Technique in Endourology: Vesicourethral anastomosis during laparoscopic radical prostatectomy: The running suture method

Mary ^AnnLiebert,^Inc.

Techniques ⁱⁿ Endourology

Vesicourethral Anastomosis During Laparoscopic ^Radical Prostatectomy: ^The Running Suture Method

ANDRAS

HOZNEK, M.D.,

^LAURENT

SALOMON, M.D.,

^REDOUANE

RABII, M.D.,

MOHAMED-RIADH ^BEN

SLAMA, M.D.,

^ANTONY

CICCO, M.D.,

^PATRICK

ANTIPHON,

M.D.,

and CLEMENT-CLAUDE

ABBOU,

^M.D.

ABSTRACT

Vesicourethral reconstruction is the mostcritical and

time-consuming step

^of

laparoscopic

^radical

prostatec¬

tomy.

We describe the use oftwo hemicircumferential

running

sutures that has

significantly simplified

^the

procedure

^{inour last30}

patients.

^The vesicourethral reconstruction^took31 minutesonaverage. Six ^months

postoperatively,

^{84% of the}

patients

^were

fully ^continent,

^{and no bladder neck} stenosis had ^occurred. The economy of

intracorporeal suturing provided by

^{this novel}

method, together

^with

geometric

^{factors such as}

the

optimal position

^{ofthetrocars,}contributestothe

improvement

of ergonomy,

allowing

the surgeon^tode¬

crease

operating

^times.

INTRODUCTION

LAPAROSCOPIC

^{SURGERY is}

particularly advantageous

for the excision ofsmall,

deeply

^situatedorgans,whichare

difficultto^access

during

open surgery and would

require

^a

large

parietal ^wound. Therefore, ^and given ^the

epidemiologic

^im¬

portance^ofprostate^cancer,

laparoscopic

^radicalprostatectomy aroused considerableinterest inrecentyears. Oneofthe

major

controversies

concerning

^this

technique

^{is the}

long operating

time.Asin open surgery, the vesicourethral anastomosis is^one of the criticalsteps^{of the}

surgical procedure.

^{However,forer¬}

gonomic

^reasons,the

techniques

used in open surgery ^arenot

optimal during laparoscopic

surgery because

endoscopic

^knot-

tying

^is

exceedingly

^time

consuming.

^{In the}initial series of la¬

paroscopic

^radical

prostatectomies,

^the anastomosis

required

thegreatest^{time and} took twice^aslong ^asthe removal of the

prostate.'

We describe herein ^a novel

technique

using ^{two hemicir¬}

cumferential

running

^{sutures for} vesicourethral anastomosis

during

laparoscopic

^radicalprostatectomy.

TECHNIQUE

The

patient

is installed in the dorsal decubitus

position,

^with

the

legs slightly spread, allowing

^an

intraoperative

^{rectal ex¬}

amination. Fivetrocarsareused; their

disposition

^has

primary importance

^{in the} anastomotic

technique,

^because

they

^deter¬

mine the axis of the needleholder,^theplaneof theneedle,and theanglebetweenthe instruments. The sites of thetrocarsare

displayed

ⁱⁿ

Figure

^1.The

equipment

is listed in Table 1.

The

technique

^ofdissection and excision of theprostate ^re¬

capitulates

^thesteps^{of radical}retropubicprostatectomy^except for the

transperitoneal approach

^to the seminal vesicles. The successivesteps of the

procedure

^are summarized inTable 2.

The

optimal preparation

of the bladder neck and the urethra atthe apex of the prostate^aretwocriticaldeterminants ofthe

ease and

adequacy

^ofvesicourethral anastomosis. Because of the lack of manual

palpation,

the identification of theexact tran¬

sition oftheprostate^andbladder neck

requires

^adifferent per¬

ception.

^{In fact,} the bladder is coveredby

prevesical adipose

tissue, incontrasttotheprostate, which is coveredonly

by

^the

Serviced'Urologie,^CentreHospitalierUniversitaireHenriMondor, Creteil,France.

