Robotic-assisted combined buccal mucosal graft and advancement bladder flap for prostatic urethral obliteration

Abstract

Introduction and objectiveBladder neck contracture is an uncommon yet problematic adverse event following BPH surgery. In its most severe form, complete outlet obliteration can result. In the face of a long segment obliteration, reconstruction may involve a urethral ‘pull-through’ technique, or alternatively, excision of the intervening segment with primary urethrovesical anastomosis; this may require additional maneuvers such as partial prostatectomy. Recently, a robotic-assisted laparoscopic (RAL) subtrigonal inlay of buccal mucosal graft was described for bladder neck reconstruction in the setting of refractory contracture formation. We elaborate on this technique with the addition of an advancement bladder flap to form the anterior plate, opposing a posteriorly positioned buccal mucosal graft, for the treatment of complete prostatic urethral obliteration. MethodsA 71-year old male with a history of BPH and detrusor underactivity presented after open simple prostatectomy with urinary retention and bilateral hydronephrosis. Bladder emptying was managed with a suprapubic tube. Retrograde urethrogram (RUG)/voiding cystourethrogram (VCUG) demonstrated complete obliteration from the bladder neck through the prostatic urethra. The patient underwent a RAL reconstruction with buccal mucosal graft and advancement bladder flap without intraoperative complication. There was no perineal incision or open conversion. ResultsThe patient was discharged on postoperative day 1. His-urethral catheter was removed at 1 month, and RUG/VCUG showed no obstruction or extravasation. He voids spontaneously with large residual volumes, for which he performs nightly clean intermittent catheterization. Cystoscopy at most recent follow-up demonstrated patency and a well-healed posterior buccal graft and anterior advancement bladder flap. ConclusionsWe describe one option for repairing prostatic urethral obliteration which utilizes a posterior buccal mucosal graft inlay and an anterior advancement bladder flap. Perineal dissection and urethral transection is avoided, thus preserving urethral blood supply by not compromising the bulbar artery. Additionally, it avoids extirpative surgery with attendant risks of erectile dysfunction and urinary incontinence.