Anastomosis

To begin the anastomosis, a needle driver is on the right and the long tip forceps on the left or two needle drivers may be used. In the beginning of our experience, the anastomosis was performed with eight or more interrupted sutures. A running anastomotic suture had been described for laparoscopic prostatectomy and was integrated into the Vattikuti Institute of Prostatectomy technique early in the evolution of the procedure (Fig. 9) (8,16,17). A running suture was found to be more efficient with excellent functional results. Presently, the anastomotic suture is made from two 7-8 cm 3-0 Monocryl (poligle-caprone 25) sutures on an RB-1 needle, dyed and undyed, tied together extracorporeally with the knot in the middle and a needle on either end. The running anastomosis is started with the dyed end, inside out on the bladder at the 4 o'clock position and continues in a clockwise direction. After two to three passes, the suture is cinched down with gentle downward traction on the bladder. After the bladder is brought down to the urethra, a needle driver is used on the left for the remainder of the anastomosis. The suture may be periodically locked to maintain tension or the right-sided surgeon may hold the suture on mild tension. At approximately the 9 o'clock position, the suture is reversed; inside to out on the bladder, outside to in on the urethra for two to three passes, then the second assistant holds the dyed needle on mild tension. Next, the undyed monocryl is passed outside in on the urethra at the 4 o'clock position and continued in a counterclockwise direction until the anastomosis is completed. The needles are removed and a single intracorporeal knot completes the anastomosis. A 20 French Foley catheter is placed, the bladder is distended to assess for anastomotic leaks, and 20 cc of saline is placed in the balloon.

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