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Laparoscopic Running Urethrovesical Anastomosis with Posterior Fixation
Surgical Techniques in Urology Laparoscopic Running Urethrovesical Anastomosis with Posterior Fixation Anibal Wood Branco, William Kondo, Affonso Henrique Leão Alves de Camargo, Alcides José Branco Filho, Marco Aurélio de George, and Luciano Carneiro Stunitz INTRODUCTION
Laparoscopic radical prostatectomy is a minimally invasive approach for the treatment of localized prostate cancer. The most technically demanding and time-consuming part of this procedure is the urethrovesical anastomosis. Here we describe our technique for the urethrovesical anastomosis with a posterior fixation, using a running suture with two monofilament absorbable sutures.
TECHNICAL CONSIDERATIONS The first step comprises two X-shaped stitches placed in the posterior wall of the anastomosis (at 7 and 5 o’clock). Each suture is independently tied, leaving the knot (and consequently the needle) on the outside. The 7 and 5 o’clock sutures are then used to perform a clockwise (left wall) and a counterclockwise (right wall) running suture, respectively, and will meet at the 12 o’clock position for the third and final knot. An abdominal Penrose drain is routinely used for monitoring possible anastomotic leakages and is withdrawn when the 24-hour output is less than 100 mL. The patient is discharged as soon as the drain is removed. We performed this technique in 12 consecutive transperitoneal laparoscopic radical prostatectomies, with a mean anastomosis time of 37 minutes, mean operative time of 144 minutes, and mean hospital stay of 2.4 days. The average Foley catheter permanence was 9 days, and no bladder neck sclerosis/stricture was observed with a minimum follow-up of 12 months. CONCLUSIONS The described technique is a feasible and safe method for urethrovesical anastomosis. Although we had positive results in this initial cohort, further studies with larger series are needed to confirm these findings. UROLOGY 70: 799 – 802, 2007. © 2007 Elsevier Inc.
L
aparoscopic radical prostatectomy (LRP) is routinely performed for localized prostate cancer.1–5 The urethrovesical anastomosis is definitely the most technically demanding part of the procedure and requires an experienced surgeon with advanced laparoscopic skills.1– 4 This step of the surgery can be performed with either interrupted or running sutures. Many investigators consider the latter somehow easier and faster.1,2,4,5 Here we describe our technique of urethrovesical anastomosis with posterior fixation.
SURGICAL TECHNIQUE The procedure of choice in our department is the transperitoneal LRP. Immediately after the prostate is extirpated and hemostasis is performed, the bladder neck and urethral stump are properly exposed for the anastomosis. We use 3.0 polydioxanone (PDS) suture, an absorbable monofilament synthetic suture on a 27” taper point nee-
From the Department of Urology and General Surgery, Curitiba, Paraná, Brazil Reprint requests: William Kondo, M.D., Cruz Vermelha Hospital, General Surgery, R. Vicente Machado, 1310, Curitiba, Parana 80240041, Brazil. E-mail: [email protected] Submitted: September 23, 2006, accepted (with revisions): June 21, 2007
© 2007 Elsevier Inc. All Rights Reserved
dle, because of its low friction characteristics. The needle is small enough to make the rotation in even the narrowest pelvis ring, and the PDS suture is strong enough to bring the urethral stump and the bladder neck together. The technique is initiated by placing two X-shaped sutures at 5 and 7 o’clock, which establish a safe posterior wall for the anastomosis (Figs. 1 and 2). These sutures are independently tied, leaving the knots on the outside, and at this point we are left with the posterior fixation (two knots) and two needles, which will be used to complete the lateral and anterior portions of the anastomosis. We proceed with a counterclockwise running suture in the right lateral wall of the anastomosis using the 5 o’clock stitch needle (Fig. 3). The needle is always driven full-thickness outside-in in the bladder neck and inside-out on the urethra. This suture advances through the 12 o’clock position, with the needle coming out of the urethral stump. The 7 o’clock stitch needle is used to perform a clockwise running suture in the left lateral wall to the 12 o’clock position, completing the full circumference. This needle comes inside-out of the urethra, approximately 0.5 cm apart from the 5 o’clock needle for further tying (third knot). To avoid a loose anastomosis, gentle traction is applied on each suture; the system of loops acts as a “winch” to 0090-4295/07/$32.00 doi:10.1016/j.urology.2007.06.1095
799
Figure 1. Placing the 5 o’clock position stitch. Figure 3. Counterclockwise running suture using the 5 o’clock position stitch needle until the 12 o’clock position.
