Comparison of the efficacy and safety of various management approaches in post-prostatectomy strictures of vesicourethral anastomosis: a systematic review and meta-analysis

Introduction. Vesicourethral anastomotic stricture is a common and clinically significant complication of radical prostatectomy, leading to infravesical obstruction and substantial impairment of quality of life. Despite the availability of endoscopic, stenting, and reconstructive surgical options, recurrence rates remain high, and the optimal management strategy continues to be debated. A comprehensive evaluation of the effectiveness and safety of current treatment approaches is therefore warranted.

Objective. To evaluate and compare the outcomes of different treatment modalities for vesicourethral anastomotic (VUA) strictures following radical prostatectomy (PPE strictures), focusing on anastomotic patency, recurrence, stress urinary incontinence, and quality of life.

Materials & methods. A systematic review and meta-analysis was conducted in accordance with PRISMA guidelines. Medline/PubMed, Embase, and Cochrane Library were searched through January 2025 for original studies including ≥5 patients with PPE-related VUA strictures treated with endoscopic, stenting, or open reconstructive approaches. Primary outcomes included effectiveness (patency), recurrence rates, complications, incontinence, and need for reintervention. Two reviewers independently screened studies, extracted data, and assessed risk of bias (ROBINS-I). The quality of evidence was rated using GRADE.

Results. A total of 24 studies (n = 745 patients) were included, primarily retrospective case series. Endoscopic approaches yielded an initial success rate of 55% (95% CI 40 – 70%), increasing to 91% with repeat procedures. Recurrence rates reached 40% within 1 – 2 years. De novo stress incontinence was rare (≤ 5%). Temporary urethral stents (Memokath®️, Allium®️) showed patency rates up to 93%, with migration in 7% and incontinence in ≤ 10% of patients. Open reconstructive techniques, including buccal mucosa grafts, achieved success rates of 73 – 85%, but were associated with new-onset incontinence in 40 – 75% of cases. Radiation history significantly reduced treatment success (OR 0.20; 95% CI 0.05 – 0.80).

Conclusion. Endoscopic procedures are optimal as first-line treatment due to minimal invasiveness and preservation of continence but have high recurrence risk. Temporary stents are a viable intermediate option after failed endoscopy. Open reconstruction provides the most definitive outcomes in complex cases but is burdened by a high incontinence risk. Treatment decisions should be individualized, considering prior radiation, stricture severity, and continence preservation.

1. Delchet O, Nourredine M, González Serrano A, Morel-Journel N, Carnicelli D, Ruffion A, Neuville P. Post-prostatectomy anastomotic stenosis: systematic review and meta-analysis of endoscopic treatment. BJU Int. 2024;133(3):237-245. DOI: 10.1111/bju.16141

2. Herschorn S, Elliott S, Coburn M, Wessells H, Zinman L. SIU/ICUD Consultation on Urethral Strictures: Posterior urethral stenosis after treatment of prostate cancer. Urology. 2014;83(3 Suppl):S59-70. DOI: 10.1016/j.urology.2013.08.036

3. Rosenbaum CM, Fisch M, Vetterlein MW. Contemporary Management of Vesico-Urethral Anastomotic Stenosis After Radical Prostatectomy. Front Surg. 2020;7:587271. DOI: 10.3389/fsurg.2020.587271

4. Campos-Juanatey F, Portillo Martín JA. Manejo de la estenosis de la anastomosis posprostatectomía radical [Management of vesicourethral anastomotic stenosis after radical prostatectomy]. Rev Int Androl. 2019;17(3):110-118. (In Spanish). DOI: 10.1016/j.androl.2018.05.003

5. LaBossiere JR, Cheung D, Rourke K. Endoscopic Treatment of Vesicourethral Stenosis after Radical Prostatectomy: Outcomes and Predictors of Success. J Urol. 2016;195(5):1495-1500. DOI: 10.1016/j.juro.2015.12.073

6. Hacker EC, Maganty A, Pere MM, Rusilko PJ. Outcomes of Vesicourethral Anastomotic Stenosis and Bladder Neck Contracture With Direct Visual Internal Urethrotomy With Mitomycin-C After Prostate Cancer Treatment. Urology. 2022;165:331-335. DOI: 10.1016/j.urology.2022.01.041

7. Nathan A, Mazzon G, Pavan N, De Groote R, Sridhar A, Nathan S. Management of intractable bladder neck strictures following radical prostatectomy using the Memokath®045 stent. J Robot Surg. 2020;14(4):621-625. DOI: 10.1007/s11701-019-01035-9

8. Cubuk A, Weinberger S, Moldovan ED, Schaeff V, Neymeyer J. Use of the Allium Round Posterior Stent for the Treatment of Recurrent Vesicourethral Anastomosis Stricture. Urology. 2023;179:118-125. DOI: 10.1016/j.urology.2023.06.024

