Surgeon Positioning

The urethrovesical anastomosis is generally carried out with preferably two needle holders, eventually with one needle holder in the dominant surgeon's hand, assisted by a straight or Maryland forceps. The choice of the trocars defines the spatial relationship between the needle holders and hence has also a direct impact on the suturing technique.

It has been described by Frede et al. (6) that the angles between the instruments and the suture line are of outmost importance. Acute angles between instruments of 25° and 45° maximize the efficiency of suturing and knotting. This statement is adopted by several teams, irrespectively of the trocar placement. In addition, angles inferior to 55° between needle holders and the horizontal plane simplify also these maneuvers. If the latter sentence seems quite obvious in order to reduce surgeon's fatigue and frustration, the former appears more questionable.

As the urethrovesical suture line is anatomically oriented in the horizontal plane, suturing maneuvers and appropriate needle direction may be eased by needles working as much as possible in a vertical plane, that is perpendicular to the suture plane (Fig. 1). Taking into account the respective orientations of the needle and of the needle holder tip, this is hardly feasible if the main needle holder works through a midline port. In this situation, the needle should work rather parallel to the suture line and this might compromise the achievement and the quality of some stitches with respect to the position of the urethral stump.

In the author's view, needle holders should work preferably with an angulation between 60° and 90°, through the lateral or the pararectal ports.

As a matter of fact, this favorable situation is reproduced when the suture is "robotassisted." It is well known that the working arms of the "slave system" work through the lateral iliac ports, reproducing as such an ideal isosceles triangulation shape with "the eyes of the surgeon" materialized by the lens, located on the midline port.

The preserved length of the urethra is essential to the quality of the urethrovesical anastomosis.

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