V6-05: Urethro-vescical anastomosis during robot-assisted radical prostatectomy: a total anatomical reconstruction
VideoIntroductions and Objectives
Catheterization and eventual urinary incontinence can reduce quality of life and raise the cost of care after radical prostatectomy. Among surgical modifications proposed to minimize the incidence of urinary incontinence and to potentially shorten catheterization, we present our personal surgical technique of total anatomical reconstruction for urethro-vescical anastomosis during robot-assisted radical prostatectomy.
Extirpative phase: after the endopelvic fascia incision, control of the dorsal venous complex is performed by a pubo-prostatic ligament-sparing suture. Dissection and transection of the bladder neck are performed. Sharp dissection now follows a vertical course to open the retrotrigonal space containing the seminal vesicles. After completing the seminal vesicle dissection, posterior layer of Denonvilliers’ fascia is cut. Caudal incision of visceral layer of endopelvic fascia is performed and prostatic apex is dissected while sparing urethral sphincter. Reconstructive phase: posterior reconstruction is performed in triple layer by 3/0 barbed suture. The first suture is performed between the cranial portion of previously sectioned Denonvilliers’ fascia and the median raphe. The second suture is performed between the retrotrigonal layer and the median raphe. In the third suture the needle involves extra-mucosally the bladder neck and the posterior portion of rabdosphincter. Tension-free urethro-vescical anastomosis is now performed by 3/0 barbed running suture beginning from 4 o’clock and then continuing clockwise. It involves the full thickness of bladder neck and urethra. Anteriorly, to give reinforce and to reduce tension to the performed suture, muscular fibres of bladder neck are sutured by extramucosal involvement of the anterior part of rabdosphincter. The visceral layer of endopelvic fascia is now sutured to endopelvic fascia covering dorsal venous complex, involving puboprostatic ligaments so that they can now be renamed as pubovescical ligaments. At the end, urethro-vescical anastomosis is posteriorly protected by commonly performed total posterior reconstruction and anteriorly protected by two layers, achieving total anatomical reconstruction of peri-urethral structures.
we performed 73 procedures by described technique. Catheterization time and early continence results were impressive as showed in the video figures.
In our experience, the proposed technique of total anatomical reconstruction allowed early catheter removal and maximization of early continence.