Van Velthoven suturing after a laparoscopic radical prostatectomy is effective, easily learned

Berlin-The Van Velthoven suspended running suture technique used for vesicourethral anastomosis after a laparoscopic radical prostatectomy is very effective, according to a recent multicenter study. Results of the study also show this novel technique is easily applied and taught, and it can generate reproducible functional and anatomic outcomes, while demonstrating a fairly low rate of early and late postoperative complications.

"The rationale behind this technique is mainly aimed at improving the geometry and the ergonomics of the vesicourethral anastomosis," explained Roland Van Velthoven, MD, PhD, chairman of the department of urology, Jules Bordet Institute, Brussels, Belgium, who developed the technique.

At the European Association of Urology annual congress, Dr. Van Velthoven reported on the results of a study in which this vesicourethral anastomosis technique was used in 5,158 patients following laparoscopic radical prostatectomy.

Dr. Van Velthoven explained how the technique is performed.

"Starting at the mid-portion of the posterior lip of the bladder neck and running clockwise on the left side and counterclockwise on the right side, a medial posterior knot allows the system to work as a winch, approximating the posterior aspect of the suture without impairing the vision of the surgeon. A single knot achieves the running suture on its anterior aspect," he said.

The mean operative time using this technique was 16 minutes for experts, 23 minutes for second-generation surgeons, and 30 minutes for trainees, he said. The learning curve might be reflected to some extent in the length of the procedure for second-generation surgeons or for trainees. Additional stitches can be part of the learning curve, he said, but on average, they represent only 1% of all cases from the survey.

"The mean catheter time also reflects a part of the learning curve. [The catheter] was removed at an average of 7 days. Nowadays, we know that we probably can remove the catheter at 5 days for most of the surgeons following the retrograde cystogram. It was so in all of the centers that participated in the study except for one," Dr. Van Velthoven said.

Leakage control

Early leakage post-procedure occurred in 2% of cases. According to Dr. Van Velthoven, this low number reflects the tightness of the wall and success of the anastomosis seen in the retrograde cystogram.

"When we stick to a catheter time of 5 days, we can afford the main risk of acute retention. The results of the study showed acute retention to be as low as 0.5%. In these few cases, an additional time of 3 days was required," he said.

According to Dr. Van Velthoven, the tightness of the wall and the good adequation of the mucosal adjustment in this anastomosis technique are reflected in the very low urethral stenosis rate, and were found to be just below 1% of cases. For the most part, this small percentage of patients subsequently required an internal urethrotomy.

He noted that the technique is also suitable for treating discrepancies between bladder and urethral diameters or for orthotopic anastomosis of neobladders.

"In my opinion, the results of continence are not obvious because a lot of issues are happening during the dissection phase, and many different surgeons can achieve different outcomes," he said. "So this result is much more operator dependent and is not linked to the an-astomosis technique. I believe that its impact on early continence must be further evaluated."

Richard Gaston, MD, of the Center of Urologic Laparoscopy, Cliniq Saint Augustin, Bordeaux, France, applauded Dr. Van Velthoven's technique.

"This excellent suturing technique is now the gold standard for suturing the bladder everywhere in the world," he said.

Helmut C. Klingler MD, of the Medical University of Vienna, Austria, concurred.

"This is a very interesting and important study, as it demonstrates that such techniques that are done at one center with formidable success can be reproduced at another center with quite exquisite excellence, and the data from the study clearly reflect this," Dr. Klingler said.