Unidirectional barbed suture versus standard monofilament for urethrovesical anastomosis during robotic assisted laparoscopic radical prostatectomy

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Abstract

PURPOSE: V-LocTM180 (Covidien Healthcare, Mansfield, MA) is a new unidirectional barbed suture that may reduce loss of tension during a running closure. We evaluated the use of the barbed suture for urethrovesical anastomosis (UVA) during robotic assisted laparoscopic prostatectomy (RALP). Time to completion of UVA, post-operative anastomotic leak rate, and urinary incontinence were compared in patients undergoing UVA with 3-0 unidirectional-barbed suture vs. 3-0 MonocrylTM (Ethicon, Somerville, NJ). MATERIALS AND METHODS: Data were prospectively collected for 70 consecutive patients undergoing RALP for prostate cancer between November 2009 and October 2010. In the first 35 patients, the UVA was performed using a modified running van Velthoven anastomosis technique using two separate 3-0 monofilament sutures. In the subsequent 35 patients, the UVA was performed using two running novel unidirectional barbed sutures. At 7-12 days postoperatively, all patients were evaluated with a cystogram to determine anastomotic integrity. Urinary incontinence was assessed at two months and five months by total daily pad usage. Clinical symptoms suggestive of bladder neck contracture were elicited. RESULTS: Age, PSA, Gleason score, prostate size, estimated blood loss, body mass index, and clinical and pathologic stage between the 2 groups were similar. Comparing the monofilament group and V-LocTM180 cohorts, average time to complete the anastomosis was similar (27.4 vs. 26.4 minutes, p = 0.73) as was the rate of urinary extravasation on cystogram (5.7 % vs. 8.6%, p = 0.65). There were no symptomatic bladder neck contractures noted at 5 months of follow-up. At 2 months, the percentage of patients using 2 or more pads per day was lower in the V-LocTM180 cohort (24% vs. 44%, p < 0.02). At 5 months, this difference was no longer evident. CONCLUSIONS: Time to complete the UVA was similar in the intervention and control groups. Rates of urine leak were also comparable. While the V-LocTM180 was associated with improved early continence, this difference was transient.

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Evolution of robotic radical prostatectomy: assessment after 2766 procedures.

Ketan K Badani, Mani Menon, Sanjeev Kaul (2007)

Robotic-assisted radical prostatectomy (RAP) is the dominant minimally invasive surgical treatment for patients with localized prostate cancer. Only a few large series have been published to date, with few long-term data available. The current study presents what to the authors' knowledge is the largest series of patients undergoing RAP with the longest follow-up to data available to date. Using a continuous quality improvement initiative, several technical refinements were adopted, evaluating the impact of this on patient outcome. Over a 6-year period, 2766 consecutive men underwent RAP at the study institution. Data were collected prospectively including demographic, surgical, oncologic, and functional outcomes with up to 5-year follow-up. The first 200 and most recent 200 patients were compared to determine the impact of experience and quality improvement for patients. The mean age of the patients was 60.2 years and the mean prostate-specific antigen (PSA) level at time of diagnosis was 6.43 ng/mL; 42.4% and 64.2% of patients, respectively, had a biopsy and pathologic Gleason sum of >/=7. The mean surgical and console time was 154 minutes and 116 minutes, respectively. Estimated blood loss was 100 mL; 96.7% of patients were discharged within 24 hours of surgery. At a median follow-up of 22 months, 7.3% of men had a PSA recurrence. The 5-year actuarial biochemical free survival rate was 84%. To the authors' knowledge, the current study is the first report of 5-year outcomes in men undergoing RAP. These data demonstrate that RAP can be performed with favorable outcomes while minimizing complications. As experience increases, further improvements in clinicopathologic and functional parameters are achieved.

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Early complication rates in a single-surgeon series of 2500 robotic-assisted radical prostatectomies: report applying a standardized grading system.

Rafael Coelho, Kenneth J. Palmer, Bernardo Rocco … (2010)

Perioperative complications following robotic-assisted radical prostatectomy (RARP) have been previously reported in recent series. Few studies, however, have used standardized systems to classify surgical complications, and that inconsistency has hampered accurate comparisons between different series or surgical approaches. To assess trends in the incidence and to classify perioperative surgical complications following RARP in 2500 consecutive patients. We analyzed 2500 patients who underwent RARP for treatment of clinically localized prostate cancer (PCa) from August 2002 to February 2009. Data were prospectively collected in a customized database and retrospectively analyzed. All patients underwent RARP performed by a single surgeon. The data were collected prospectively in a customized database. Complications were classified using the Clavien grading system. To evaluate trends regarding complications and radiologic anastomotic leaks, we compared eight groups of 300 patients each, categorized according the surgeon's experience (number of cases). Our median operative time was 90min (interquartile range [IQR]: 75-100min). The median estimated blood loss was 100ml (IQR:100-150ml). Our conversion rate was 0.08%, comprising two procedures converted to standard laparoscopy due to robot malfunction. One hundred and forty complications were observed in 127 patients (5.08%). The following percentages of patients presented graded complications: grade 1, 2.24%; grade 2, 1.8%; grade 3a, 0.08%; grade 3b, 0.48%; grade 4a, 0.40%. There were no cases of multiple organ dysfunction or death (grades 4b and 5). There were significant decreases in the overall complication rates (p=0.0034) and in the number of anastomotic leaks (p<0.001) as the surgeon's experience increased. RARP is a safe option for treatment of clinically localized PCa, presenting low complication rates in experienced hands. Although the robotic system provides the surgeon with enhanced vision and dexterity, proficiency is only accomplished with consistent surgical volume; complication rates demonstrated a tendency to decrease as the surgeon's experience increased. Copyright © 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved.