Variant of urethrovesical anastomosis during robot assisted radical prostatectomy – video

Overview

Introduction: There are many methods of per forming a urethrovesical anastomosis during robot assisted radical prostatectomy, while there are no data from prospective randomized studies to pre fer 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 ex traperitoneal 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 San torini 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 methodol ogy 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 qual ity 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 complica tions 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 anasto mosis . 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 tak ing 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 reconstruc tion 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 .