Figure 2. Placing the 7 o’clock position stitch.
bring the bladder in contact with the urethra without excessive tension, as described by Van Velthoven et al.2 At this point the assistant advances the 20F Foley catheter into the bladder, and the two sutures meeting at 12 o’clock are finally tied with the knot left on the outside of the urethral wall (Fig. 4). This establishes the third fixation point of the anastomosis. After completing the urethrovesical anastomosis, any remaining opening in the bladder neck can be closed with interrupted 3.0 PDS sutures. The Foley catheter balloon is then inflated with 20 mL of distilled water. To test the integrity of the urinary reconstruction, the bladder is filled with 200 mL of saline. We avoid traction 800
Figure 4. Both sutures tied outside of the urethral stump at the 12 o’clock position.
on the catheter balloon against the anastomosis because it can lead to a false-negative result for leakage. Any saline extravasation identified during this maneuver is controlled with additional stitches. We routinely use an abdominal drain (an 8F nasogastric catheter inside a Penrose drain), which is inserted through the right lateral 5-mm port and left in the pelvis by the anastomosis. A sterile colostomy bag is placed around the drain to quantify its output. The patient is discharged as soon as UROLOGY 70 (4), 2007
the abdominal drain can be safely removed. We use the criteria of less than 100 mL output in a 24-hour period to guide this withdrawal. The bladder catheter is withdrawn between postoperative days 7 and 10 if no significant urinary leakage is observed during hospital stay. We do not indicate routine postoperative cystography and perform it only in cases involving persistent urinary leaks.
RESULTS Between October and December 2005, we prospectively evaluated 12 consecutive patients who underwent LRP with the posterior fixation urethrovesical anastomosis. The average anastomosis time was 37.3 minutes (range 29 to 50 minutes), and the mean operative time was 144 minutes (range 110 to 155 minutes). During the leakage test, 11 patients (91.7%) presented no leakage after the saline instillation. In 1 case (8.3%), a significant leakage was observed in the anterior wall of the anastomosis and was promptly corrected. The mean hospital stay was 2.4 days (range 1 to 3 days), and mean catheterization time was 9.1 days (range 7 to 10 days). The only complication observed in our series was a mild hematuria after Foley catheter withdrawal, which required recatheterization. There was no postoperative persistent urinary leak or anastomotic stricture with a minimum follow-up of 12 months (range 12 to 14 months). Regarding postoperative continence, three patients (25%) were using one pad per day after 1 month. Follow-up revealed that only 1 of these 3 patients (8%) needed the pad after a period of 6 months.
