Discussion

As stated by Hoznek et al., in open retropubic radical prostatectomy, the pubic bone impairs the visibility and the access to the urethral stump making the placement of the sutures difficult. In addition, the surgeon must tie the knots in a blind field and must rely on tactile sensation only. Therefore, there is a risk of inadequate suture knot positioning. Moreover, if the knot is pulled too strongly it may tear out of the urethra, whereas if it is too loose, the vesical neck and the urethral stump will not be correctly aligned (5).

One of the major advantages of laparoscopic radical prostatectomy is its potential to perform all the sutures under total visual control. However, knotting of the sutures is time consuming and contributes to prolonged operating time (1). In open surgery, in fact, a half-knot necessitates less than two seconds, whereas the same requires 15 to 20 seconds during laparoscopy (14).

The difficulties inherent to vesicourethral anastomosis are illustrated in conventional open retropubic prostatectomy where several authors developed maneuvers designated to ease the approximation of the bladder to the urethra or the suture technique itself, some of these tips might be transposed to laparoscopy.

The exposition of the urethra may be eased by a Benique dilator, held by the assistant at the edge of the cut urethra; the manipulation of its tip opens the urethral stump according to the various orientation of the needles requested for the four to seven stitches generally used for the anastomosis (8). Currently, the dilator may be replaced by a Foley catheter, put in tension by a traction on its tip combined by a counter-traction on a forceps placed at the urethral meatus. These artifices are used in open and in laparoscopic surgery.

For tying the knots after an open procedure, surgeons may temporarily "hire the assistance" of a laparoscopic instrument like a knot pusher, combined with a Reuder knot, to ease the maneuver when tactile control seems insufficient (15). Approximation of the bladder to the pelvic floor may be eased by additional sutures, sometimes placed through the perineum (16) in case of morbid obesity (17). Novicki et al. consider even the modified Vest suture as a valid alternative to direct anastomosis, providing similar results in terms of long-term continence (18). Anchoring the bladder to the pelvic wall near the urethra is also realized by modified sutures tying the surface of bladder neck to the base of the urethral stump (19). Beyond anecdotical reports, none of these artifices where ever described in laparoscopy where the visual advantage of a direct approach and the magnification factor seem to solve most of the technical problems, in conjunction with a relatively wider perivesical dissection allowing for a direct anastomosis.

Assistance to the open suturing procedure is brought either by a Foley catheter leading the needle to the urethral lumen (20) or by several suturing devices such as Maniceps® (21,22) or Endostitch® (23). It seems here again that skilled laparoscopic surgeon solved most of the suture technique problems with straight or slightly curved needle holders combined to 4/8 or 5/8 22-26 mm needles.

In laparoscopic vesicourethral anastomosis, the main difficulty may still reside in the tying of the first knot. In fact, this step must successfully achieve two main goals, as the approximation of the bladder as well as the adequate start point of an immediately watertight anastomosis.

Quality control problems with interrupted sutures are illustrated by the complication rates observed even on large cohorts; however, one must yet remain aware of the fact that these cumulative series also describe forever the discovery-learning curve of these protocols. Guillonneau and Rozet reported about 57 cases out of 567 (10%) with early urine leakage resulting in aspiration of urine by the suction drain (24). In 43 patients, the diagnosis occurred before the removal of the catheter and healing followed spontaneously with longer catheter drainage. Two patients requested percutaneous aspiration of urine, while one patient had to be reoperated laparoscopically. In 11 cases, catheter removal was followed by a status of acute pain, acute urinary retention, and peritoneal irritation syndrome, leading to the diagnosis of secondary anastomotic leakage requiring continuous bladder drainage for another week.

The reported difficulties encountered in vesicourethral reconstruction during laparoscopic prostatectomy prompted the group of Creteil to use two hemicircumfer-ential running sutures for the anastomosis instead of interrupted sutures, which so far, were used in all of the reported series (3,4,25). The authors also observed four cases of intraperitoneal urine extravasation in the beginning of their experience; these patients requested open or laparoscopic repair, for three and one of them, respectively. No reoperation was necessary for the second half of the experience in Creteil, although postoperative cystography, performed at postoperative days 4 to 5, demonstrates that about 15% of patients have at least some degree of anastomotic leak (26).

To ensure the quality of the direct anastomosis, Türk et al. emphasize the importance of an atraumatic and precise dissection of the bladder neck. They observed 13.6% anastomotic leakage in their series of 125 patients, almost all of them gathered during the learning curve; overzealous use of diathermy around the bladder neck was estimated responsible for these relatively poor results (13).

Beside the arguments in favor of running techniques to increase the watertight-ness of anastomoses, several experimental studies on small bowel demonstrate, that the time required is significantly shorter with running sutures compared to interrupted sutures. However, interrupted sutures are often preferred on small bowel, because running sutures may lead to anastomotic stenosis when the suture line is tightened (27). In spite of this, stenosis almost never occurs on urethrovesical anastomosis with running sutures, because the Foley catheter prevents early narrowing of the anastomotic circumference and because reduced extravasation prevents subsequent fibrosis.

Increased surgical precision may reduce the risk of postoperative urethral strictures. Catalona et al. reported 4% urethral strictures in his series of 1870 open prostatec-tomies (28). Furthermore, as reported for the Medicare population, transurethral incision in 3.3%, transurethral resection in 2.9%, and urethral dilation in 7.3% were performed, respectively, after radical retropubic prostatectomy, for the relief of urethral or bladder neck strictures (29). Vesicourethral anastomosis stricture is reported as high as 0.48% to 32% in the literature; several comorbidity conditions may influence this outcome of surgery through the mechanism of microvascular disease having a direct impact on oxygenation and tissue healing (30,31).

