Urethrovesical Anastomosis In The Montsouris Technique

This protocol was described by Guillonneau and Vallancien (8) after a continuous cohort of 260 patients operated in 23 months. According to these authors, when compared to the technique described by Walsh (12), it is not necessary to evert the bladder mucosa or to narrow the bladder neck. Knots may be formed inside or outside of the anastomotic lumen. The surgeon works with two needle holders all along this step.

Anastomosis is performed with interrupted 3-0 resorbable 4/8 or 5/8 sutures on a No. 26 needle.

All sutures are tied intracorporeally, although the assistance of a knot pusher may ease the maneuver for beginners. For internally tied interrupted sutures a 6-in. length is sufficient. A metal Benique dilator with a depressed tip allows for the placement of the needle into the urethra and the metal sheet can also help by allowing the needle to slide along the dilator.

The first suture is placed at the 5 o'clock position, running inside-out on the urethra (right hand, forehand) and outside-in on the bladder neck (right hand, forehand). The knot is tied inside the urethral lumen (Fig. 2). Then four sutures are placed symmetrically at the 2, 4, 8, and 10 o'clock positions, the knots are tied outside the lumen.

For a right-handed surgeon, the right-sided sutures run outside-in on the bladder (right hand, forehand) and inside-out on the urethra (left hand, backhand). The left-sided stitches run outside-in on the urethra (right hand, forehand) and inside-out on the bladder neck (right hand, forehand). Finally two sutures are placed at the 11 and 1 o'clock positions, running outside-in on the urethra (right hand, forehand) and inside-out on the bladder neck (right hand, forehand, on the left; left hand forehand, on the right) (Fig. 3). These two last sutures are tied only when the Foley catheter has been correctly positioned in the bladder and checked. The knots are tied outside the lumen, without any risk of balloon injury. The balloon is inflated with 8-10 cc and the bladder is irrigated with 120-200 mL of saline to assess the watertightness of the anastomosis.

Türk et al. described a similar approach in 2001 (13) without major modifications; for these authors, the anastomosis requires 8 to 10 single stitches of 2-0 Vicryl. The same year, Gill and Zippe reported the same attitude; moreover, they described carefully the choreographed sequence of planning and placing the interrupted sutures (Table 1) (7).

Stitch placement is performed using both hands, because more than 50% of the sutures are passed with the left hand.

These authors also address the possible difficulties encountered when starting the sutures. Per Türk et al., to facilitate placement of the initial two stitches, a sponge stick can be employed to place perineal pressure, thereby presenting the urethral stump somewhat more clearly. Difficulties encountered with the placement of the Foley catheter may be

FIGURE 2 ■ Ureterovesical anastomosis in the Montsouris technique. The first suture is placed at the 5 o'clock position, running inside-out on the urethra (right hand, forehand) and outside-in on the bladder neck (right hand, forehand). The knot is tied inside the urethral lumen.
FIGURE3 ■ Urethrovesical anastomosis in the Montsouris technique. Finally two sutures are placed at the 11 and 1 o'clock positions, running outside-in on the urethra (right hand, forehand) and inside-out on the bladder neck (right hand, forehand, on the left; left hand forehand, on the right).

If the posterior stitches are too distant to each other, a "fausse route" may develop during catheter insertion. This gap may also cause delayed healing of the anastomosis at the 6 o'clock level, which may require considerable additional catheter time.

solved by a finger placed into the rectum to lift the bulbar urethra anteriorly; alternatively a catheter insertion mandrin (Guyon) can be employed (7).

If the posterior stitches are too distant to each other, a "fausse route" may develop during catheter insertion. This gap may also cause delayed healing of the anastomosis at the 6 o'clock level, which may require considerable additional catheter time.

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