Ces Urol 2024, 28(1):10-12

Variant of urethrovesical anastomosis during robot assisted radical prostatectomy - video

Jan Schraml¹, Martin Hlavička², Milan Hora²

¹ Klinika urologie a robotické chirurgie Fakulty zdravotnických studií Univerzity J. E. Purkyně v Ústí nad Labem a Krajské zdravotní, a. s. – Masarykovy nemocnice v Ústí nad Labem, o. z.

² Urologická klinika LF UK a FN Plzeň

Schraml J, Hlavička M, Hora M. Variant of urethrovesical anastomosis during robot assisted radical prostatectomy - video.

Introduction: There are many methods of performing a urethrovesical anastomosis during robot assisted radical prostatectomy, while there are no data from prospective randomized studies to prefer one specific technique. The aim of this video is to present the technique used at the workplace of the main author of this work. Methodology description: A trans- or extraperitoneal antegrade radical prostatectomy is performed in the Trendelenburg position with the DaVinci Xi robotic system - the prostate is separated from the bladder neck and dorsally from the neurovascular bundles. The operation in the video is performed by a right-handed surgeon. The video begins by cutting the Santorini plexus and the urethra in its 5/6 circumference with scissors, the urethra is left dorsally to prevent its retraction caudally into the pelvic floor. The bleeding Santorini plexus is sutured with a Stratafix® Monocryl 3-0 continuation self-anchoring suture, and the thread is left in the abdominal cavity fixed with a needle to the anterior abdominal wall for further use. A second identical suture is placed on the non-retracted urethra at no. 5. Using a cutting needle (Larger SutureCut needle driver) the urethra is interrupted. This is followed by a urethrovesical anastomosis without supporting reconstruction of the levator ani muscle. Three thread turns are made without tension on No. 5-8 and only then the stitch is gradually tightened. The anastomosis at No. 8-12 is completed, and the stump of the Santorini plexus is sutured ventral to the urethra. The anastomosis is closed with the remainder of the first suture from No. 5 in the ventral direction to No. 12. The needles of both sutures are cut and both ends of the self-anchoring sutures are still tied. Comment on the technique: The methodology has been used for over 10 years in more than 2,000 cases with satisfactory functional results, but the results have not been analysed in a high quality study. We do not routinely perform posterior reconstruction, this is also a given historically, when we did not perform it even in open procedures and we did not have more frequent complications of urinary continence. We perform posterior supportive reconstruction only very exceptionally when there is a large spacer defect after removal of the prostate, and in this case our intention is to reduce the tension of the subsequent anastomosis. We perform the actual interruption of the urethra at the apex of the prostate with an effort to preserve the puboprostatic ligaments as much as possible, especially their distal fibres, which also go into the external bundle. By subsequently taking this area into a suture, we carry out a certain reconstruction of the suspension apparatus in the neck of the bladder and there is no decrease in this area. We consider this front-upper reconstruction to be more physiological than performing a routine posterior support reconstruction. Our functional results, including economic aspects, have not forced us to change our strategy for more than 10 years.

Conclusion: The video presents one of the possible variants of urethrovesical anastomosis during robotic-assisted radical prostatectomy.

Keywords: Prostate cancer, prostatectomy robot, uretrovesical anastomosis.

Received: January 2, 2024; Revised: January 21, 2024; Accepted: January 23, 2024; Prepublished online: January 28, 2024; Published: May 2, 2024