The technique of apical dissection of the prostate and urethrovesical anastomosis in robotic radical prostatectomy

Much of the current interest in robotic surgery in urology has been caused by the results of the work from the Vattikuti Urology Institute in Detroit, and these authors describe their extensive experience in the technique of radical prostatectomy; specifically their modified single running suture urethrovesical anastomosis. They ascribe their ability to remove the urethral catheter at 4 days, and to have an excellent continence rate, to this technique, and to their apical dissection. The European Randomised Study for Screening of Prostate Cancer will generate much interesting information over the nest few years and will in itself become one of the landmark urological studies. The authors from Amsterdam evaluated (‐7‐5)proPSA and hK2 in a subset of patients from this study for detecting and grading prostate cancer, and found that their impact in these areas remains limited. Screening for prostate cancer is a controversial but very interesting topic for those involved in urological oncology. Although many countries have not advocated a national screening programme, and indeed some have advised against screening of any kind for this condition, “backdoor” screening does in fact take place. The authors from Belfast have reviewed PSA testing in Northern Ireland from 1990 to 1999, finding that many men have an elevated PSA level, with a resulting requirement for further evaluation. OBJECTIVE To describe the technique of dissecting the apex of the prostate and a modified single running‐suture urethrovesical anastomosis in patients undergoing robot‐assisted radical prostatectomy for organ‐confined prostate cancer. PATIENTS AND METHODS Over 550 robot‐assisted radical prostatectomies have been undertaken using Vattikuti Institute Prostatectomy (VIP) technique in patients with localized carcinoma of the prostate. We present a critical analysis of the first 120 procedures by one surgeon (M.M.) at our institution using this newly developed technique of urethrovesical anastomosis preceded by dissecting the apex of the prostate. RESULTS The mean time for the urethrovesical anastomosis was 13 min. All but 24 patients had their catheter removed 4 days after surgery, as indicated by a cystogram. The catheter was removed successfully at 7 days in the remaining 24 patients who had a mild leak on cystography. Two patients had urinary retention within a week of removing the catheter and had to be re‐catheterized. Continence was evaluated using standardized criteria before and after the procedure. The patients also replied to a mailed validated questionnaire survey; 96% were continent at 3 months and the remaining 4% used a thin pad for security. CONCLUSIONS We report a technique of dissecting the apex of the prostate and prostatovesical junction for dividing the bladder neck, and a modified single running‐suture urethrovesical anastomosis, in patients undergoing robot‐assisted radical prostatectomy for organ‐confined cancer of the prostate. The same principles can also be applied for the anastomosis during pure laparoscopic procedures and for urethro‐neovesical anastomosis in patients undergoing robotic radical cystoprostatectomy for carcinoma of the bladder.