Ileal Free Flap Urethroplasty May Remedy Devastated Bladder Outlet

A new type of robotic posterior surgery has been shown to be a treatment option for patients with devastated bladder outlets.

A recent presentation from the 2025 American Urological Association (AUA) Annual Meeting highlighted the use of ileal free flap urethroplasty as a surgical option for devastated bladder outlets among patients who have already been treated with radiation.

Lee C. Zhao, MD, an author on this study, spoke with CancerNetwork® regarding this new procedure, which, to date of research publication, has only been completed in 3 patients. A single-port robot was used to intraabdominally dissect the bladder neck and remove any necrotic issue or infected bone. Additionally, for flap vascularization, the inferior epigastric vessels (IEV) were harvested, and the bulbar urethra was mobilized to allow for distal anastomosis.

During the procedure, a 20 cm ileal segment was harvested, allowing for mesenteric vessels to be dissected while facilitating microsurgical anastomosis to the IEV. Indocyanine green confirmed perfusion of the flap. Next, 8 cm of the ileal was configured into a Monti tube, and the proximal end was anastomosed to the bladder neck robotically, with the distal end attached to the urethra perennially. The remaining 12 cm of the segment was used as a stoma between the bladder dome and the skin.

Furthermore, the procedure, which took between 9.5 and 13.0 hours, incurred hospital stays of 6 to 10 days. Zhao highlighted that this surgery provides a first-of-its-kind treatment option for this condition.

During the procedure and follow-up, there were no intraoperative complications, and all flaps survived with no instances of flap loss. After 2 weeks, foley catheters were removed, and 1 patient had leakage, which required catheterization for an additional 4 weeks.

Zhao is a professor in the Department of Urology and professor of the Hansjorg Wyss Department of Plastic Surgery at NYU Grossman School of Medicine; Unit Surgical Director at Tisch Hospital; director of Male Reconstructive Surgery at NYU Health System; and co-director of the Transgender Reconstructive Surgery Program at NYU Health.

CancerNetwork: What is ileal free flap urethroplasty?

Zhao: Let’s break it down by each word. The ileal refers to the ileum, the portion of the small intestine that is closest to the large intestine. Free flap means a piece of tissue that is disconnected from its blood supply and reconnected at a distant site. Then, urethroplasty is a type of plastic surgery that repairs the tube that connects the bladder to the outside that allows the urine to pass through. This reconstruction of the urethra uses a fragment of the ileum that is brought away from its original blood supply and connected to another site.

What patients are ideal to be selected for this surgery vs other reconstructive options?

These are typically patients who’ve had radiation therapy to the pelvis and other organs. These patients had cancer, and then they received radiation. The radiation serves treat the original cancer, but the way the radiation works is that it destroys the small blood vessels that go to the patient’s organs. For example, the prostate is an apricot-sized structure that lies on the underside of the bladder, and the urethra goes through it. Typically, prostate cancer is a disease that affects 1 in 6 men. There’s a lot of patients like this, and more than half the patients undergo radiation as a component of their treatment. When you administer radiation to the prostate, you need to cure the cancer, but the pathways of blood flow, which is how the radiation works, can cause significant injury to the urethra, which flows through the prostate. For those patients, radiation causes so much damage that the urine leaks through the urethra at the level of the pubic bone, sits above the prostate. Those are the patients who warrant this operation.

What were the overall findings of this study?

This is a new operation that has now been described to solve the problems that have not been solved. Because of the location of the transfer and the difficulties of structures that have been radiated, there was no option for these patients prior to developing this technique. Yes, it's a smaller study; that’s because it’s a completely new technique.

What are the potential long-term complications associated with this specific reconstructive technique?

The major long-term complications is that while the urethra is restored using this technique, the patients will need another procedure to fix their incontinence. The patients are usually incontinent prior to this surgery anyway, because of radiation therapy. That’s the one thing that we saw: the need for further operations for these patients.

How does this technique compare with other established methods for managing devastated bladder outlets among irradiated patients in terms of complexity, operative time, hospital stay, and functional outcomes?

There is no other technique that fixes this issue. The alternative is to either live with the urine leaking into the bone, which is debilitating, or have complete removal of the bladder. There is no other established technique.

What are the next steps for this research?

We’ve done this operation on 3 more patients since submitting the study for publication. We have more patients scheduled. This is the beginning of solving a problem that's very challenging. I’m a reconstructive urologist; I fix problems like this. What’s next is that we have finally found a solution to this problem and we plan to do many more of these cases.

Reference

Ratanapornsompong W, Sarawong S, Levine JP, Elbakry A, Zhao LC. Robotic posterior urethroplasty with tubularized ileal free flap interposition for management of devastated bladder outlet: a novel reconstructive approach. Presented at the 2025 American Urological Association Annual Meeting; Las Vegas, NV; April 26-29, 2025.