Analysis Of Three Different Vesicourethral Anastomotic Techniques In Laparoscopic Radical Prostatectomy

Laparoscopic radical prostatectomy (LRP) and robotic assisted laparoscopic radical prostatectomy (RALP) comprise the majority of radical prostatectomies performed in the US. The vesicourethral anastomosis is paramount to postoperative continence and potential complications such as urinary extravasation or bladder neck contracture. In the December 2008 issue of World Journal of Urology, Dr. Dogu Teber and colleagues reported on the outcomes of 3 different vesicourethral anastomotic techniques.

Since 1999, 1,900 patients underwent LRP by a single surgeon. Three anastomotic techniques were studied:

-- Group 1 had intracorporeal continuous anastomosis with a single knot using 3-0 PDS suture

-- Group 2 had standard interrupted sutures performed using 3-0 Vicryl suture

-- Group 3 had a 6 o'clock interrupted suture performed prior to division of the posterior wall of the urethra, followed by standard interrupted sutures using 3-0 Vicryl suture

The Rocco suturing technique often used in RALP was not investigated. Data were compared for 200 patients in each group, matched for clinicopathological variables. Bladder neck reconstruction was performed in about 10% of patients in each group. Voiding cystourethrograms were performed between postoperative days 5 and 7.

All three groups were comparable regarding clinicopathological factors. Mean operative time in groups 1, 2 and 3 were 155 minutes, 185 minutes and 202 minutes, respectively. The respective anastomotic times were 15, 23 and 27 minutes. No statistical differences were found in blood loss or transfusion rates. Cystourethrograms demonstrated urinary extravasation in 86 of the group 1 patients, 78 of the group 2 patients, and 85 of the group 3 patients. Group 1 had a 9-day mean duration of catheter time compared to 11.9 days in group 2 and 9.8 days in group 3. However, the median duration of catheter time was 7 days for each group. Acute urinary retention was comparable in 5.5 - 7.5% of patients and was managed with an additional catheter for 2-3 days. Continence rates assessed at 12 months were 93.4%, 92.8% for groups 1, 2, and 3, respectively. Endoscopic incision of an anastomotic stricture was required in 3 - 3.5% of men and was not different among groups.

This study suggests that LRP intracorporeal continuous anastomosis with a single knot is quicker than interrupted suturing. LRP is hindered by the ability to tie knots and these data support that. This problem is less significant due to the improved degree of freedom in RLP.

Teber D, Erdogru T, Cresswell J, Gözen AS, Frede T, Rassweiler JJ
World J Urol. 2008 Dec;26(6):617-22.
doi:10.1007/s00345-008-0281-0