Vesicourethral Anastomosis

Laparoscopic reconstructive surgery has been applied to one of the most difficult repairs urologists perform, vesicourethral reanastomosis following radical prostatectomy. First attempted clinically in 1992, research work in animal models continues (105). In combined canine series of 20 animals, the radical retropubic prostatectomy and reconstruction was accomplished with a mean operative time of 294.5 minutes (106,107). In the study by Moran et al. the laparoscopic reconstruction was performed with the laparoscope closely approximated to the tissues for a microscopic repair. Six to eight fluorescently colored polyglactin intracorporeal sutures were placed utilizing microsurgical suspension techniques to convert square knots to slip configurations and back (Fig. 8) (106). No Foley catheters were positioned so as to evaluate the completeness of the microlaparoscopic repair (Fig. 9). One anastomotic leak occurred in six animals available for long-term follow-up. Minimal scarification was noted grossly or on trichrome stained sections in animals at necropsy (Fig. 10) (106).

Clinical application of laparoscopic repair of the vesicourethral anastomosis has been widely performed. There appears to be two basic approaches by review of the literature. There are those who favor an interrupted anastomosis and those who prefer a running anastomosis. There is no prospective randomized data to support either philosophy at present. Claims for almost any belief suggesting an advantage or disadvantage for each technique can be found. For instance, there are those who suggest that the running anastomosis simplifies and facilitates the repair. But there is a large series that argues the opposite (108). There are investigators that believe that the anastomosis capable laparoscopically is potentially better than its open counterpart. Large series are just beginning to be able to investigate this possibility. The complications from the vesicourethral anastomosis should be less. Urinary extravasation should be minimal. In one current series, Menon's group has now begun to leave no postoperative drains when they use a running anastomosis (109). Bladder neck contracture should likewise be lowered, but the exact incidence even in open series is not known (110). One such investigation noted contracture in 11% of radical prostatectomy patients (111). The data are not yet fully available, but there are groups suggesting that symptomatic bladder neck contractures are less following the laparoscopic repair. Is this due to the anastomotic technique or rather secondary to the method of prostatobladder neck division or to the method of mobilization of the bladder for performing a laparoscopic radical prostatectomy? Innovative investigations that might answer this question are beginning to emerge but follow-up remains short (112). A new semiautomatic suturing device has recently been reported from Yamada et al., called Maniceps. Using this device in 15 patients, the urethrovesical anastomosis was completed in 8.1 minutes (range 5-12). They report one bladder neck contracture at short followup (113). Another recent investigational method used 2-octyl cyanoacrylate adhesive for an in vivo canine study to glue the anastomosis in 12 dogs. Four anastomoses were performed with eight interrupted

FIGURE 8 ■ Suspension stitch technique for converting square knots to slipknots.

FIGURE 8 ■ Suspension stitch technique for converting square knots to slipknots.

FIGURE9 ■ Voiding cystogram following laparoscopic radical prostatectomy and microsurgical vesicourethroplasty in a canine model.

sutures compared to eight using the adhesive. Only one of the adhesive animals anastomoses had leak pressures 70 mmHg or greater whereas all four control suture animals achieved this expected outcome (114). Laser welding has also been attempted in the canine model to facilitate this anastomosis. This was an open radical prostatectomy model, but four animals had a conventional eight interrupted suture technique while the experimental group had four support sutures followed by a diode laser welded anastomosis using a chromophore doped albumin solder. They noted superphysiologic leak pressures in all of these animals with no other differences in healing (115).

FIGURE9 ■ Voiding cystogram following laparoscopic radical prostatectomy and microsurgical vesicourethroplasty in a canine model.

FIGURE 10 ■ Gross pathology of laparo-scopic intracorporeal reconstruction eight weeks following radical prostatectomy.

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