V4-03: CONCOMITANT URETHRAL SLING AT THE TIME OF ROBOTIC PROSTATECTOMY USING AN IN SITU VASCULARIZED ROTATIONAL PERITONEAL FLAP
Post prostatectomy stress urinary incontinence is common. Many men ultimately require surgical intervention for correction of their incontinence. Our objective was to describe our initial experience with a novel technique performed at the time of robotic prostatectomy to improve postoperative continence.
The technique consists of a suburethral hammock using a vascularized flap of peritoneum. During the dissection of the seminal vesicles through the posterior cul de sac, a 4 cm flap of peritoneum is raised off the posterior bladder. Upon completion of the prostatectomy and bilateral pelvic lymphadenectomy, the flap is placed onto the prostatic fossa with the peritoneal surface facing the anastomosis. The posterior urethral stitch is placed through the cut edge of the peritoneal flap and then on to the posterior bladder neck. Three such sutures are placed at 5, 6 and 7 o'clock bringing together urethra, edge of peritoneal flap, and bladder neck. The remainder of the urethrovesical anastomosis is then performed. An absorbable suture is placed along each lateral aspect of the peritoneal flap at the level of the anastomosis and secured to the periosteum of the pubic bone directly anterior to the anastomosis, thereby lifting the urethrovesical anastomosis and placing it to its normal anatomic position and angle.
113 men with complete 2 year follow-up after robotic assisted laparoscopic prostatectomy with concomitant sling were identified. Mean age was 63 and pretreatment PSA was 9.15 ng/mL. The majority of men had clinical T1c disease with Gleason grades 6 and 7. At one month postoperatively, pad usage per day was reported as 0 pads in 36% of men, 1 pad in 21%, 2 pads in 11%, and 3 or more pads in 32%. Pad use decreased over time with less than 6% of patients reporting using more than 1 pad per day at 24 months follow-up (Figure 1). No clinical urine leaks, urinary retention, bladder neck contractures, or significant voiding complaints were noted.
Our experience with this novel technique using a well vascularized peritoneal flap at time of vesicourethral anastomosis is a safe and effective method that appears to improve early return of continence in men undergoing robotic prostatectomy. Further research is needed to recommend its universal use.