COMMENTS It is well known that the urethrovesical anastomosis is the most challenging step of LRP and is the main barrier to a wider application of the procedure. In an attempt to substantially reduce the operative time, running suture techniques for this urinary reconstruction have been developed and recommended in several reports.1,2,4 In 2003, van Velthoven et al.2 described a running suture technique that required a single intracorporeal knot. This method was proved feasible and presented with low rates of urinary leakage and bladder neck stricture. Other investigators have also reported their experience with running suture for the urethrovesical anastomosis with good results in terms of safety and operative time.1 In our technique we are able to establish safe fixation in the posterior wall of the anastomosis, which is the most frequent site of urinary fistulas. In addition, this posterior fixation clearly exposes both the urethral stump and the bladder neck edges and significantly facilitates suturing. This exposure makes unnecessary the use of metallic urethral dilators to guide the needle tip inside-out the urethral wall. UROLOGY 70 (4), 2007
Another advantage inherent to the present technique is the fact that each of the two sutures is used to complete half of the anastomosis circumference. Therefore, if one of the sutures breaks, at least part of the anastomosis can survive and possibly heal well. Although many institutions perform a routine postoperative cystography to assess the integrity of the vesicourethral anastomosis before bladder catheter withdrawal,1,5–7 we do not find that mandatory. In 1995, Leibovitch et al.8 observed that significant extravasation is a common finding between postoperative days 5 to 8 and that this leakage, when present, did not affect outcome after catheter removal. Santis et al.9 removed catheters on postoperative days 8 or 9 of retropubic radical prostatectomies without radiographic studies in 100 patients. Two and nine patients developed urinary retention and bladder neck stricture, respectively. Anastomotic disruption, urinary tract infection, and pelvic abscess were not observed in this series. An abdominal drain was placed in the anastomosis site in all of the 12 patients who underwent the posterior fixation method. The increased familiarity with the technique, coupled with the fact that none of the initial patients developed persistent leaks, encouraged our department to recently select favorable cases in which no abdominal drain was left. These cases were not included here due to the short postoperative follow-up (less than 6 months). In a recent study, Araki et al.10 reported 419 of 552 patients (76%) undergoing radical retropubic prostatectomy without abdominal drainage. There were 27 (5%) immediate postoperative complications and no significant difference between the groups with and without drain: 3 patients (1%) without drain developed urinomas, 1 (1%) who was drained developed a lymphocele, and a small pelvic hematoma was found in 2 patients (2%) with drainage. The investigators consider abdominal drainage an absolute indication in cases of (1) anastomotic leakage after saline irrigation, (2) unsatisfactory hemostasis, and (3) injury to adjacent organs. We would also include cases of complex bladder neck reconstruction as an absolute indication.
CONCLUSIONS We consider the posterior fixation technique to be a safe and feasible approach for the urethrovesical anastomosis in LRP. Nevertheless, because of the small number of patients who underwent this technique, further evaluation and larger series are needed to confirm these encouraging initial results. References 1. Shichiri Y, Kanno T, Oida T, et al: Facilitating the technique of laparoscopic running urethrovesical anastomosis using Lapra-ty absorbable suture clips. Int J Urol 13: 192–194, 2006. 2. Van Velthoven RF, Ahlering TE, Peltier A, et al: Technique for laparoscopic running urethrovesical anastomosis: the single knot method. Urology 61: 699 –702, 2003.
801
3. Rozet F, Fournier G, Cathelineau X, et al: Vesico-urethral anastomosis during total laparoscopic prostatectomy. Ann Urol (Paris) 40: 50 –56, 2006. 4. Katz R, Nadu A, Olsson LE, et al: A simplified 5-step model for training laparoscopic urethrovesical anastomosis. J Urol 169: 2041–2044, 2003. 5. Menon M, Tewari A, Peabody JO, et al: Vattikuti Institute prostatectomy, a technique of robotic radical prostatectomy for management of localized carcinoma of the prostate: experience of over 1100 cases. Urol Clin North Am 31: 701–717, 2004. 6. Rassweiler J, Sentker L, Seemann O, et al: Laparoscopic radical prostatectomy with the Heilbronn technique: an analysis of the first 180 cases. J Urol 166: 2101–2108, 2001.
802
7. Nadu A, Salomon L, Hoznek A, et al: Early removal of the catheter after laparoscopic radical prostatectomy. J Urol 166: 1662–1664, 2001. 8. Leibovitch I, Rowland RG, Little JS Jr, et al: Cystography after radical retropubic prostatectomy: clinical implications of abnormal findings. Urology 46: 78 – 80, 1995. 9. Santis WF, Hoffman MA, Dewolf WC. Early catheter removal in 100 consecutive patients undergoing radical retropubic prostatectomy. BJU Int 85: 1067–1068, 2000. 10. Araki M, Manoharan M, Vyas S, et al: A pelvic drain can often be avoided after radical retropubic prostatectomy—an update in 552 cases. Eur Urol 50: 1241–1247, 2006.
