Modified posterior reconstruction and vesicourethral anastomosis in robot-assisted radical prostatectomy and its impact on anastomosis stricture rate and clips migration

Most of the surgeons dealing with the surgical treatment of prostate cancer apply a popularised kind of posterior reconstruction known as the Rocco stitch. It is an approximation of the remnants of the rectourethral muscles with the remnants of the Denonvilliers’ fascia (DF). Originally, this technique was implemented in a retropubic radical prostatectomy, and in multiple published studies, authors concluded that it allows improvement of early confidence after surgery. Concurrently, multiple reports highlight a concept that DF is too weak to give sufficient support for a posterior reconstruction. Following this idea, some other concepts are being applied, for example, reapproximation of the urethra with the tendinous arch of the levator ani. Reapproximation of the urethral stump and the vesical opening promotes a tension-free anastomosis, allows achieving a longer membranous urethra, and creates a firm posterior support. After the transition from a classic laparoscopy to robot-assisted radical prostatectomies in our institution, an increased number of cases of vesico-urethral anastomosis strictures (VUAS) were noted. In most cases, polymer clip migration was revealed during endoscopic inspection. VUAS is not easy to treat and entails a risk of debilitating complications. That has prompted the authors to look for a solution. Our modification applies an approximation of the urethral stump with the vesical opening using a barbed running suture in two layers. The first layer is an equivalent of a Rocco stitch, which brings together the posterior aspect of the urethral stump and the external aspect of the bladder neck. After an adequate tightening of this first line of the sutures, an additional layer of the same running suture is placed to precisely reapproximate the mucosa of the urethra and the bladder opening. This reconstruction is followed by a regular vesico-urethral anastomosis using a standard van Velthoven technique. In the period from March 2020 to March 2024, there were 291 robot-assisted radical prostatectomies (RARP) performed in our Institution. The first 50 RARP were not included in the study as a learning curve group. In our retrospective observational study, we have compared an initial group of patients with the use of the classic Rocco stitch (n = 135) with a study group (n = 156) where the aforementioned modification of the posterior reconstruction was applied. VUAS was noted in 9 cases (6.67%) in the initial group, and 3 (1.92%) in the study group. The endoscopic inspection revealed 7 cases with clip migration after the classic Rocco stitch and 1 after the modified method. In our opinion, such modification can be a valuable option for the robot assisted VUA due to many factors: a reduction of tension in the anastomosis, an increased number of tissue layers that may promote healing through an improved blood supply and create separation of the healthy tissue from the polymer clips, and finally a reduction of VUAS. Furthermore, the mucosa approximation and the multilayer posterior plate can guarantee an unobstructed catheterization if any unexpected catheter loss happens. Nevertheless, further studies are required for a stronger confirmation.

Funding Statement

FUNDING This research received no external funding.

CONFLICTS OF INTEREST

The authors declare no conflict of interest.

ETHICS APPROVAL STATEMENT

The ethical approval was not required.

Video can be found at https://www.ceju.online/journal/2024/posterior-reconstruction-2418.php