Preparation Of The Bladder Neck

Complete resection of the prostate unavoidably removes a significant length of urethra, according to the prostate's size.

Relative preservation of the bladder neck contributes to the feasibility of the anastomosis not only in terms of smooth muscle preservation but also by the saving of available centimeters of tissue to fill the prostate gap.

A wider opening of the bladder neck, in case of the presence of a large median prostatic lobe has only reduced impact on the anastomotic technique (8).

The posterior lip of the bladder neck is generally approximated first to the posterior urethra. In case of excessive discrepancy between the diameters of both organs, an anterior vesicoplasty will be carried out at the end of the anastomosis in most of the cases. A posterior vesicoplasty, performed prior to the anastomosis, is generally not necessary but must be achieved only when the ureteric orifices are at 5 mm or less from the bladder limit; this suture is carried out with either interrupted or running stitches; it allows for a larger safety distance between orifices and suture line but may also enable the anasto-motic technique by reducing and tubulizing the diameter of the bladder neck. This latter artifice becomes mandatory in case of previous transurethral resection of the prostate or of Millin's adenomectomy; in these instances, both the ureters are at high risk of obstructive stretching if the bladder is simply pulled down toward the urethra.

Three main techniques are presented in the literature to achieve the vesicourethral anastomosis: the Montsouris technique (8) for interrupted sutures; the running suture, popularized by Gaston in Bordeaux and described in 2000 by the group of Creteil (France) (5); and the modified running suture, described by our group (9-11).

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