Anastomotic stricture after minimally invasive radical prostatectomy: what should be expected from the Van Velthoven single-knot running suture?

Continuous poliglecaprone suture versus bidirectional barded suture for urethrovesical anastomosis during laparoscopic radical prostatectomy: a single-institute retrospective analysis of Chinese patients

BACKGROUND

To compare the outcomes of bidirectional barbed suture and continuous poliglecaprone suture for urethrovesical anastomosis (UVA) during laparoscopic radical prostatectomy (LRP).

METHODS

Single-needle poliglecaprone suture was used for UVA in Group 1 (n=27), and double-needle bidirectional barbed suture was used for UVA (n=27) in Group 2. Age, body mass index (BMI), prostate-specific antigen (PSA) level, prostate volume, operative time, anastomosis time, estimated blood loss, Gleason score, number of hospitalization days, and urinary continence at postoperative month 1, 3, 6, and 12 were analyzed statistically.

RESULTS

There were no significant differences in age, BMI, prostate volume, PSA level, Gleason score, and indwelling catheter time between the two groups. However, bidirectional barbed suture was associated with a significantly shorter anastomosis time (P=0.007), operation time (P=0.008) and hospitalization duration (P<0.001), and a significantly lower blood loss volume (P=0.005). At the first-month follow-up, urinary continence was achieved in 5 (19%) and 15 (56%) patients in Group 1 and 2, respectively (P=0.005); postoperative third month: 11 (41%) and 23 (85%) patients in Group 1 and 2 respectively (P=0.001); postoperative sixth month: 21 (78%) and 25 (93%) patients in Group 1 and 2 respectively (P=0.250); postoperative first year: 25 (93%) and 27 (100%) patients in Group 1 and 2 respectively (P=0.471). Multivariate regression analysis showed that anastomosis time (HR =0.636; P<0.001) was an independent predictor of postoperative continence.

CONCLUSIONS

The current findings show that bidirectional barbed suture for UVA during LRP can shorten UVA time and provide better outcomes in terms of early urinary continence recovery.

The Single-Knot Running Vesicourethral Anastomosis after Minimally Invasive Prostatectomy: Review of the Technique and Its Modifications, Tips, and Pitfalls

The vesicourethral anastomosis represents a step of major difficulty at the end of minimally invasive radical prostatectomy. Over 10 years ago, we have devised the single-knot running vesicourethral anastomosis, which has been widely adopted in urologic departments worldwide. Aim of the current paper is to review the technique, its adaptability in complex situations, its complications, and possible modifications, including the use of barbed sutures.

A new technique of bladder neck reconstruction during radical prostatectomy in patients with prostate cancer

Purpose:

To evaluate continence after radical prostatectomy in prostate cancer patients, in whom a new method of the bladder neck reconstruction (BNR) using deep dorsal stitch was implemented (deep single stitch through all bladder layers directly dorsal to the bladder opening after “tennis racket” reconstruction) and to provide justification for its use by means of anatomical study in cadavers.

Material and Methods:

Open radical retropubic prostatectomy was performed in 84 patients: 39 patients with a new BNR method used to improve continence and control group of 45 patients with standard “tennis racket” BNR. Median follow-up was 14 months in control group and 12 months in study group. Continence recovery was accessed early postoperatively and every 3 months thereafter. Anatomical study was performed on 2 male fresh cadavers reproducing two different BNR techniques to clarify any underlying continence related mechanisms.

Results:

Patients with new BNR achieved full continence significantly faster (p=0.041), but the continence rates after 12 months were similar between groups. The severity of incontinence up to month 9 was significantly reduced in BNR group. The anastomotic stricture rate was not affected. Applying new BNR to the cadaver model revealed effects on early continence, namely presence of proximal passive closure mechanism in area of bladder neck.

Conclusions:

Continence in patients with the new BNR method using deep dorsal stitch recovered significantly faster. Moreover, a reduced grade of residual incontinence was documented. The effect was non-significant at month 12 of follow-up, meaning that only early effect was present.

Evaluation of the single-knot running vesicourethral anastomosis 10 years after its introduction: results from an international survey

OBJECTIVE

To evaluate the acceptance of the single-knot running vesicourethral anastomosis in a worldwide survey, 10 years after its introduction.

MATERIALS AND METHODS

A survey composed of 13 multiple-choice questions was launched on the Internet. Urologists involved in minimally invasive surgery were invited to participate. Questions explored professional characteristics of the respondents, experience with the single-knot running vesicourethral anastomosis, complications (including technical, early, and late complications), and a general opinion on the technique.

RESULTS

The 391 urologists who participated in the survey worked in academic, private, and community settings. Live surgeries appear to have been the most important tool to teach the technique. The global experience gained with this technique is vast: in the last 10 years we calculated over 120,000 anastomoses were performed by our cohort of respondents. Overall, technical, early (mainly uncomplicated early leakage), and late complications (mainly anastomotic stricture) were observed in <2% of cases by the majority of surgeons in the survey. Most urologists in the survey seem to accept the technique as a commonly used procedure in urologic surgery.

CONCLUSIONS

Today, in 2014, the single-knot running anastomosis technique appears to have been well accepted by the urologic community. However, research should continue always in order to explore and invent better surgical solutions for our patients.

Modified technique for laparoscopic running vesicourethral anastomosis

Introduction

A vesicourethral anastomosis is the most challenging and time-consuming step of radical prostatectomy. In 2003, van Velthoven introduced his own technique of connecting the bladder neck with the membranous urethra, which has remained the most popular method since. Despite being effective, this method is time consuming and is not free from the risk of complications.

Aim

Here we describe our technique for laparoscopic vesicourethral anastomosis using a running suture as an alternative to the traditional approach.

Material and methods

The vesicourethral anastomosis is created using a running stitch placed first at the 5 o'clock position on the posterolateral aspect of the bladder outside-in and then through the urethra at the same location inside-out. Proceeding anticlockwise, the running suture is placed 5 times more through both the bladder neck and the urethra in a similar fashion until it meets the free end at the 5 o'clock position. A single knot is then tied outside the bladder.

Results

The anastomotic technique has been used in 28 patients with clinically organ confined prostate cancer. The mean anastomosis time was 9.53 min, the mean operative time was 155.20 min, the mean drain permanence was 2.71 days, and the mean catheterisation time was 17.28 days. Continence rate 3 months after surgery was 92.85%, and 100% at 6- and 12-month follow-up visits.

Conclusions

We describe a safe, feasible and efficient technique for vesicourethral anastomosis. Further studies on a larger group of patients are needed to confirm our encouraging preliminary results.