Running Suture Technique For Vesicourethral Anastomosis

Hoznek et al. started their own laparoscopic experience with prostatectomy about six months later than the Montsouris group. One will notice that these authors moved very early to a running suture to deal with the urethrovesical anastomosis. This attitude aimed at sparing the time devoted to knots on interrupted stitches as well as to avoid any intraluminal knotting (5).

The patient is positioned in dorsal decubitus, with the legs slightly spread to allow intraoperative rectal examination. Five trocars are used; as already mentioned, trocar disposition has primary importance in the anastomotic technique, because they determine the axis of the needle holder, plane of the needle, and angle between the instruments. Once the prostate is excised, there is usually no need to perform a racket

TABLE 1 ■ Choreographed Sequence of Successive Stitches in Interrupted Vesicourethral Anastomosis

Stitch

Location (o'clock)

Start

Hand

End

Hand

Knot

1

5

UR-Io

Rh Fh

BN-Oi

Rh Fh

Inside

2

7

UR-Io

Lh Fh

BN-Oi

Lh Fh

Inside

3

8

BN-Oi

Lh Fh

UR-Io

Lh Fh

Outside

4

4

BN-Oi

Rh Fh

UR-Io

Lh Bh

Outside

5

9-10

BN-Oi

Lh Fh

UR-Io

Rh Bh

Outside

6

2-3

BN-Oi

Rh Fh

UR-Io

Lh Bh

Outside

7

11-12

UR-Oi

Lh Fh

BN-Io

Rh Fh

Outside

8

12-01

UR-Oi

Lh Fh

BN-Io

Lh Fh

Outside

Abbreviations: UR, urethra; BN, bladder neck; Rh, right hand; Lh, left hand; Bh, backhand; Fh, forehand; lo, inside-outside; Oi, outside-inside. Source: From Refs.7 and 8.

FIGURE5 ■ The running suture technique. One or two sutures are then placed near the 6 o'clock position of the bladder and urethra. The sutures at the bladder side are easier to perform with the more horizontal left needle holder.

FIGURE4 ■ The running suture technique. A starter knot is done at the 3 o'clock position, the suture is conducted from outside-in on the bladder, then from inside of the urethra to the outside. For both needle passages, we use the right needle holder. The suture is then tightened with intracorporeal technique.

FIGURE5 ■ The running suture technique. One or two sutures are then placed near the 6 o'clock position of the bladder and urethra. The sutures at the bladder side are easier to perform with the more horizontal left needle holder.

The vesicourethral anastomosis consists in a posterior and an anterior hemicircumferential running suture. Two needle holders are used simultaneously.

handle bladder neck reconstruction. Indeed, due to improved visibility and identification of anatomic landmarks during laparoscopy, the bladder neck is often sectioned in the optimal plane.

The vesicourethral anastomosis consists in a posterior and an anterior hemicir-cumferential running suture. Two needle holders are used simultaneously.

The right needle holder is inserted through the 12-mm disposable trocar situated at the right margin of the rectus sheath. This trocar allows also the passage of the suturing material: a 3-0 Vicryl suture with a 26-mm needle, where the optimal length of the suture is about 20 cm. The left needle holder is passed through the 5-mm port near the left anterior superior iliac spine. One will notice here again that this implies an angle of at least 60° between the needle holders axes. The surgeon manipulates these two needle holders. The first assistant holds the 0° lens which is passed through the 12-mm trocar at the umbilicus. In the other hand, he holds the suction-irrigation device, passed through the left 12-mm trocar. The suction-irrigation device allows exposing the bladder neck and removing the accumulated urine from the operating field. A second assistant or the instrumentalist uses a narrow forceps to hold the long tail of the running suture. On the urethral side, the long tail is maintained under traction in the direction of the symphysis, while on the bladder side it is pulled cephalad.

A starter knot is done at the 3 o'clock position. The suture is placed from outside in on the bladder, then from inside of the urethra to the outside. For both needle passages we use the right needle holder. The suture is then tightened with intracorporeal technique (Fig. 4). Next, the needle is passed from outside to inside of the bladder, below the starter knot, at the lower margin of the bladder neck in the 4 o'clock position. This is done with the right needle holder. One or two sutures are then placed near the 6 o'clock position of the bladder and urethra. The sutures at the bladder side are easier to perform with the more horizontal left needle holder (Fig. 5). For the left lateral zone of the bladder neck and urethra, we use the right needle holder (Fig. 6).

For the terminal knot of the posterior hemicircumferential suture, a closed loop is prepared at the 9 o'clock position. The needle is passed from inside to outside on the bladder, then from outside to inside on the urethra, thus forming a loop, and again from inside to outside on the bladder side. The suture line is thus ended extramurally with a three-legged. The Foley catheter is pushed without any difficulty into the bladder.

Then, a second running suture is realized on the anterior margin of the bladder and urethra, beginning at the 2 o'clock position on the bladder side, then in the urethra with the help of the right needle holder (Fig. 7). Two or three needle passages

FIGURE 7 ■ The running suture technique. Then, a second running suture is realized on the anterior margin of the bladder and urethra, beginning at the 2 o'clock position on the bladder side, then in the urethra with the help of the right needle holder. Two or three needle passages are sufficient to close entirely the anterior aspect of the anastomosis.

FIGURE6 ■ The running suture technique. For the left lateral zone of the bladder neck and urethra, we use the right needle holder.

FIGURE 7 ■ The running suture technique. Then, a second running suture is realized on the anterior margin of the bladder and urethra, beginning at the 2 o'clock position on the bladder side, then in the urethra with the help of the right needle holder. Two or three needle passages are sufficient to close entirely the anterior aspect of the anastomosis.

are sufficient to close entirely the anterior aspect of the anastomosis. A loop is again formed at the 10 o'clock position and the knot is tied. These different sutures are performed with deliberate structured and error-free choreography, which has evolved progressively during the developmental phase of laparoscopic radical prostatectomies.

Since 2000, about 265 consecutive patients have been treated with this modified running suture consisting of one single intracorporeal knotch.

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