9. Giudice CR, D’Alessandro FJ, Galarza GA, Fernández DS, Damia OH, Favre GA. Surgical approach to vesicourethral anastomotic stricture following radical prostatectomy. Actas Urol Esp. 2016;40(2):124-130. (In English, Spanish). DOI: 10.1016/j.acuro.2015.08.006

10. Kuyumcuoglu U, Eryildirim B, Tarhan F, Faydaci G, Ozgül A, Erbay E. Antegrade endourethroplasty with free skin graft for recurrent vesicourethral anastomotic strictures after radical prostatectomy. J Endourol. 2010;24(1):63-67. DOI: 10.1089/end.2009.0076

11. Şimşek A, Danacıoğlu YO, Arıkan Y, Özdemir O, Yenice MG, Atar FA, Taşçı Aİ. Perineoscopic vesicourethral reconstruction: A novel surgical technique for anastomotic stricture following radical prostatectomy. Turk J Urol. 2021;47(1):51-57. DOI: 10.5152/tud.2020.20372

12. Sterling J, Simhan J, Flynn BJ, Rusilko P, França WA, Ramirez EA, Angulo JC, Martins FE, Patel HV, Higgins M, Swerdloff D, Nikolavsky D. Multi-Institutional Outcomes of Dorsal Onlay Buccal Mucosal Graft Urethroplasty in Patients With Postprostatectomy, Postradiation Anastomotic Stenosis. J Urol. 2024;211(4):596-604. DOI: 10.1097/JU.0000000000003848

13. Giúdice CR, Lodi PE, Olivares AM, Tobia IP, Favre GA. Safety and effectiveness evaluation of open reanastomosis for obliterative or recalcitrant anastomotic stricture after radical retropubic prostatectomy. Int Braz J Urol. 2019;45(2):253-261. DOI: 10.1590/S1677-5538.IBJU.2017.0681

14. Rozanski AT, Zhang LT, Holst DD, Copacino SA, Vanni AJ, Buckley JC. The Effect of Radiation Therapy on the Efficacy of Internal Urethrotomy With Intralesional Mitomycin C for Recurrent Vesicourethral Anastomotic Stenoses and Bladder Neck Contractures: A Multi-Institutional Experience. Urology. 2021;147:294-298. DOI: 10.1016/j.urology.2020.09.035

15. Erickson BA, McAninch JW, Eisenberg ML, Washington SL, Breyer BN. Management for prostate cancer treatment related posterior urethral and bladder neck stenosis with stents. J Urol. 2011;185(1):198-203. DOI: 10.1016/j.juro.2010.09.020

16. Vitarelli A, Minafra P, Vulpi M, Piana A, Torre G, Carbonara U, Divenuto L, Papapicco G, Chiaradia F, Alba S, Lucarelli G, Battaglia M, Ditonno P. A new approach to repair recurrent vescicourethral anastomotic strictures after radical prostatectomy: The use of prerectal access. Urologia. 2025;92(2):335-341. DOI: 10.1177/03915603241300877

17. Leddy L, Myers J, Broghammer J, Alsikafi N, Erickson B, Elliot S, Elliot S, Wessells H, McClung C, Brant W, Smith T, Voelzke B. Multi-center evaluation of anastomotic urethroplasty after radiotherapy for prostate cancer. J Urol. 2014;191(4S). DOI: 10.1016/j.juro.2014.02.189

18. Simonato A, Ennas M, Benelli A, Gregori A, Oneto F, Daglio E, Traverso P, Carmignani G. Comparison between Two Different Two-Stage Transperineal Approaches to Treat Urethral Strictures or Bladder Neck Contracture Associated with Severe Urinary Incontinence that Occurred after Pelvic Surgery: Report of Our Experience. Adv Urol. 2012;2012:481943. DOI: 10.1155/2012/481943

19. Selvi I, Arik AI, Basay MS, Basar H. The effect of proliferative hypertrophic scars on determining treatment options for preventing recurrence of vesicourethral anastomotic stenosis after radical prostatectomy: a single-center cross-sectional study. Sao Paulo Med J. 2021;139(3):241-250. DOI: 10.1590/1516-3180.2020.0349.R1.28012021

20. Zhang CY, Zhu Y, Li K, Ian L, Ho S, Pun W, Lao H, Carvalho V, Liu DY, Shen ZJ. Outcome of nephrostomy balloon dilation for vesicourethral anastomotic strictures following radical prostatectomy: a retrospective study. Asian J Androl. 2014;16(1):115-119. DOI: 10.4103/1008-682X.122348

21. Kumar P, Nargund VH. Management of post-radical prostatectomy anastomotic stricture by endoscopic transurethral balloon dilatation. Scand J Urol Nephrol. 2007;41(4):314-315. DOI: 10.1080/00365590601017030

