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Robotic assisted laparoscopic radical prostatectomy anastomotic technique with quill sutures
Mehrdad Alemozaffar, M.D., Wesley Choi, M.D., Jim Hu, M.D., M.P.H..
Brigham and Women's Hospital, Boston, MA, USA.

BACKGROUND: There is a well-known learning curve to performing robotic-assisted radical prostatectomy, and one of the more initially difficult and time-consuming steps is the urethrovesical anastomosis. Several techniques have been reported, each including their own downsides such as: simple interrupted sutures that require more time tying knots or the Van Velthoven and other running suture techniques that can lead to loosening of the suture prior to tying the final knot. We describe our technique that combines an initial interrupted suture followed by a running anastomosis using a new quill suture that prevents loosening of the anastomosis between sutures. These sutures are made from an absorbable monofilament material and contain many small unidirectional barbs that prevent slipping once placed through tissue.
METHODS: After dissection of the anterior urethra, the posterior urethra is left attached to provide traction on the urethral stump. A 3-0 vicryl suture on a CT-3 needle is placed inside-out on the urethra at 6 o’clock and the remainder of the urethra is divided allowing the specimen to be placed aside. The needle is then passed outside-in through the bladder neck and the bladder is brought down to the urethral stump and tied and cut. Two 3-0 six-inch quill sutures are brought in, and placed inside-out at the 5 and 7 o’clock positions on urethra, then placed inside-out through corresponding positions of the bladder neck, and then placed through the pre-looped end of the respective suture and pulled tight. In differing clockwise directions, each needle is then repeatedly passed inside-out through the urethra and outside-in through the bladder neck in a running fashion towards the 12 o’clock position. Once both needles are near the 12 o’clock position one needle is passed through to the other side (i.e. urethra or bladder side) and then tied down with the knot on the bladder side and cut. The bladder is then filled with 120cc of normal saline to check for leaks and the old 16-fr catheter is replaced with a tested 20-fr catheter.
RESULTS: Using this technique, the entire urethrovesical anastomosis can be consistently completed within 10 minutes resulting in a tight anastomosis with no leakage. The technique is demonstrated in the following narrated 8-minute video.
CONCLUSIONS: Our technique for performing the urethrovesical anastomosis during robotic-assisted radical prostectomy uses a combination of interrupted and running sutures with a quill suture and allows surgeons - both novices at the beginning of the learning curve and experts - to consistently perform a water tight anastomosis, requiring only 2 knots, within 10 minutes.


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