest site include patient discomfort, decreased ability to open the mouth, and oral pain (34). The long-term durability of certain graft materials is not fully understood, highlighting the need for ongoing research in this area. Studies have demonstrated high success rates with robotic-assisted graft ureteroplasty. For instance, the use of buccal mucosa grafts in robotic ureteroplasty has shown success rates of up to 90% in managing complex ureteral strictures with minimal complications (35). These advantages make using grafts in robotic-assisted urethroplasty a valuable option for managing complex posterior ureteral strictures, offering a combination of precision, reduced morbidity, and high success rates.

Limitations

Despite the growing use of robotic-assisted posterior urethral reconstruction, several limitations should be acknowledged. This literature review focused on studies available in English in the listed databases and may not encompass all possible literature available on the topic. Articles for which we were unable to obtain a full-text manuscript were also excluded, further limiting available literature. Additionally, the study focused on posterior urethral reconstruction in adults and is thus not applicable to the pediatric population. Furthermore, the heterogeneity of available literature, including variations in methodology, sample size, and follow-up duration, makes it difficult to establish standardized conclusions regarding long-term outcomes. The lack of randomized controlled trials (RCTs) directly comparing robotic-assisted posterior urethral reconstruction to open or endoscopic approaches limits definitive conclusions on superiority in terms of functional outcomes, complication rates, and cost-effectiveness. Furthermore, long-term data on graft durability remain limited, particularly in robotic-assisted posterior urethral reconstruction. While buccal mucosa grafts are well studied, additional research is needed to assess graft integration, functional outcomes, and risk of recurrence over extended follow-up periods.

Lastly, despite the advantages of robotic platforms, the posterior urethra remains a challenging anatomical site, particularly in cases with severe fibrosis, prior radiation therapy, or complex anastomoses, where open or combined approaches may still be preferred (36). Future studies should focus on prospective, multicenter trials to compare robotic and open approaches, evaluate long-term outcomes, and refine surgical techniques. Standardized reporting of patient selection criteria and surgical outcomes will improve clinical decision-making and optimize patient care.

Future directions

Future urethral reconstruction advancements should encourage longitudinal studies to optimize patient selection and refine surgical techniques. The development of novel biomaterials for grafting holds significant promise. One such material, Alloderm™, offers the advantage of avoiding the morbidity associated with graft or flap harvesting, as it is a commercially available graft material. Notably, Alloderm™ is currently being investigated in a clinical trial for its potential use in closing buccal graft donor sites, which could further reduce postoperative morbidity (37).

Another promising approach involves using urinary bladder extracellular matrix (UB-ECM) scaffolds. Ogaya-Pinies et al. demonstrated that incorporating UB-ECM scaffolds into vesicourethral anastomosis during salvage robot-assisted radical prostatectomy significantly reduced anastomotic leak rates and catheterization times, indicating improved healing and decreased morbidity (30).

Liu et al. described using buccal mucosa grafts in single-port robotic posterior urethroplasty, incorporating ancillary maneuvers such as flap interposition (3). This technique was found to be both durable and safe, with outcomes comparable to traditional open approaches. However, the widespread applicability of robotic-assisted urethroplasty warrants critical discussion. Important barriers such as cost, steep learning curve, required surgeon expertise, and limited access to robotic platforms (particularly in resource-constrained or rural settings) may limit its broader adoption. These factors should be acknowledged and addressed when considering the global implementation of robotic techniques.

Future innovations in reconstructive urology may include improved visualization tools and advanced technologies to ensure precise graft placement. The development of synthetic alternatives represents an exciting avenue for research and application. Basic science and animal studies exploring novel graft materials, including stem cells and tissue-engineered scaffolds, could further transform the field by enhancing healing, reducing complications, and expanding options for personalized treatment strategies.

Further, longitudinal studies are crucial for optimizing patient selection, refining surgical techniques, and tracking long-term outcomes. Additionally, developing novel biomaterials for grafting and their integration into reconstructive procedures holds significant promise for advancing the field. These efforts will pave the way for more effective, durable, patient-centered solutions in reconstructive urology.

Conclusions

Addressing complex posterior BN defects, such as those resulting from trauma, fibrosis, or surgical complications, is crucial for restoring urinary function and quality of life. The use of the surgical robot increases visualization and access when a transabdominal approach is performed for these repairs. Grafts provide a safe scaffolding to promote healing and create a functional urinary channel, contributing to high success rates and improved outcomes. Posterior urethral reconstruction is a highly specialized field requiring comprehensive anatomical knowledge, advanced surgical skills, and meticulous postoperative care. Emerging techniques, including robotic-assisted surgery and tissue engineering, hold promise for further enhancing surgical precision and patient recovery. Future research should focus on standardizing protocols, optimizing management strategies, and conducting long-term studies to refine techniques and improve the quality of life for affected patients.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Jay Simhan and Samuel Ivan) for the series “A Contemporary Approach to Complex Posterior Urethral Reconstruction” published in Translational Andrology and Urology. The article has undergone external peer review.

Reporting Checklist: The authors have completed the SUPER reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-183/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2025-183/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2025-128/coif). The series “A Contemporary Approach to Complex Posterior Urethral Reconstruction” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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