Gabriel Favre

Abordaje quirúrgico de la estenosis de anastomosis vesicouretral posprostatectomía radical

INTRODUCTION Vesicourethral anastomotic stricture following prostatectomy is uncommon but represents a challenge for reconstructive surgery and has a significant impact on quality of life. The aim of this study was to relate our experience in managing vesicourethral anastomotic strictures and present the treatment algorithm used in our institution. PATIENTS AND METHODS We performed a descriptive, retrospective study in which we assessed the medical records of 45 patients with a diagnosis of vesicourethral anastomotic stricture following radical prostatectomy. The patients were treated in the same healthcare centre between January 2002 and March 2015. Six patients were excluded for meeting the exclusion criteria. The stricture was assessed using cystoscopy and urethrocystography. The patients with patent urethral lumens were initially treated with minimally invasive procedures. Open surgery was indicated for the presence of urethral lumen obliteration or when faced with failure of endoscopic treatment. Urinary continence following the prostatectomy was determinant in selecting the surgical approach (abdominal or perineal). RESULTS Thirty-nine patients treated for vesicourethral anastomotic stricture were recorded. The mean age was 64.4 years, and the mean follow-up was 40.3 months. Thirty-three patients were initially treated endoscopically. Seventy-five percent progressed free of restenosis following 1 to 4 procedures. Twelve patients underwent open surgery, 6 initially due to obliterative stricture and 6 after endoscopic failure. All patients progressed favourable after a mean follow-up of 29.7 months. CONCLUSIONS Endoscopic surgery is the initial treatment option for patients with vesicourethral anastomotic strictures with patent urethral lumens. Open reanastomosis is warranted when faced with recalcitrant or initially obliterative strictures and provides good results.

V10-05 ROBOT ASSISTED BLADDER AUGMENTATION AND BILATERAL URETERAL REIMPLANTATION

INTRODUCTION AND OBJECTIVES: Despite use of barbed suture during robot-assisted radical prostatectomy or partial nephrectomy, concerns have been raised about a high early failure rate when used during minimally-invasive pyeloplasty (MIP). In this video, we present our technique of robotic pyeloplasty using barbed suture, review the literature on barbed suture for MIP and discuss the controversies, tips, and tricks. METHODS: We present a case of a 55 year old man with rightsided uretero-pelvic junction obstruction (UPJO). The patient was placed in the modified flank position. Port placement was a 12 mm camera port, two 8 mm robotic ports, and a 5 mm assistant port. The robot was docked at a 30-degree angle to the flank. A robotic cautery hook was used to aid with fine hemostatic dissection. The renal pelvis and upper ureter were mobilized to reveal a crossing vessel. Round tip scissors were used to perform dismemberment and spatulation (Anderson-Hynes technique). The ureter was transposed over the crossing vessel and anastomosis was performed using a unidirectional barbed suture (3-0 Stratafix ; Ethicon, Somerville, NJ, USA) in a running fashion. Following completion of the posterior layer, an antegrade ureteral stent was placed followed by closing the anterior layer in a similar fashion. RESULTS: Strategies for successful robotic pyeloplasty using barbed suture include: (1) selection of appropriate barbed suture e suture composition, absorbability, distribution of barbs and needle type vary between manufacturers (2) minimizing tension during suture placement to avoid tissue necrosis (3) use of round tip scissors to avoid spiral spatulation of the ureter (4) use of the obstructing UPJ tissue as a handle-hold for manipulation (5) avoid use of 12 mm assistant port for needle entry by utilizing needle placement via a robotic port. Advantages of barbed suture include no loss of tension as seen in non-barbed monofilament suture with possibility of suture loosening, and use of a “continuous interrupted” method; the barbs allow the anastomotic tension to be evenly spread to avoid gaps and mimic interrupted suture. Of 18 patients who have undergone laparoscopic or robotic pyeloplasty using barbed suture at our institution, the success rate was 17/ 18 (94%). CONCLUSIONS: Barbed suture for MIP provides a watertight anastomosis that is technically easier to perform. A key principle is to know your barbed suture as incorrect suture selection may compromise success. Our results demonstrate excellent success rates when using the barbed suture for MIP.