Strictures after laparoscopic prostatectomy were reported in 2.8% only by Rassweiler et al. (32) and in only 0.5% during the further experience of Abbou and coworkers (33).

In the author's own experience, only 4/265 (1.5%) anastomotic or urethral strictures with a mean follow-up above 18 months (range, 1-43 months) were observed. This compares favorably with the 4/85 cases (4.7%) observed with our initial series of patients. The difficulties already mentioned with the first knot remain true with the technique of two hemirunning sutures, where the anastomosis is initiated by approximating the bladder neck to the urethra at the 3 o'clock position with one suture only.

Our technique described herein as the single knot method, offers further simplification of the running suture technique. The first knot is prepared extracorporeally by joining the two ends of the threads together. After both needles are passed through the posterior bladder neck and urethra, the bladder neck is easily moved into position at the 6 o'clock position where the knot sits. So, the entire bladder neck from the 5:30 to 6:30 position is moved as a unit toward the urethra, acting much as a mattress suture. After one suture is run from the 5:30 position to the 3 o'clock position, the other suture is run from the 6:30 to 9 o'clock position. We believe this latter method may decrease the chances of pulling through the initial suture. The catheter is then placed into the bladder. The transition suture allows the stitch to now exit the bladder on its outer surface. The sutures are continued to the 12 o'clock position and tied to each other. This solitary intracorporeal knot now, like the initial extracorporeal knot, rests on the bladder side of the anastomosis.

This simplification of the running suture technique has now been adopted by several teams. For example, Menon et al. moved from the two hemicircle running suture to the single knot technique during their experience with robot-assisted prostatectomy (34,35). This technique was also firstly adopted by Ahlering et al. during the development of his own robot-assisted protocol of laparoscopic prostatectomy (36,37).

The impact of the suturing technique on the days before catheter removal was nicely illustrated by Gill and coworkers (38); they showed that mean catheter time after interrupted, two hemirunning, and single knot running suture at one institution were 14.4 ± 8.4, 9.0 ± 9.2, and 7.6 ± 6.7 days, respectively.

Contrary to our initial concerns with an interrupted suture anastomosis, there have been few problems with bladder neck contractures that have come to our clinical attention. However, we have not been routinely performing cystoscopy on our patients to assess for this problem. Not surprisingly, symptomatic postoperative urinary extravasation has not occurred. Based on a retrograde cystogram, 17/265 patients operated at our center or during mentoring of coworking teams requested additional catheter time beyond days 5 to 7 postoperatively. We believe the initiating mattress-type stitch at the 5:30 to 6:30 position area effectively buttresses and seals this area while the running nature of the closure further results in a urine-tight anastomosis. Referring to our personal experience, we believe also that the avoidance of even minimal urine leak between the suture points may reduce the rate of anastomotic strictures observed by other authors with separated stitches.

It may seem meaningless to compare these running techniques whose results are rather comparable in skilled hands; reduction of operative time was certainly obtained through the development of a stepwise standardized protocol for the whole laparo-scopic prostatectomy.

The choreographic sequence of technical steps is closely linked to a thoroughful reflexion about suturing ergonomy. The best and easiest anastomoses are obtained through an iterative sequence of maneuvers, ensuring an optimal management of the needle exchange between both needle holders.

Strictures after laparoscopic prostatectomy were reported in 2.8% only by Rassweiler et al. and in only 0.5% during the further experience of Abbou and coworkers.

The choreographic sequence of technical steps is closely linked to a thorough reflexion about suturing ergonomics. The best and easiest anastomoses are obtained through an iterative sequence of maneuvers, ensuring an optimal management of the needle exchange between both needle holders.

In the chicken model, the "intrapelvic perspective" on the esophagal stump and on the gastric lumen will easily reproduce the vesicourethral picture. This model is easily adapted to learn interrupted or running suture techniques, and is undebatably cost-effective when compared to other sophisticated models available.

Not surprisingly are these maneuvers accomplished in an improved ergonomic environment when the prostatectomy is robot-assisted.

Currently, daily conventional laparoscopic practice may be enabled by the respect of a strict spatial organization of the needle holders in the working space. The axes of the instruments should work at an angle of 60° to 90°; through pararectal or lateral ports. In this position, when the needle is prepared for stitching, its curve is situated in a vertical plane, hence the jaws of the working needle holder belong to an horizontal plane, perpendicular to the needle plane. If the second needle holder is moved to place its jaws in the same plane as the needle, then when the latter will be pulled through the stitch, a slight rotation of the wrist will replace it immediately ready to be caught for another stitch. This rule works irrespectively of the right or left side of the working hand and with either forehand or backhand maneuvers and of course with interrupted or running sutures. This type of ergonomic rule may be reproduced for any type of suture such as for pyeloplasty or in case of robot-assisted procedures. In our experience, this technique brought our suturing time for urethrovesical anastomosis around 20 minutes during a whole prostatectomy lasting 2 to 2.5 hours.

Basic suturing principles should always be taught in dry boxes where these ergonomic rules are easily illustrated; thereafter, their application to tissues could be extended to still and live animal models such as simple chicken skin models (39,40), chicken breast models (41,42) or in surgery on the pig or on human cadavers (43,44). The chicken thoraco-abdominal cavity reproduces very nicely the human pelvis hollow cavity. The esophagus dissection starts at the joint with the glandular stomach releasing it basically, from the surrounding fat; the esophagus-gastric junction is then divided sharply.

In the chicken model, the "intrapelvic perspective" on the esophagal stump and on the gastric lumen will easily reproduce the vesicourethral picture. This model is easily adapted to learn interrupted or running suture techniques, and is undebatably cost-effective when compared to other sophisticated models available.

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