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Optimizing the formation of vesicourethral anastomosis and reduction of procedure time. A two-year experience with a modified technique for endoscopic running vesicourethral anastomosis.

Golabek T, Wiatr T, Przydacz M, Bukowczan J, Dudek P, Sobczynski R, Golabek K, Chłosta PL - Cent European J Urol (2015)

Bottom Line: In an attempt to simplify this critical step of radical prostatectomy we have developed a laparoscopic running single suture technique and presented preliminary results previously.There was no clinically significant anastomotic leakage observed.Only 3 patients developed perioperative morbidity, but none of them was classified as major.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Collegium Medicum at the Jagiellonian University, Cracow, Poland.

ABSTRACT

Introduction: Creation of a watertight vesicourethral anastomosis is a challenging and time-consuming procedure. In an attempt to simplify this critical step of radical prostatectomy we have developed a laparoscopic running single suture technique and presented preliminary results previously. Here we report our two-year experience with the Chlosta's single running suture technique.

Material and methods: Between January 2013 and June 2014, 60 consecutive patients underwent laparoscopic radical prostatectomy with a running vesicourethral anastomosis using our modified technique for clinically localized prostate cancer. Analyses of the patients' data from a prospectively maintained database with respect to perioperative characteristics, morbidity and urinary continence was performed.

Results: The mean anastomotic time was 10.2 min. There was no clinically significant anastomotic leakage observed. Only 3 patients developed perioperative morbidity, but none of them was classified as major. Bladder neck contracture occurred in only one man and it was managed endoscopically. Overall continence rates at 3, 6, 12, and 18 months were 73%, 85%, 96.7%, and 95%, respectively, and 76.8%, 89.3%, 96.4%, and 96.4%, respectively when analysis was limited to those without adjuvant radiotherapy.

Conclusions: Obtained results confirm our initial observation from the preliminary report and support the use of our single running suture for the vesicourethral anastomosis in LRP.

No MeSH data available.


Related in: MedlinePlus

Intraoperative photograph illustrating step one of the Chlosta's technique for performing the single running suture vesicourethral anastomosis. The stitch is 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.
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Figure 0001: Intraoperative photograph illustrating step one of the Chlosta's technique for performing the single running suture vesicourethral anastomosis. The stitch is 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.

Mentions: In our institution, the extraperitoneal approach was the procedure of choice for low risk prostate cancers that did not require lymph node dissection, whereas the transperitoneal technique was applied whenever the extended lymph node dissection was indicated. Immediately after the urethral transection and hemostasis were performed, the vesicourethral anastomosis was fashioned with a continuous running suture with our own modification, as described in detail elsewhere [11]. Briefly, the running stitch (2-0 polyglactin, absorbable synthetic suture) was 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 (Figures 1 and 2). A gentle traction was applied to the free end of the stitch at the 5 o'clock position throughout the procedure to prevent the anastomosis from loosening or, alternatively, the first stitch could have been tied to keep it secure. Proceeding counterclockwise, the running suture was always driven full thickness and was placed 3 to 5 times more through both the bladder neck and the urethra in a similar fashion until it met the free-end at the 5-o'clock position (Figure 3). The running sutures were snug down after each apposition to ensure that there was no slack. Just before placing the last stitch, a 18F silicone Foley catheter was inserted into the bladder and its balloon inflated with 10 ml of distilled water. Both ends of the suture were then tied outside the bladder with several knots and a triple knot being the first one, otherwise they were easily undone (Figure 4). To prevent a loose anastomosis a gentle traction was applied on the free-end of the stitch at 5-o'clock position as it entered the bladder throughout the procedure. Upon completion of the anastomosis, the integrity of the urinary reconstruction was tested with filling the bladder with 200 ml of normal saline. A 20F Redon drain was placed in the pelvis by the anastomosis. We did not place traction on the catheter balloon against the anastomosis because it could have resulted in a false negative outcome of the anastomosis integrity test and lack of urinary leakage. The patient was discharged as soon as the abdominal drain was safely removed i.e. its output was less than 100 ml in a 24-hour period and there was no sign of urinary leakage evidenced by a low creatinine concentration in a drain fluid sample. The bladder catheter was removed approximately 2 weeks after the procedure without performing cystography unless there was urinary leakage that persisted.


