UROLOGICAL ONCOLOGY Revisiting Vesicourethral Anastomosis during Open Radical Retropubic Prostatectomy; A Simple and Reproducible Technique: A Single Center Experience with 200 Cases Abbas Basiri1,2*, Seyed Hossein Hosseini Sharifi2 Purpose: Vesicourethral anastomosis (VUA) represents a challenging step of open radical prostatectomy (ORP) because of limitation of space in the depth of male pelvis, lack of control on knots during tightening which subse- quently causes inadequate coupling of VUA or breakdown of knots, and also extremely difficult reapplication of sutures. To facilitate this step of ORP, we have developed a simple and reproducible technique and reported our 8-year experience. Materials and Methods: We used two extra-long DeBakey tissue forceps to approximate the bladder neck to the urethral stump. We found it more beneficial than Babcock clamp especially in obese patients with excess fatty tissue in the pelvic area. In this technique, the surgeon's assistant creates more space for the surgeon’s hand by sweeping the fatty tissue away from the anastomotic area and then pushes the reconstructed bladder neck down while the sutures are being tied. Results: We analyzed data from 200 patients with prostatic cancer who underwent open radical prostatectomy performed from 2009 to 2017. There were only 2 sutures disrupted during knot tying. In two cases (1%), drain output was more than 30 mL/day on postoperative day 2 and drainage was left in place for a longer duration. With the help of medications, time voiding and dedicated pelvic floor exercise whenever needed,.the goal of full urinary continence (0- 1 pad/day) was achieved in 85%, 94% and 98% of patients immediately after catheter removal, 3 months and 6 months after surgery, respectively. Eight patients (4%) developed urethral stricture. Conclusion: The surgical technique has been shown to be an independent predictor of urinary continence. We introduce a new simple modification of vesicourethral anastomosis during RP. Using this technique; in addition to reducing anastomotic disruption rate and increasing knot tying control, postoperative urinary continence after ORP may also be improved. Keywords: vesicourethral anastomosis; open radical prostatectomy; follow up INTRODUCTION Radical prostatectomy (RP) is the gold standard treatment for prostate cancer. Perioperative com- plication rates have been reported between 7.8% and 17.9%, which include prolonged vesicourethral anas- tomotic leak in up to 3.5% of cases and anastomotic stricture in up to 4.9% of patients during follow-up.(1,2) A key step during the procedure is the formation of a watertight vesicourethral anastomosis (VUA). This maneuver, however, remains one of the most challeng- ing parts of the surgery, requiring significant training and experience and is commonly a time consuming task even in the hands of an experienced surgeon. The impact of urethral stricture and urinary incontinen- cy on patient’s quality of life can be devastating even in the case of an oncologically perfect surgery. For these reasons, this step must be mastered by any urologist who wants to perform impeccable radical prostatecto- my. (3) In laparoscopic RP, running anastomosis is usually used which is quicker and technically less challenging than interrupted anastomosis. For open radical prosta- 1Urology and Nephrology Research Center (UNRC), Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences (SBMU), Tehran, Iran. 2Department of Urology, Erfan Hospital, Tehran, Iran. *Correspondence: Urology and Nephrology Research Center, Shahid Labbafinejad Medical Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran. Tel: +98 21 2256 7222. E mail: basiri@unrc.ir. Received September 2018 & Accepted November 2018 tectomy(ORP), most surgeons perform vesicourethral anastomosis using interrupted sutures because of the difficulty of continuous suturing.(4) There are numerous studies comparing suturing tech- niques (i.e. interrupted versus continuous suturing) for vesicourethral anastomosis but it seems that limitation of space in the depth of male pelvis, especially in obese patients, and lack of control on knots during tightening are important factors that should be addressed first. To facilitate this step of ORP we have developed a feasible and reproducible technique and aim to report our 8 year experience. MATERIALS AND METHODS Between January 2009 and June 2017, 200 consecutive patients with organ confined prostate cancer regardless of patient’s characteristics such as age, BMI and comor- bidities underwent open retropubic radical prostatecto- my for clinically localized prostate cancer and were selected for the novel modified vesicourethral anasto- mosis technique , which was approved by