Abstract
Introduction:
In the literature, technical modifications have been proposed to reduce urinary incontinence rates after radical prostatectomy. These include bladder neck preservation, neurovascular bundle preservation, and bladder neck reconstruction or reinforcement. 1 The Heilbronn LRP ascending technique, as defined by Rassweiler et al., is an anterior reconstruction method. It involves placing a continuous suture for backflow 2–3 cm proximal to the bladder neck during radical prostatectomy to reduce potential bleeding from the bladder. 2 In addition to reducing bleeding, it was hypothesized that the backflow suture could enhance continence by narrowing the bladder neck near the bladder outlet and reducing pressure up to the anastomosis and sphincter. Therefore, the impact of applying the backflow suture, as described in the Heilbronn technique, using a continuous bidirectional suture was investigated for its effects on continence in patients undergoing robot-assisted radical prostatectomy (RARP).
Materials and Methods:
After obtaining approval from the Antalya Training and Research Hospital Ethics Committee, the tube-shaped bladder neck technique was applied to five consecutive patients scheduled for routine RARP in our clinic. The patients' demographic, surgical, and oncologic data are presented in Table 1. Patients who did not use any pads or used one safety pad were considered urinary continent. According to the author disclosure statement, there have been no commercial relationships that could create a conflict of interest in connection with the video in the past 3 years. We have received and archived patient consent for video recording/publication in advance of video recording of procedure.
Demographic, Surgical, and Oncologic Data of the Patients IPSS, International Prostate Symptom Score; PSA, prostate specific antigen; TNM, tumour, node, metastasis.
Feature
Patient 1
Patient 2
Patient 3
Patient 4
Patient 5
Age, years
63
64
70
65
67
Preoperative PSA, ng/mL
4
8
15
8
9.59
Prostate volume, cc
54
24
100
58
55
Preoperative IPSS
19
10
30
20
15
Postoperative IPSS
5
4
8
7
5
Biopsy Gleason score
3 + 3
3 + 3
3 + 3
4 + 3
3 + 3
Clinic TNM category
pT2b
pT2c
pT2c
pT2c
pT1c
Console time, minutes
240
330
420
210
250
Estimated blood loss, mL
125
200
300
250
250
Complications
Ileus
0
0
0
0
Catheterization time, days
8
9
8
8
9
In-hospital stay
4
3
3
3
5
Pathologic TNM category
pT3a
pT3aN0
pT3aN0
pT2cN0
pT2bN0
Positive margins
No
Yes
No
No
Yes
Pathologic Gleason score
3 + 4
3 + 4
3 + 4
4 + 3
3 + 4
Urinary continence
1 Month
1 Month
3 Months
3 Months
1 Month
Postoperative Qmax
20 mL/s
22 mL/s
18 mL/s
25 mL/s
28 mL/s
Postoperative bladder capacity
400 cc
550 cc
600 cc
450 cc
520 cc
Tube-Shaped Bladder Neck Technique:
The surgeries were conducted under general anesthesia with the patient in a 30° Trendelenburg position, after standard surgical preparation using a transperitoneal anterior approach. After completing the surgical steps described, the bladder neck was identified. To narrow the bladder neck, 2–0 multifilament absorbable continuous sutures were applied at 1 cm intervals, starting ∼2 cm proximal to the bladder neck. This resulted in a tubular narrowed bladder neck. The sutures were advanced through the serosal and muscular surfaces of the bladder, with an aim to remain on the serosal surface as much as possible. Suturing began on the right lateral side and continued at 1-cm intervals until reaching the left lateral side. The suturing then continued by returning 1 cm proximal to the left lateral side, and the procedure was terminated by tying the threads on the right lateral side (Fig. 1). The aim was to narrow the angle of the vesicourethral junction and partially resemble the geometry of the bladder neck to that of the urethra, thereby increasing the functional urethral length. Reflux bleeding was prevented while also aiming to reduce the reflection of intrabladder pressure to the external urethral sphincter in cases of increased intra-abdominal pressure.
Our modified urethral anastomosis technique.
Results:
Demographic, surgical, and oncologic data of the patients are given in Table 1.
Conclusions:
The physiologic mechanisms associated with urinary continence after radical prostatectomy are still not fully understood. 3 At this point, we think that our technique will contribute to the literature in this respect, because the favorable early continence times obtained in our first five cases encourage us to continue this new approach.
No competing financial interests exist
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Runtime of video: 4 mins 40 secs