UROLOGY 70 (4), 2007
Laparoscopic radical prostatectomy is a minimally invasive approach for the treatment of localized prostate cancer. The most technically demanding and time-consuming part of this procedure is the urethrovesical anastomosis. Here we describe our technique for the urethrovesical anastomosis with a posterior fixation, using a running suture with two monofilament absorbable sutures.
TECHNICAL CONSIDERATIONS The first step comprises two X-shaped stitches placed in the posterior wall of the anastomosis (at 7 and 5 o’clock). Each suture is independently tied, leaving the knot (and consequently the needle) on the outside. The 7 and 5 o’clock sutures are then used to perform a clockwise (left wall) and a counterclockwise (right wall) running suture, respectively, and will meet at the 12 o’clock position for the third and final knot. An abdominal Penrose drain is routinely used for monitoring possible anastomotic leakages and is withdrawn when the 24-hour output is less than 100 mL. The patient is discharged as soon as the drain is removed. We performed this technique in 12 consecutive transperitoneal laparoscopic radical prostatectomies, with a mean anastomosis time of 37 minutes, mean operative time of 144 minutes, and mean hospital stay of 2.4 days. The average Foley catheter permanence was 9 days, and no bladder neck sclerosis/stricture was observed with a minimum follow-up of 12 months. CONCLUSIONS The described technique is a feasible and safe method for urethrovesical anastomosis. Although we had positive results in this initial cohort, further studies with larger series are needed to confirm these findings. UROLOGY 70: 799 – 802, 2007. © 2007 Elsevier Inc.
L
aparoscopic radical prostatectomy (LRP) is routinely performed for localized prostate cancer.1–5 The urethrovesical anastomosis is definitely the most technically demanding part of the procedure and requires an experienced surgeon with advanced laparoscopic skills.1– 4 This step of the surgery can be performed with either interrupted or running sutures. Many investigators consider the latter somehow easier and faster.1,2,4,5 Here we describe our technique of urethrovesical anastomosis with posterior fixation.
SURGICAL TECHNIQUE The procedure of choice in our department is the transperitoneal LRP. Immediately after the prostate is extirpated and hemostasis is performed, the bladder neck and urethral stump are properly exposed for the anastomosis. We use 3.0 polydioxanone (PDS) suture, an absorbable monofilament synthetic suture on a 27” taper point nee-
From the Department of Urology and General Surgery, Curitiba, Paraná, Brazil Reprint requests: William Kondo, M.D., Cruz Vermelha Hospital, General Surgery, R. Vicente Machado, 1310, Curitiba, Parana 80240041, Brazil. E-mail: [email protected] Submitted: September 23, 2006, accepted (with revisions): June 21, 2007
© 2007 Elsevier Inc. All Rights Reserved
dle, because of its low friction characteristics. The needle is small enough to make the rotation in even the narrowest pelvis ring, and the PDS suture is strong enough to bring the urethral stump and the bladder neck together. The technique is initiated by placing two X-shaped sutures at 5 and 7 o’clock, which establish a safe posterior wall for the anastomosis (Figs. 1 and 2). These sutures are independently tied, leaving the knots on the outside, and at this point we are left with the posterior fixation (two knots) and two needles, which will be used to complete the lateral and anterior portions of the anastomosis. We proceed with a counterclockwise running suture in the right lateral wall of the anastomosis using the 5 o’clock stitch needle (Fig. 3). The needle is always driven full-thickness outside-in in the bladder neck and inside-out on the urethra. This suture advances through the 12 o’clock position, with the needle coming out of the urethral stump. The 7 o’clock stitch needle is used to perform a clockwise running suture in the left lateral wall to the 12 o’clock position, completing the full circumference. This needle comes inside-out of the urethra, approximately 0.5 cm apart from the 5 o’clock needle for further tying (third knot). To avoid a loose anastomosis, gentle traction is applied on each suture; the system of loops acts as a “winch” to 0090-4295/07/$32.00 doi:10.1016/j.urology.2007.06.1095
799
Figure 1. Placing the 5 o’clock position stitch. Figure 3. Counterclockwise running suture using the 5 o’clock position stitch needle until the 12 o’clock position.