the ethical committee of the institution. Urology Journal/Vol 16 No. 5/ September-October 2019/ pp. 475-477. [DOI: 10.22037/uj.v0i0.4800] Vesicourethral anastomosis was performed using an interrupted suturing technique. We used six 3-0 vicryl sutures starting by tightening the anterior one then mov- ing on to the 10-, 8-, 6-, 4- and 2-o’clock positions. We used two long DeBakey tissue forceps to approxi- mate the bladder neck to the urethral stump. We found it more beneficial than a single Babcock clamp in the midline which all sutures are tied, especially in obese patients with excess fatty tissue in the pelvic area. By using this technique, the surgeon's assistant can sweep the fatty tissue away from the anastomotic area and cre- ate more working space for the surgeon and then push the reconstructed bladder neck down and hold it close to the urethra while the sutures are being tied. We found it beneficial to prevent tension on sutures as it could avert suture breakdown. (Figures 1 & 2) RESULTS We analyzed data from 200 patients with prostatic can- cer who underwent RP performed from 2009 to 2017. Only 2 sutures were disrupted while tying in the initial experience. In two cases (2%), we encountered drain output more than 30 mL/day on postoperative day 2 and the drain was left in place for a longer duration. The goal of full urinary continence (0- 1 pad/day) was achieved in 85%, 94% and 98% of patients immediate- ly after catheter removal, 3 months and 6 months after surgery, respectively, with the aid of medications, time voiding and dedicated pelvic floor exercise. Eight pa- tients (4%) developed urethral stricture. DISCUSSION VUA represents a challenging step of ORP because of low depth of the male pelvis, lack of control on knots during tightening and subsequent inadequate coupling of VUA or breakdown of knots and also extremely difficult reapplication of sutures. The vesicourethral anastomosis creates watertight closure with urethral realignment and mucosal coaptation. Disruption of the vesicourethral anastomotic sutures while tying is not uncommon and reapplication of sutures is often diffi- cult(5). It seems that suture breakdown during vesicoure- thral anastomosis is not a rare experience for surgeons who perform radical prostatectomy. Imperfect vesi- courethral anastomosis can cause significant postop- erative urinary extravasation which results in a longer catheterization time, increased risk of long-term anas- tomotic strictures and longer hospital stay. Due to the high number of radical prostactemy operations being performed annually in the world, even small differenc- es in surgical outcomes and complications can possibly affect a great number of patients. The rate of urinary incontinence after RP is significantly affected by the surgeon’s experience, surgical technique and definition of continence. The surgical technique has been shown as an independent predictor of urinary continence. Be- yond any technique used to improve the result of vesi- courethral anastomosis for short term and long term continence rate, feasibility, convenience and simplicity are the most important factors that should be addressed initially.(6) Several technical modifications have been introduced to improve postoperative urinary conti- nence. Most studies that address increasing the quali- ty of vesicourethral anastomosis focus on comparing suture techniques (continous and interrupted), bladder neck reconstruction and reducing anastomosis time.(7,8) In this study we introduced a simple technique to facil- itate vesicourethral anastomosis. Primarily, we did not intend to evaluate the continence rate and urethral stric- ture but the results are comparable with those obtained using standard techniques. Ficarra et al. reported the 12-month urinary incontinency rate to range from 4% to 31% and also stricture-related complications after open radical prostatectomy was reported by Sujenthiran et al. to be 6.9% .(9,10) Figure 1. Using two extra-long Debakey forceps to approximate the bladder neck to the urethral stump Figure 2. Surgeon's assistant can sweep the fatty tissue posteriorly away from anastomotic area Vesicourethral anastomosis following open radical retropubic prostatectomy-Basiri et al. Urological Oncology 476 Vol 16 No 04 September-October 2019 477 CONCLUSIONS Although the quality of the vesico-urethral anastomosis is unlikely to have an impact on the oncological out- come of radical prostatectomy, it undoubtedly affects functional outcome and quality of life(11). Using this simple modified technique helps to prepare more space in the cramped and confined pelvic space to apply proper knot placement and better tissue appo- sition. 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