Does the Laparoscopic Approach Reduce the Incidence of Vesicourethral Anastomotic Stricture Compared with the Open Approach After Radical Prostatectomy in Patients with Microangiopathic Risk Factors?

<i>Background</i>: Vesicourethral anastomotic stricture (VUAS) remains a clinically relevant complication following radical prostatectomy, with important implications for postoperative urinary function. Minimally invasive approaches may offer technical advantages; however, their impact on stricture formation in patients with microangiopathic risk factors remains incompletely defined. <i>Objective</i>: We aimed to compare the incidence of vesicourethral anastomotic stricture following open radical prostatectomy (ORP) and laparoscopic radical prostatectomy (LRP) in patients with microangiopathic comorbidities and to explore clinical and perioperative factors associated with stricture development. <i>Materials and Methods</i>: A retrospective two-centre cohort study was conducted including 115 patients who underwent radical prostatectomy for clinically localized prostate cancer between 2022 and 2024. All patients had at least one microangiopathic risk factor (diabetes mellitus, hypertension, or coronary artery disease). Seventy-two patients underwent ORP and forty-three underwent LRP. VUAS was defined by obstructive symptoms with endoscopic confirmation requiring intervention within 12 months postoperatively. Univariate analyses and exploratory logistic regression models were performed to assess factors associated with stricture formation. <i>Results</i>: Vesicourethral anastomotic stricture occurred in 21 patients (18.3%). The crude incidence of VUAS was lower after LRP compared with ORP (9.3% vs. 23.6%); however, this difference did not reach statistical significance. Patients who developed VUAS had a significantly higher body mass index, longer operative time, and greater intraoperative blood loss. In exploratory multivariable analyses, body mass index and operative duration were consistently associated with increased odds of stricture, whereas the effect of surgical approach was unstable and imprecise due to limited event numbers. <i>Conclusions</i>: In patients with microangiopathic risk factors, laparoscopic radical prostatectomy was associated with a lower crude incidence of vesicourethral anastomotic stricture compared with open surgery; however, this association was not robust after adjustment. Perioperative and technical factors appear to play a more prominent role in anastomotic healing than surgical approach alone. These findings highlight the importance of optimizing intraoperative conditions to reduce postoperative stricture risk.