Figure 2. Placing the 7 o’clock position stitch.
bring the bladder in contact with the urethra without excessive tension, as described by Van Velthoven et al.2 At this point the assistant advances the 20F Foley catheter into the bladder, and the two sutures meeting at 12 o’clock are finally tied with the knot left on the outside of the urethral wall (Fig. 4). This establishes the third fixation point of the anastomosis. After completing the urethrovesical anastomosis, any remaining opening in the bladder neck can be closed with interrupted 3.0 PDS sutures. The Foley catheter balloon is then inflated with 20 mL of distilled water. To test the integrity of the urinary reconstruction, the bladder is filled with 200 mL of saline. We avoid traction 800
Figure 4. Both sutures tied outside of the urethral stump at the 12 o’clock position.
on the catheter balloon against the anastomosis because it can lead to a false-negative result for leakage. Any saline extravasation identified during this maneuver is controlled with additional stitches. We routinely use an abdominal drain (an 8F nasogastric catheter inside a Penrose drain), which is inserted through the right lateral 5-mm port and left in the pelvis by the anastomosis. A sterile colostomy bag is placed around the drain to quantify its output. The patient is discharged as soon as UROLOGY 70 (4), 2007
the abdominal drain can be safely removed. We use the criteria of less than 100 mL output in a 24-hour period to guide this withdrawal. The bladder catheter is withdrawn between postoperative days 7 and 10 if no significant urinary leakage is observed during hospital stay. We do not indicate routine postoperative cystography and perform it only in cases involving persistent urinary leaks.
RESULTS Between October and December 2005, we prospectively evaluated 12 consecutive patients who underwent LRP with the posterior fixation urethrovesical anastomosis. The average anastomosis time was 37.3 minutes (range 29 to 50 minutes), and the mean operative time was 144 minutes (range 110 to 155 minutes). During the leakage test, 11 patients (91.7%) presented no leakage after the saline instillation. In 1 case (8.3%), a significant leakage was observed in the anterior wall of the anastomosis and was promptly corrected. The mean hospital stay was 2.4 days (range 1 to 3 days), and mean catheterization time was 9.1 days (range 7 to 10 days). The only complication observed in our series was a mild hematuria after Foley catheter withdrawal, which required recatheterization. There was no postoperative persistent urinary leak or anastomotic stricture with a minimum follow-up of 12 months (range 12 to 14 months). Regarding postoperative continence, three patients (25%) were using one pad per day after 1 month. Follow-up revealed that only 1 of these 3 patients (8%) needed the pad after a period of 6 months.
