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.