Laparoscopic radical prostatectomy (LRP) still remains a challenging procedure reserved mostly for devoted centers. Three dimension (3D) imaging is an important facilitation in this demanding procedure. The urethrovesical anastomosis (UVA) with intracorporeal precise suturing is one of the most critical part of LRP. The quality and precision of a UVA is a major factor of fast and thorough recovery of continence after surgery. Simplifications, especially in this part of the surgery, are needed to decrease the operative time, reduce the operating team fatigue and can potentially encourage urology surgeons to utilize laparoscopy for prostate cancer treating. Posterior reconstruction of urethra support was first described by Rocco in an open approach than soon adopted by robotic surgeons and widely modified since then. While its direct impact to continence is still debatable posterior reconstruction can promote better continence outcomes by providing tension-free anastomosis and preventing posterior retraction of the urethral stump. There are many modification of so called Rocco stitch, mainly in robotic surgery, which also include multi-layer suturing thus cannot be easily implemented in classical laparoscopy. We present a simplified single suture technique for reapproximation of a urethra and a bladder neck that precede UVA with two monofilament running sutures.
After prostate gland being removed from the pelvis single braided 2.0 suture with a V-20, 26mm needle is used for posterior reconstruction. First passage of a needle is right hand with inverted needle grasping the remnants of rectourthtralis muscle beneath the urethra that is facilitated by the assistant compressing the perineum with a finger or a sponge stick. Second passage of the needle is left hand forehand on the posterior wall of a bladder wall just beneath the bladder neck. Approximation and tying of this suture is facilitated by assistant locking first node with a needle driver.
For the anastomosis we use two monofilament 3.0 Biosyn sutures on a V-20, 26mm needle. UVA is performed according to the method proposed by Dr. Reanaud Bollens and to our best knowledge the method has never been published yet. First suture is placed outside-in the bladder neck at 6:00-o'clock than two passages through outside-in and inside-out of the urethra, finishing with outside-in the bladder. The first knot is tight inside the bladder nevertheless we have never encountered any calcification in about 5 years of utilizing this method. This first suture creates a firm and solid posterior plate of the anastomosis that can be easily proceeded by running sutures on both sides finalizing the procedure.
This method of posterior reconstruction and UVA was used in more 226 LRPs in 3D with an average time of 17minutes. This modification enables to perform repeatable and teachable, water tight, tension-free urethrovesical anastomosis with use of more cost effective material than barbed sutures.