COMMENTS It is well known that the urethrovesical anastomosis is the most challenging step of LRP and is the main barrier to a wider application of the procedure. In an attempt to substantially reduce the operative time, running suture techniques for this urinary reconstruction have been developed and recommended in several reports.1,2,4 In 2003, van Velthoven et al.2 described a running suture technique that required a single intracorporeal knot. This method was proved feasible and presented with low rates of urinary leakage and bladder neck stricture. Other investigators have also reported their experience with running suture for the urethrovesical anastomosis with good results in terms of safety and operative time.1 In our technique we are able to establish safe fixation in the posterior wall of the anastomosis, which is the most frequent site of urinary fistulas. In addition, this posterior fixation clearly exposes both the urethral stump and the bladder neck edges and significantly facilitates suturing. This exposure makes unnecessary the use of metallic urethral dilators to guide the needle tip inside-out the urethral wall. UROLOGY 70 (4), 2007
Another advantage inherent to the present technique is the fact that each of the two sutures is used to complete half of the anastomosis circumference. Therefore, if one of the sutures breaks, at least part of the anastomosis can survive and possibly heal well. Although many institutions perform a routine postoperative cystography to assess the integrity of the vesicourethral anastomosis before bladder catheter withdrawal,1,5–7 we do not find that mandatory. In 1995, Leibovitch et al.8 observed that significant extravasation is a common finding between postoperative days 5 to 8 and that this leakage, when present, did not affect outcome after catheter removal. Santis et al.9 removed catheters on postoperative days 8 or 9 of retropubic radical prostatectomies without radiographic studies in 100 patients. Two and nine patients developed urinary retention and bladder neck stricture, respectively. Anastomotic disruption, urinary tract infection, and pelvic abscess were not observed in this series. An abdominal drain was placed in the anastomosis site in all of the 12 patients who underwent the posterior fixation method. The increased familiarity with the technique, coupled with the fact that none of the initial patients developed persistent leaks, encouraged our department to recently select favorable cases in which no abdominal drain was left. These cases were not included here due to the short postoperative follow-up (less than 6 months). In a recent study, Araki et al.10 reported 419 of 552 patients (76%) undergoing radical retropubic prostatectomy without abdominal drainage. There were 27 (5%) immediate postoperative complications and no significant difference between the groups with and without drain: 3 patients (1%) without drain developed urinomas, 1 (1%) who was drained developed a lymphocele, and a small pelvic hematoma was found in 2 patients (2%) with drainage. The investigators consider abdominal drainage an absolute indication in cases of (1) anastomotic leakage after saline irrigation, (2) unsatisfactory hemostasis, and (3) injury to adjacent organs. We would also include cases of complex bladder neck reconstruction as an absolute indication.
CONCLUSIONS We consider the posterior fixation technique to be a safe and feasible approach for the urethrovesical anastomosis in LRP. Nevertheless, because of the small number of patients who underwent this technique, further evaluation and larger series are needed to confirm these encouraging initial results. References 1. Shichiri Y, Kanno T, Oida T, et al: Facilitating the technique of laparoscopic running urethrovesical anastomosis using Lapra-ty absorbable suture clips. Int J Urol 13: 192–194, 2006. 2. Van Velthoven RF, Ahlering TE, Peltier A, et al: Technique for laparoscopic running urethrovesical anastomosis: the single knot method. Urology 61: 699 –702, 2003.
801
3. Rozet F, Fournier G, Cathelineau X, et al: Vesico-urethral anastomosis during total laparoscopic prostatectomy. Ann Urol (Paris) 40: 50 –56, 2006. 4. Katz R, Nadu A, Olsson LE, et al: A simplified 5-step model for training laparoscopic urethrovesical anastomosis. J Urol 169: 2041–2044, 2003. 5. Menon M, Tewari A, Peabody JO, et al: Vattikuti Institute prostatectomy, a technique of robotic radical prostatectomy for management of localized carcinoma of the prostate: experience of over 1100 cases. Urol Clin North Am 31: 701–717, 2004. 6. Rassweiler J, Sentker L, Seemann O, et al: Laparoscopic radical prostatectomy with the Heilbronn technique: an analysis of the first 180 cases. J Urol 166: 2101–2108, 2001.
802
7. Nadu A, Salomon L, Hoznek A, et al: Early removal of the catheter after laparoscopic radical prostatectomy. J Urol 166: 1662–1664, 2001. 8. Leibovitch I, Rowland RG, Little JS Jr, et al: Cystography after radical retropubic prostatectomy: clinical implications of abnormal findings. Urology 46: 78 – 80, 1995. 9. Santis WF, Hoffman MA, Dewolf WC. Early catheter removal in 100 consecutive patients undergoing radical retropubic prostatectomy. BJU Int 85: 1067–1068, 2000. 10. Araki M, Manoharan M, Vyas S, et al: A pelvic drain can often be avoided after radical retropubic prostatectomy—an update in 552 cases. Eur Urol 50: 1241–1247, 2006.
UROLOGY 70 (4), 2007