749

Palpation

the scissors

permits

^onealsoto

distinguish

the mobile bladder wall from firm

prostatic

tissue. We incise with

coagulating

^scis¬

sorsatthe frontierbetween the

endopelvic

fascia and the^more

cephalad^zonecovered by fatty tissue. This

permits

^exposure

ofthe lower

edge

of the muscular fibers of the detrusormus¬

cle. The

plane

between the bladder neck and theprostateis then

developed alongthese muscular fibers^{on one}side and thecon¬

nectivetissue

layer

^ontheother side. The

magnified

vision per¬

mits^oneto

distinguish

veryclearly^{thesetwodifferent}types^of tissues. To avoid

positive surgical margins,

^{it is}

preferable

^to

carry^out thisdissection closertothe vesical side than tothe

prostatic capsule.

^Theanterioraspectof the bladder neck is in¬

cised in themidline,and the

Foley

catheter is

pulled

^{in the di¬}

rection of the

pubic symphysis,

^thus

exposing

^the

posterior

^edge

of the bladder neck.Meanwhile,

indigo

^{carmine is}

injected

^in¬

travenously ^{to better} identify the ureteral orifices. Next, ^the bladder neck isincised

posteriorly,

^{and the}

previously

^dissected

seminal vesiclesarefoundagain.It should be

emphasized,

^how¬

ever, that in

patients

^with

history

of transurethral

prostatic

^re¬

section,^{all the}anatomic landmarks that

help

^thesurgeon^tofind the

right plane

between the bladder and prostatemay be lost,

making

^thedissection much^moredifficult.

The Santorini

plexus,

^{which was}

ligated

previously, ^issec¬

tioned

only

when the transection of the bladder neck is finished.

The apex of theprostateand the urethra^aredissected under_op¬

timal visualconditionsbecause of the

magnified

view and the selective illumination.

Once theprostate^{has been}excised,^thereusually ^isnoneed

to

perform

^aracket-handle bladder neck reconstruction. How¬

ever,thecircumference ofthebladder neck

depends

^{onthe pres¬}

ence orabsence of associated

prostatic hyperplasia

^{or an en¬}

largedmedian lobe.As^aresult,the number of needle passages

required

^{for the} vesicourethral anastomosis _may differsome¬

what fromone

patient

^toanother.

The vesicourethral anastomosis is created with a

posterior

and^an anteriorhemicircumferential

running

^{suture. Two nee¬}

dle holdersareused

simultaneously.

^Therightneedle holder is inserted

through

^{the 12-mm}

disposable

^{trocar situated at the}

right margin

^{of therectus sheath}

(Fig.

1;^trocar2).^{This trocar}

also allows the passage of the

suturing

^{material: a 3-0} Vicryl

suturewitha26-mmneedle;^the

optimal length

^{of thesutureis}

about 20 cm.The leftneedle holder is passed through ^{the 5-}

mmport^{neartheleftanterior}

superior

^iliac

spine (Fig.

^{1; tro¬}

car5).^Thesurgeon

manipulates

^thesetwoneedle holders.The first assistant holds the 0°lens,^{which is}

passed through

^{the 12-}

mmtrocar atthe umbilicus

(Fig.

1;^trocar3).Inthe otherhand, the assistant holds the

suction-irrigation

^device,

passed through

the left 12-mmtrocar

(Fig.

^1;trocar4).This instrument allows exposure of thebladderneck andremoval of the accumulated urine from the

operating

field. A second assistantorthe in¬

strumentalist uses narrow

forceps

^{tohold the}

long

tail of the

running

^suture

(Fig.

1;^trocar 1).On the urethralside,the

long

tail is maintained undertraction in the direction of the _sym¬

physis,

^whileon the bladderside, it ispulled cephalad. ^Con¬

cerning

^theuseof the leftor

right

needle holderfor the differ¬

entsutures, the rule of thumb is ^tousethe ^morevertical

right

needle holder for the lateralsuturesand themorehorizontalleft needle holder for the suturesinthe nadir and zenith

positions.