Optimizing the formation of vesicourethral anastomosis and reduction of procedure time. A two-year experience with a modified technique for endoscopic running vesicourethral anastomosis.

Golabek T, Wiatr T, Przydacz M, Bukowczan J, Dudek P, Sobczynski R, Golabek K, Chłosta PL - Cent European J Urol (2015)

Intraoperative photograph illustrating step one of the Chlosta's technique for performing the single running suture vesicourethral anastomosis. The stitch is 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.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4643710&req=5

Figure 0001: Intraoperative photograph illustrating step one of the Chlosta's technique for performing the single running suture vesicourethral anastomosis. The stitch is 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.
Mentions: In our institution, the extraperitoneal approach was the procedure of choice for low risk prostate cancers that did not require lymph node dissection, whereas the transperitoneal technique was applied whenever the extended lymph node dissection was indicated. Immediately after the urethral transection and hemostasis were performed, the vesicourethral anastomosis was fashioned with a continuous running suture with our own modification, as described in detail elsewhere [11]. Briefly, the running stitch (2-0 polyglactin, absorbable synthetic suture) was 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 (Figures 1 and 2). A gentle traction was applied to the free end of the stitch at the 5 o'clock position throughout the procedure to prevent the anastomosis from loosening or, alternatively, the first stitch could have been tied to keep it secure. Proceeding counterclockwise, the running suture was always driven full thickness and was placed 3 to 5 times more through both the bladder neck and the urethra in a similar fashion until it met the free-end at the 5-o'clock position (Figure 3). The running sutures were snug down after each apposition to ensure that there was no slack. Just before placing the last stitch, a 18F silicone Foley catheter was inserted into the bladder and its balloon inflated with 10 ml of distilled water. Both ends of the suture were then tied outside the bladder with several knots and a triple knot being the first one, otherwise they were easily undone (Figure 4). To prevent a loose anastomosis a gentle traction was applied on the free-end of the stitch at 5-o'clock position as it entered the bladder throughout the procedure. Upon completion of the anastomosis, the integrity of the urinary reconstruction was tested with filling the bladder with 200 ml of normal saline. A 20F Redon drain was placed in the pelvis by the anastomosis. We did not place traction on the catheter balloon against the anastomosis because it could have resulted in a false negative outcome of the anastomosis integrity test and lack of urinary leakage. The patient was discharged as soon as the abdominal drain was safely removed i.e. its output was less than 100 ml in a 24-hour period and there was no sign of urinary leakage evidenced by a low creatinine concentration in a drain fluid sample. The bladder catheter was removed approximately 2 weeks after the procedure without performing cystography unless there was urinary leakage that persisted.

Bottom Line: In an attempt to simplify this critical step of radical prostatectomy we have developed a laparoscopic running single suture technique and presented preliminary results previously.There was no clinically significant anastomotic leakage observed.Only 3 patients developed perioperative morbidity, but none of them was classified as major.

View Article: PubMed Central - PubMed

Affiliation: Department of Urology, Collegium Medicum at the Jagiellonian University, Cracow, Poland.

ABSTRACT

Introduction: Creation of a watertight vesicourethral anastomosis is a challenging and time-consuming procedure. In an attempt to simplify this critical step of radical prostatectomy we have developed a laparoscopic running single suture technique and presented preliminary results previously. Here we report our two-year experience with the Chlosta's single running suture technique.

Material and methods: Between January 2013 and June 2014, 60 consecutive patients underwent laparoscopic radical prostatectomy with a running vesicourethral anastomosis using our modified technique for clinically localized prostate cancer. Analyses of the patients' data from a prospectively maintained database with respect to perioperative characteristics, morbidity and urinary continence was performed.

Results: The mean anastomotic time was 10.2 min. There was no clinically significant anastomotic leakage observed. Only 3 patients developed perioperative morbidity, but none of them was classified as major. Bladder neck contracture occurred in only one man and it was managed endoscopically. Overall continence rates at 3, 6, 12, and 18 months were 73%, 85%, 96.7%, and 95%, respectively, and 76.8%, 89.3%, 96.4%, and 96.4%, respectively when analysis was limited to those without adjuvant radiotherapy.

Conclusions: Obtained results confirm our initial observation from the preliminary report and support the use of our single running suture for the vesicourethral anastomosis in LRP.

No MeSH data available.


Related in: MedlinePlus