Optimizing vesicourethral anastomosis healing after robot-assisted laparoscopic radical prostatectomy: lessons learned from three techniques in 1900 patients.
OBJECTIVE
Creation of an optimally apposed, tension-free, well-supported vesicourethral anastomosis remains the cornerstone for anastomotic healing after radical prostatectomy. We report the effect of three techniques of bladder neck reconstruction during robot-assisted radical prostatectomy on anastomotic leak, stricture formation, and continence recovery.


METHODS
Between January 2005 to September 2009, 1900 consecutive patients underwent robotic-assisted laparoscopic prostatectomy (RALP) by a single surgeon. Of these, the first 214 underwent vesicourethral conventional anastomosis (CA); the next 303 men underwent anterior reconstruction (AR) only; and last 1383 men underwent total anatomic restoration (TR). Data elements included patient age, body mass index, preoperative biopsy Gleason score and prostate-specific antigen level, prostate volume, total operative time, console time, time for performing vesicourethral anastomosis, estimated blood loss, tumor stage, and margin status on final pathologic findings. Primary end points were rates of clinically significant anastomotic leaks, bladder neck contractures, and time to return of continence. Chi-square and Fisher exact tests were used for analysis of categoric variables. The Cox proportional hazard model was used for both univariate and multivariate analysis.


RESULTS
Clinically significant anastomotic leakage and bladder neck strictures were significantly fewer in the reconstructed groups (2.3% vs 1.0% vs 0.3% and 3.7% vs 1.3% vs 0.5% in the CA, AR, and TR groups, P < 0.01). Continence rates at 1, 6, 12, 26, and 52 weeks after RALP were also significantly better at all time points with AR and TR compared with CA alone (P < 0.001).


CONCLUSIONS
TR of the continence mechanism optimizes vesicourethral anastomosis healing and hastens early continence return after RALP.
Department of Urology, Weill Medical College of Cornell University, New York Presbyterian Hospital, LeFrak Center of Robotic Surgery and Institute of Prostate Cancer, James Buchanan Brady Foundation, New York, New York 10065, USA.
Gerald
G
Tan
Abhishek
A
Srivastava
Sonal
S
Grover
David
D
Peters
Philip
P
Dorsey
Ann
A
Scott
Jay
J
Jhaveri
Derya
D
Tilki
Alexis
A
Te
Ashutosh
A
Tewari
D000714:Anastomosis, Surgical / Q000009:adverse effects / Q000379:methods*; D001706:Biopsy; D003710:Demography; D006801:Humans; D010535:Laparoscopy; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000209:etiology; D011300:Preoperative Care; D011467:Prostate / Q000473:pathology / Q000601:surgery; D011468:Prostatectomy / Q000379:methods*; D012371:Robotics / Q000379:methods*; D013997:Time Factors; D014521:Urethra / Q000601:surgery*; D001743:Urinary Bladder / Q000601:surgery; D001748:Urinary Bladder Neck Obstruction / Q000503:physiopathology / Q000601:surgery; D014945:Wound Healing