This

permits

the surgeon^tohave the needle holder

parallel

^and

nearly perpendicular

ception

^tothis rule is in the lowerpart^oftheurethra,where the

right

^{needleholder is}

always

^{easierto use.}

1. Astarter knot iscreated atthe 3 o'clock

position,

^{and the}

sutureisconductedfromoutside inonthebladder,^{then from} inside the urethratothe outside. For both needle passages,

we usethe

right

needle holderwith the needlein the fore¬

hand direction. Thesuture is then

tightened

^{with an intra¬}

corporeal

technique.

2. The needle is

passed

from the outside to the inside of the bladder, ^below the starterknot,^{at the lower}

margin

^ofthe

bladder neck in the 4 o'clock

position.

This is done with the

right

needle holder with the needle in aforehanddirection

(Fig.

^2a).

3. One^ortwosutures arethen

placed

^nearthe 6 o'clock

posi¬

tion of thebladderandurethra. Thesutures onthe bladder sideareeasierto

perform

^{with themore}horizontal leftnee¬

dle holder

(Fig.

^2b),whileonthe urethralside,they^aredone

with theright needle holder. For both, the needle is

posi¬

tioned in the forehand direction.

4. For the left lateral zoneof thebladder neck andurethra,^we

usethe

right

needle holder^ontheurethral side withaback¬

hand needledirection(Fig.2c)and the left needle holderon

the bladder side witha forehand needle direction.

5. For the terminal knot of theposterior hemicircumferential suture, ^aclosed

loop

^is

prepared

^atthe 9 o'clock

position.

The needle is

passed

^{fromthe insideto}the outside of the bladder, ^then from the outsidetothe inside of the urethra, thus

forming

^a

loop (Fig.

2d),^and

again

from the insideto theoutside^onthe bladder side. All thesuturesaredonewith the

right

needle holder with^aforehand needle

position.

^The

suture line is thus ended extramurally ^{with a}

three-legged

tie

(Fig.

^2e).

6. The

Foley

catheter ispushed^withoutany

difficulty

^{into the}

bladder.

7. Asecond

running

^{suture isrealized on}the anterior

margin

ofthe bladder and urethra,

beginning

^{atthe 2o'clock}

posi¬

tion^ontheurethralside, then in the bladder. Botharedone with the left needle holder and^aforehandneedle direction

(Fig.

^2f).

8. Twoorthreeneedle passages^are sufficienttoclose the^an¬

terioraspectofthe anastomosis

entirely.

9. A

loop

^is

again

^formedatthe 10 o'clock

position,

^{and the}

knot is tied.

Thesedifferentsuturesare

performed

with deliberate structured and error-free

choreography,

which has evolved

progressively during

^the

developmental phase

^of

laparoscopic

^{radicalprosta¬}

tectomies.

ROLE IN UROLOGIC PRACTICE

During

open

retropubic

^radicalprostatectomy,^the

pubic

^bone

impairs

^the

visibility

^andaccesstothe urethral stump,

making

theplacement^{of the sutures difficult.}In addition,the surgeon musttie the knots in^ablind field and

rely

^ontactile sensation alone. Therefore, there isarisk of incorrectsuture knot

posi¬

tioning:

if the knot is

pulled

^toostrongly,^itmay^tearoutof the

FIG. 1. Site oftrocars.

urethra,whereas if it istooloose,the vesical neck and theure¬

thralstump ^willnotbe correctly aligned.

