Assistant-Less Urethrovesical Anastomosis During Robot-Assisted Radical Prostatectomy Using a Unidirectional Barbed Wound Closure Device

Abstract

Introduction: Urethrovesical anastomosis (UVA) is a critical and technically demanding step during robot-assisted radical prostatectomy (RARP). The commonly used Van Velthoven stitch has limitations relating to slippage and unraveling of the monofilament suture. This necessitates constant traction by an assistant or repeated tightening of suture by the surgeon, necessitating an experienced assistant, prolonging UVA time, and increasing risk of instrument clashes and urethral tears. We present a novel technique of UVA utilizing unidirectional barbed suture that overcomes these limitations. Materials and Methods: The UVA suture is pre-prepared from two 6-inch 3-0 polyglyconate barbed sutures by running the needle of each suture through the loop of the other suture, creating a sturdy, bidirectional, barbed suture. This 12-inch composite suture is used to perform UVA as previously described. However, the patient side assistant does not follow the suture or provide any help with the UVA and the two sutures are not tied at the conclusion of UVA, but merely continued across for one additional throw. Fifty-one consecutive patients undergoing RARP at our institution underwent a dual-layer UVA using the barbed suture. Integrity of anastomosis was tested intraoperatively by instilling 240 mL of saline in the bladder. Cystogram was performed at 7 days. Preoperative, demographic, and perioperative data were recorded prospectively. Intraoperative adverse events (including anastomotic leaks) and post-operative complications (urinary retention and anastomotic strictures) were recorded. Follow-up was at least 1 month. Results and Conclusions: Median time for UVA was 11 min, with 45% performed in <10 min. Eight (16%) required anterior bladder neck reconstruction by extending the suture across in figure of eight pattern. No patients had cystogram-detected urinary leaks, urinary retention, or anastomotic strictures. Not having an assistant who follows the suture minimizes instrument clashes, suture entanglement, inadvertent suture breakage, and urethral tears, and makes UVA faster and efficient. This advantage translates into avoiding an assistant for an inexperienced surgeon and faster UVA for an experienced one. We noted 25% reduction in UVA time in a comparative study performed at our institution. It is postulated that because of the barbs, each throw becomes an independent interrupted suture and holds itself in place, making knot tying unnecessary. Hypothetical concerns include strangulation of urethra causing strictures or urinary retention; neither occurred in our cohort. Since the barbs do not allow the suture to be retracted once placed, any mistake in placing throws necessitates the UVA to be redone. However, the first inch of the suture is without barbs, and if a misstep is recognized early, the suture may be readjusted easily. No patients required UVA to be redone for this reason. Although there have been no short-term sequelae, long-term results are awaited. This technique has become the standard of care at our institution. We present a novel technique of UVA during RARP that is safe and efficient, and overcomes the limitations of current techniques. Utilizing barbed self-locking suture obviates the need for assistance, prevents slippage, and allows for knotless anastomosis. No competing financial interests exist. Runtime of video: 5 mins 50 secs