Bladder neck contracture after radical retropubic prostatectomy using an intussuscepted vesico‐urethral anastomosis: incidence with long‐term follow‐up

OBJECTIVE

To evaluate the incidence of bladder neck contracture (BNC), a known complication of radical retropubic prostatectomy (RRP), after a 9‐year experience by one surgeon using a novel approach to lower urinary tract reconstruction, the intussuscepted vesico‐urethral anastomosis (IVUA).

PATIENTS AND METHODS

After institutional review board approval, the charts of 406 patients who had RRP for clinically localized prostate cancer from March 1998 to July 2007 were reviewed retrospectively. All patients had lower urinary tract reconstruction using the IVUA technique, which involves a looped urethral suture using six double‐armed sutures that are drawn ‘inside‐to‐out’ from staggered points on the urethral stump through the bladder neck opening. When the sutures are tied down, the urethra is intussuscepted into the bladder neck opening.

RESULTS

At a median follow‐up of 48 months, three patients developed BNC: one was at increased risk secondary to a previous TURP; one had his catheter removed on the second day after RRP in the presence of a suprapubic tube and developed a BNC at his ‘dry’ anastomosis; and one with no risk factors developed a BNC. Balloon dilatation, laser incision and self obturation were successful in stabilizing the strictures while preserving continence. Overall, the incidence of BNC in this series was three of 406 (0.74%).

CONCLUSIONS

IVUA gives a lower incidence of BNC over a long‐term follow‐up than rates cited in previous reports. IVUA is a valuable technique for lower urinary tract reconstruction in patients undergoing RRP.     

Knotless “three‐U‐stitches” technique for urethrovesical anastomosis during laparoscopic radical prostatectomy

We describe a new technique for urethrovesical anastomosis that consists of placing three “U” stitches of Monocryl 2‐0 to connect the bladder neck and urethral stump together. The margins are united by a double passage of the suture, without tying any knots. The sutures are tied on the bladder's surface using Lapra‐Ty clips fixed at a certain distance from where to two mucosal margins have been joined. We carried out this technique on 90 patients who underwent laparoscopic extraperitoneal radical prostatectomy. The good joining of the margins, the absence of knots and the minimum trauma to the urethral wall together enable to create an anastomosis that is both “sealed” and “tension free”, allowing a quick “welding” of the margins and an early catheter removal. Regarding urinary continence, 56.6% (51) of patients were continent at catheter removal, 87.6% (78) were continent 3 months later and 98.9% (89) were continent after 6 months. In nine patients (10%), an episode of acute urinary retention occurred within 24 h after the removal of the catheter. We did not encounter any cases of vesicourethral anastomosis stenosis.     

J‐pouch vs side‐to‐end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision for rectal cancer: a multicentre randomized trial

Aim Comparison of functional and surgical outcome of the J‐pouch with the side‐to‐end coloanal anastomosis after preoperative radiotherapy and total mesorectal excision in rectal cancer patients. Method In a multicentre study, patients with a carcinoma of the lower two‐thirds of the rectum were randomized to either a J‐pouch or a side‐to‐end reconstruction. Primary outcome was function of the neorectum 1 year after surgery. A functional outcome [COloREctal Functional Outcome (COREFO)] questionnaire, and two quality of life questionnaires (EORTC‐QLQ‐CR38 and SF‐36) were to be completed by all participants preoperatively, and 4 and 12 months postoperatively. Independent data managers recorded surgical outcome. A group size of 30 patients in each group was calculated based on a 15‐point difference of the COREFO scale. Results In total, 107 patients were randomized, 55 in the J‐pouch group and 52 in the side‐to‐end anastomosis group. The COREFO incontinence scale at 4 months and the total functional outcome at 4 and 12 months showed better results for the J‐pouch group in comparison with the side‐to‐end anastomosis group. The remaining COREFO scales (frequency, social impact, stool‐related aspects and bowel medication), surgical outcome (complications, reoperations, length of hospital stay, readmissions and mortality) and quality of life did not show significant differences between treatment groups. Conclusion The overall results of a coloanal J‐pouch and a side‐to‐end anastomosis are comparable, although functional results are slightly better with a J‐pouch. The side‐to‐end anastomosis is technically less demanding and therefore a justified alternative in sphincter‐saving surgery.     

An alternative to conventional hand‐sewing colocolic anastomosis: anastomosis with absorbable surgical barrier film without sutures

Aim As a result of its high morbidity and mortality rates, anastomotic leakage is one of the most feared complications in colorectal surgery. Therefore, this issue is one of the most relevant in colorectal surgery and a lot of work has been conducted to research it. The aim of this experimental study was to compare colocolic anastomosis performed by using absorbable surgical barrier film without suture and conventional anastomosis performed by hand‐sewing technique in terms of anastomosis safety. Method In this study, 40 Norway Wistar Albino 3‐month‐old female rats were used. Each weighed between 250 and 300 g. The rates were divided into two groups, a control group and an experimental group. Full‐thickness incisions were made on the ascending colon of both groups of rats. The control group’s anastomoses were conducted using a hand‐sewn technique consisting of one layer of nonabsorbable sutures (Gambee suture). The experimental group’s anastomoses were performed using absorbable surgical barrier film without sutures. Afterwards, sample pieces of the anastomosis area were taken from all rats on either the 3rd or the 7th day following the operation, resulting in subgroups that led to a total of four test groups. The samples taken were subjected first to an anastomosis bursting pressure test followed by histopathological examinations and a test to detect the levels of hydroxyproline in the tissue. Results The control groups (groups 1 and 3) had average anastomotic bursting pressures of 33.0 ± 9.49 mmHg and 146.0 ± 15.06 mmHg respectively, whereas experimental groups (groups 2 and 4) had average anastomotic bursting pressures of 58.0 ± 10.33 mmHg and 190.0 ± 25.82 mmHg respectively. Mann–Whitney U‐test analysis of the bursting pressure values indicates the differences between groups 1 and 2 (3rd day postoperatively) and groups 3 and 4 (7th day postoperatively) to be statistically significant (P = 0.0001 and P = 0.0003 respectively). Values obtained from histopathological staging conducted according to the Ehrlich–Hunt model where the evaluation criteria in this model are: amount of inflammatory cells, fibroblasts, neovascularization and collagen and which were analysed using the Mann–Whitney U‐test have shown no significant difference between 3rd day postoperatively groups 1 and 2 (P = 0.579) while the difference between 7th day postoperatively groups 3 and 4 was found to be significant (P = 0.023). Average levels of hydroxyproline in the tissue were 88.18 ± 8.04 mg/l for group 1, 56.31 ± 5.40 mg/l for group 2, 135.0 ± 6.30 mg/l for group 3 and 100.2 ± 15.42 mg/l for group 4. Analysis of values in the groups using the Mann–Whitney U‐test indicate a significant difference (P < 0.0001) both between groups 1 and 2 and between groups 3 and 4. Conclusion The use of absorbable surgical barrier film without sutures for colocolic anastomosis in rats may be safe.