One of the

major advantages

^of

laparoscopic

^{radicalprosta¬}

tectomy is its

potential

^for

performance

^{of all the suturesun¬}

der total visual control.However,

knotting

^{of thesuturesis time} consumingand contributestothe

prolonged operating

^time.1In

open surgery, ^a half-knot necessitates less than 2 seconds, whereas the same

requires

^{15 to 20 seconds}

during

^la¬

paroscopy.2

These difficulties encountered in

attempting

^vesi¬

courethral reconstruction

during laparoscopic

surgery

prompted

usto^usetwohemicircumferential

running

^{suturesfor theanas¬}

tomosis instead of

interrupted

sutures, which ^wereused in all of the

reported

series.''3'4

Several

experimental

^{studies on} small-bowel anastomoses demonstrate that the time

required

^is

significantly

shorter with

running

^{suturesthan with}

interrupted

^sutures.5 Another advan¬

tageof this method is that it doesnotleave any knots ^on the luminalaspectof the anastomosis.However,

interrupted

^sutures

Table 1. Equipment^for Laparoscopic Vesicourethral Anastomosis

A 12-mm

disposable

^trocar(VersaSleeve with

Foam-Grip;

AutosutureFrance), ^{used at}the umbilicus. Thistrocaris reserved for the 0° lens and the insufflation tube Two 12-mm

disposable

^trocars

(Versaport;

^Autosuture

France),^{used at} the lateral border of therectus sheaths.

The valve mechanism allows the passage of the needle Two 5-mm reusable trocars, inserted ^nearthe anterior

superior

^iliac

spine

TwoEthicon needle holders

Autosuture

Surgiwand Il-type

^suction

irrigation

Narrow fenestrated

forceps

^{(Clickline; Karl Storz)}

3-0

Vicryl

^suture with 26-mm needle

Video

endoscopic

column with insufflation device

(Karl Storz)

are often

preferred

^{on small} bowel, ^because

running

^sutures

may lead^toanastomotic stenosis when thesutureline is

tight¬

ened.2 In

spite

^ofthis, stenosis does not^occuraturethrovesi- cal anastomosescreated with

running

sutures, because theFo¬

ley

^{catheter prevents any}

narrowing

^of the anastomotic circumference.

Between December 1998 and October 1999, ^we

performed

the vesicourethral anastomosis with this new

technique

^{in 30}

Table2. Steps inProcedure 1. Incision of the

peritoneum

^atthe anterior aspect^of

Douglas

pouch

^and

development

^of

rectoprostatic plane

behind the seminal vesicles. Denonvilliers' fascia is incised, and the dissection is carried out tothe levator ani muscles. The^vasa deferentia^aresectioned, ^{and the} seminal vesicles^aredetached from the

posterior

aspect^of the bladder neck

2. Incision of anterior

parietal peritoneum

^{at the}top^{of the} urachus, detachment of thebladder,^and

development

^of

the space of Retzius

3. Incision of

endopelvic

^{fascia onbothsides; double-}

ligature

of the Santorini

plexus

4. Transection of the bladderneck,

joining

of the dissection

plane

^{ofstep 1} behind the seminal vesicles

5. Section of the lateral

pedicles beginning

^atthe base of theprostate ^and

progressing

toward the apex

6. Section of the Santorini

plexus

^{and theurethra,}

transection of the rectourethralis muscle and

Denonvilliers' fascia behind the apex, completing ^the

rectoprostatic cleavage.

The last attachments of the lateral

pedicles

^nearthe apex ^aretransected. The neurovascular bundles arepreserved ^if

justified

^{andrequired. The} prostate ^is put^inan

endoscopic bag

^and

kept

^aside

during

the anastomosis

7. Vesicourethral reconstruction

8. Delivery ^{of the}surgical

specimen through

^{the slightly} enlarged^umbilical port^site

FIG. 2.

Principal

^stepsof vesicourethral anastomosis with

posterior

and anteriorhemicircumferential

running

^{suture, (a)Pas¬}

sage of needle^atlower

margin

^{of bladderneckbelow starterknot, (b)}Placement ofsuture at6 o'clock with left needle holder,

(c)^{Use of}rightneedle holder with backhanddirection in left lateral^zone,(d)Creation of

loop

^forterminal knot,(e)Extramural

completion

^{ofsutureline with}

three-legged

^tie.(f) Placement of secondrunning ^suture.

patients.

