Comparative Outcomes and Management of Vesicourethral Anastomotic Stenosis After Contemporary Standard and Pelvic-Fascia—Sparing Robotic-Assisted Radical Prostatectomy Techniques

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Abstract
Purpose: Vesicourethral anastomotic stenosis (VUAS) occurs after 1 to 3% of robotic-assisted radical prostatectomies (RARPs). Pelvic fascia–sparing techniques preserve more native anatomy and may reduce stenoses, but evidence is lacking. The aim of this study was to compare stenosis incidence, management, and outcomes after standard vs pelvic fascia–sparing RARP. Materials and Methods: We conducted a multi-institutional retrospective study of 910 standard, 409 Retzius-sparing, and 272 hood RARP during February 2012-September 2025. Standard and hood techniques used 18Fr urethral catheters, and the Retzius-sparing technique used 18Fr suprapubic catheters. The primary end point was cystoscopically confirmed VUAS requiring intervention within 12 months. Urinary continence was assessed using the validated Expanded Prostate Cancer Index Composite for Clinical Practice (EPIC-CP). Multivariable logistic regression assessed factors associated with VUAS. Results: There were 19 VUASs overall, with an incidence of 1.6%, 1.5%, and 0% after standard, hood, and Retzius-sparing techniques, respectively. In 88.2%, VUAS resolved with a single endoscopic incision or dilation followed by 6 months of intermittent self-catheterization, without worsening urinary continence ( P = .317). In adjusted analyses, Retzius-sparing vs standard RARP was associated with lower odds of VUAS (odds ratio [OR] 0.051; 95% confidence interval [CI] 0.003 to 0.870; P = .040). Diabetes was associated with almost three-fold higher odds of VUAS (OR 2.974; 95% CI 1.146-7.721; P = .025). Increasing surgeon experience was associated with fewer VUASs (OR 0.998; 95% CI 0.995-1.000; P = .046). Conclusions: There were no VUAS after Retzius-sparing RARP, and Retzius-sparing vs standard approach was associated with lower odds of stenosis. Endoscopic management with structured self-catheterization achieved high success without worsening incontinence. Prospective studies are needed to validate our findings.

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