22. Lagerveld BW, Laguna MP, Debruyne FM, De La Rosette JJ. Holmium:YAG laser for treatment of strictures of vesicourethral anastomosis after radical prostatectomy. J Endourol. 2005;19(4):497-501. DOI: 10.1089/end.2005.19.497

23. Öztürk H. Treatment of recurrent vesicourethral anastomotic stricture after radical prostatectomy using plasma-button vaporization. Scand J Urol. 2015;49(5):371-376. DOI: 10.3109/21681805.2015.1012115

24. Sourial MW, Richard PO, Bettez M, Jundi M, Tu LM. Mitomycin-C and urethral dilatation: A safe, effective, and minimally invasive procedure for recurrent vesicourethral anastomotic stenoses. Urol Oncol. 2017;35(12):672.e15-672.e19. DOI: 10.1016/j.urolonc.2017.07.031

25. Doublet JD, Barreto H, Gattegno B, Thibault P. Sténoses uréthro-vésicales après prostatectomie radicale [Urethro-vesical stenosis after radical prostatectomy]. Prog Urol. 1994;4(3):357-361. (In French). PMID: 8044178

26. Popken G, Sommerkamp H, Schultze-Seemann W, Wetterauer U, Katzenwadel A. Anastomotic stricture after radical prostatectomy. Incidence, findings and treatment. Eur Urol. 1998;33(4):382-386. DOI: 10.1159/000019620

27. Ramchandani P, Banner MP, Berlin JW, Dannenbaum MS, Wein AJ. Vesicourethral anastomotic strictures after radical prostatectomy: efficacy of transurethral balloon dilation. Radiology. 1994;193(2):345-349. DOI: 10.1148/radiology.193.2.7972741

28. Ishii G, Naruoka T, Kasai K, Hata K, Omono H, Suzuki M, Kimura T, Egawa S. High pressure balloon dilation for vesicourethral anastomotic strictures after radical prostatectomy. BMC Urol. 2015;15:62. DOI: 10.1186/s12894-015-0059-9

29. Artemov A.V., Alyaev Yu.G., Rapoport L.M., Tsarichenko D.G. Mitomycin in comprehensive treatment of vesicourethral anastomotic strictures after radical prostatectomy. Urologiya. 2014;(5):77-81. (In Russian)/ eLIBRARY ID: 22809350 EDN: TFDOKX

30. Beck V, Apfelbeck M, Chaloupka M, Kretschmer A, Strittmatter F, Tritschler S. Die Striktur der vesikourethralen Anastomose nach radikaler Prostatektomie [Stricture of the vesicourethral anastomosis after radical prostatectomy]. Urologe A. 2018;57(1):29-33. (In German). DOI: 10.1007/s00120-017-0550-x

31. Anger JT, Raj GV, Delvecchio FC, Webster GD. Anastomotic contracture and incontinence after radical prostatectomy: a graded approach to management. J Urol. 2005;173(4):1143-1146. DOI: 10.1097/01.ju.0000155624.48337.a5

32. Mundy AR, Andrich DE. Posterior urethral complications of the treatment of prostate cancer. BJU Int. 2012;110(3):304-325. DOI: 10.1111/j.1464-410X.2011.10864.x

33. Teke K, Bosnali E, Kara O, Ustuner M, Avci IE, Culha MM. Minimal invasive management of bladder neck contracture using Allium round posterior stent: the long-term results. Prostate Int. 2021;9(4):203-207. DOI: 10.1016/j.prnil.2021.05.004

34. Bayne DB, Gaither TW, Awad MA, Murphy GP, Osterberg EC, Breyer BN. Guidelines of guidelines: a review of urethral stricture evaluation, management, and follow-up. Transl Androl Urol. 2017;6(2):288-294. DOI: 10.21037/tau.2017.03.55

35. Lumen N, Campos-Juanatey F, Greenwell T, Martins FE, Osman NI, Riechardt S, Waterloos M, Barratt R, Chan G, Esperto F, Ploumidis A, Verla W, Dimitropoulos K. European Association of Urology Guidelines on Urethral Stricture Disease (Part 1): Management of Male Urethral Stricture Disease. Eur Urol. 2021;80(2):190-200. DOI: 10.1016/j.eururo.2021.05.022

36. Veeratterapillay R, Morton H, Thorpe AC, Harding C. Reconstructing the lower urinary tract: The Mitrofanoff principle. Indian J Urol. 2013;29(4):316-321. DOI: 10.4103/0970-1591.120113

37. Spahn M, Kocot A, Loeser A, Kneitz B, Riedmiller H. Last resort in devastated bladder outlet: bladder neck closure and continent vesicostomy-long-term results and comparison of different techniques. Urology. 2010;75(5):1185-1192. DOI: 10.1016/j.urology.2009.11.070