The average

operating

^{timewas 5.2hours. However,}

therewas aclear decrease withgrowing

experience:

^inourlat¬

est

patients,

the habitual

operating

^{time was}3.5 hours without and 4 hours with

lymphadenectomy.

The anastomosis took 31 minutes (23-39 minutes) ^on_average. ^Fourtofive

days

^post¬

operatively

^{we routinely}

performed

retrograde urethrocystog-

raphy.

^{If therewas no}anastomotic

leakage,

^the

Foley

^catheter

waswithdrawn,and the

patient

^{left the}

hospital.

^Three

patients

presented leakage.

Two of themweretreated

conservatively by

maintaining

^theFoleycatheter for1 ^moreweek.Only ^onepa-

tient

required

open

surgical repair

^{because of}anastomotic in¬

sufficiency.

^This

patient

^had

previously undergone

transurethral resection of theprostate, and the usual landmarksofthe blad¬

der neckwerelost. As aresult,the section line ofthebladder neckwastooclosetothe ureteralorifice,andthesuture atthis sitewastoo

superficial.

It should be

emphasized

that because of the

magnified

^{view,onetends}

generally

^tooverestimatethe

depth

^{of thesutures andin thiscase, a} secondary cut-through

may^occur.

Taking

^intoaccountthe total duration of catheteri- zation of all thepatients,the average time^{was 5.7}

days.

During

^an average

follow-up

of 9.5 months

(range

^5-17 months), ^{we have not} observed any anastomotic stenosis in these 30

patients.

^{Continence was studied}

prospectively by

^a

self-rating questionnaire. Twenty-five patients

^{sent backtheir}

6-month

questionnaire. Twenty-one

^(84%)were

perfectly

^con¬

tinent, two

patients

^had

only

minimal and occasional

leakage

that didnotnecessitate_any

pad,

^andtwo

patients

^{had mildstress}

incontinence which necessitateduseofone

pad daily.

REFERENCES

1. Schuessler WW, ^Schulam PG, dayman RV, Kavoussi LR. La¬

paroscopic ^radical prostatectomy: Initial short-term experience.

Urology 1997;50:854-857.

2. CuschieriA,^SzaboZ.Laparoscopichand-sutured andstapled^anas¬

tomoses.In: TissueApproximationⁱⁿEndoscopic Surgery.^Oxford:

IsisMedicalMedia, 1995,pp 113-139.

3. PriceDT,^ChariRS,Neighbors^{JDJr,EubanksS,SchuesslerWW,} Preminger^GM.Laparoscopic ^radicalprostatectomy in the canine model.JLaparoendoscSurg 1996;6:405^U2.

4. GuillonneauB, ^VallencienG.Laparoscopic^radicalprostatectomy:

Initialexperience ^andpreliminary ^{assessment after 65}operations.

Prostate 1999;39:71-75.

5. WaningerJ,^SalmR,^ImdahlA,^HaberstrohJ,Schoop^C,Voshege M, Farthmann EH. Comparison ^oflaparoscopic ^{handsewnsuture} techniques ^for experimental small-bowel anastomoses. Surg ^La-

parosc Endosc1996;6:282-289.

CONCLUSION

The use oftwo hemicircumferential

running

^{sutures instead}

ofinterrupted^suturesgreatly

simplifies

^{acrucialpartof}laparo¬

scopic

^radicalprostatectomy.Such technical advances may^even¬

tually^{allowustocomeclosertothe}

operating

times of open rad¬

icalprostatectomy^while

reducing postoperative morbidity.

Address

reprint

requests^to:

AndrasHoznek, ^M.D.

Service d'Urologie

Centre

Hospitaller

Universitaire Henri Mondor 51 Av. du Malde Lattre de Tussigny

94010Cre'teil, ^France E-mail:

andras.hoznek@hmn.ap-hop-paris.fr