SURGEON’S WORKSHOP
IMPROVED TECHNIQUE FOR URETHRAL SUTURING IN RADICAL RETROPUBIC PROSTATECTOMY: “THE SEATTLE SOUND” JAMES E. GOTTESMAN,
From the Department Seattle, Washington
M.D.
of Urology, The Swedish Hospital Medical Center,
The placement of sutures into the urethral stump during radical retropubic prostatectomy is among the more difficult technical maneuvers facing the urologist. The ever-present bloody periurethral ooze, the retraction and exit angle of the urethral stump, and the depth and poor illumination of the pelvis make passage of suture into the urethra a test of surgical skill. To facilitate placement of urethral sutures during radical retropubic prostatectomy a specially constructed sound with interchangeable rotating tips* has been developed.
stump and the slotted sound at the same time. The suture passes from outside-in at the 9 o’clock urethral position, then through the slot in the sound, then from inside-out at the 3 o’clock urethral position (Fig. 3). (Note: Only the urethral wall need be included in the suture. Periurethral tissue may be included if the operator so desires by starting the suture deeper or by necessity if the stump is too short or retracted.) The suture is drawn through the urethra until both ends are equal in length. The needle is removed. The sound is advanced until
Material and Methods The “Seattle Sound’ system consists of a 24F sound shaft with variable size and shape sound tips (Figs. 1, 2). The sound is used as follows. Shaft placement The sound with 24F shaft, mounted with the “atraumatic” standard 24F sound tip, is placed through the urethra into the pelvis until the sound tip is visualized (Fig. 2). At this point the surgeon removes the “atraumatic” tip and has the current option of three different sound configurations to allow placement of the urethral sutures (Fig. 2). Upward perineal pressure with a sponge stick may be used adjunctively to better visualize the urethral stump. Slotted tip (#I). The 28F slotted tip can be rotated into any orientation, but I have found the horizontal orientation to be the most useful as the first step in the urethral anastomosis. This step allows simultaneous placement of sutures at the 3 and 9 o’clock positions. The suture is passed through and through the urethral FIGURE1. 24F sound shaft with variably sized in*Cook Urological,
380
Inc.,
Spencer,
Indiana
terchangeable
UROI,OCY
and rotating
/ APRIL 1992
!
tips.
\‘OI.UME
SXXIX,
NUhlBER
1
7
FI(:URE 2. Urethral stump: sound passed with standard “atraumatic” tip. “Atraumatic” tip removed and exchanged for desired tip configuration. Slotted, spoon. and slotted spoon tips shown.
Flc:rlRl~: 3. Slotted position:;. Sllturc rlrethral .stump and position .and exiting
tip oriented in 3 and 9 o’clock pa,ssed through and through slotted tip starting at 9 o’clock urethra at 3 o’clock po,sition.
FIGURE 4. Suture drawn through urethra both ends are equal in length. Sound advanced slot has cleared urethra.
until until
the slot has cleared the urethra and tlhe snared sutures can be identified (Fig. 4). The suture is elevated off the sound with a nerve hook or forceps and divided (Fig. 5). The two sutures are freed of the sound and drawn to give equal lengths for later vesical suturing. The tip can be rotated to other orientations for additional sutures (e.g., 6 and 12 o’clock positions for four total sutures or obliquely for six sutures). The sutures in 3 and 9 o’clock positions are the most natural first sutures and the easiest with the slotted tip. The other tips are easier to use in other orientations. Important note: A requirement for the slotted tip only is an extra-long suture to accommodate the double nature of each pass. Most suture manufacturers make rolls of suture for free ties that are 54 inches long. This will leave two 27-inch pieces, which is ideal. I prefer 2-O chromic suture with a l/2 curve #5 or #6 Ferguson needle. The standard 5/xcurve GU needle is a hindrance with this technique because the suture must traverse through the opposite urethral wall rather than exit from the lumen. Any absorbable suture material is acceptableif it is long enough. The deep grooved nature Spooned tip (#2). of the 28F “spoon” tip allows excellent exposure
FIGUKE 7.
off sound with nerve hook or forceps and divided.
Slotted spoon tip allows visualization of and deep bite of urethral wall. Suture started either from inside or outside and penetrate.s urethral wall and passe.s through sound:7 slot. Rotated in figure for suture at 9 o’clock position.
FIGURE: 6. Spoon tip: deep groove allows excellent visualization of urethral lumen. Suture started either from inside or outside. Figure shows rotation to position for 3 o’clock suture placed “outside-in.”
of the urethral lumen. The tip is rotated until the groove is opposite the desired suture site. The suture can be started either inside or outside the lumen using a 5/aor l/2 curve depending on surgeon’s preference. The tip is rotated to a different position for each suture placement (Fig. 6). Slotted spoon tip (#3). The 28F “slotted spoon” tip is beneficial in all situations, but especially when the urethral lumen is short or retracted. The spoon provides exposure of the lumen while the slot allows deeper suture penetration, even at the 5 and 7 o’clock positions, usually most difficult to visualize. The tip is rotated until the groove is adjacent to the desired suture site. The suture can be started either inside or outside the lumen using a 518or l/2 curve depending on the surgeon’ s preference. The suture is passed through and through the urethral wall and the slotted tip at the same time (Fig. 7). Whether starting inside or outside, the suture is snared by the sound. The sound is advanced until the slot has cleared the urethra and the snared suture can be identified. The suture is pulled through the slot with a nerve hook or forceps. The tip can be rotated to other orientations for additional sutures.
lumen
FIGURE
382
5.
Snared
sutures
identified
and elevated
UROLOGY
i
APRIL
1992
/ VOLUME
XXXIX, NUMBER 4
Disengagement of the tip~always should be done before final removal of the sound shaft. Although the chances of spontaneous tip disengagement are small if the tip is properly rotated away from the release point, care should be taken. In addition, the sound shaft is 24F, while the sound tips are 28F. This difference can be s:ignificant on removal, causing hang-up within the urethra. Comment Many urethral suturing techniques, tools, and tricks are available including perineal pressure,’ wedge pubectomy,’ grooved sounds with or without extension rods,2,3 Foley catheters with or without suture attached,4 and placement of sutures before cutting the urethra.5 Our technique appears to be simpler and more versatile than previous techniques. The “slotted” sounds (tips 1 and 3) allow excellent bites even when the stump is short or retracted. On occasion, after the initial placement of sutures in 3 and 9 o’clock positions, gentle upward traction may facilitate placement of the additional desired sutures without a sound or catheter. The “spooned” sounds (tips 2 and 3) allow direct exposure of the urethral lumen better than any other technique. This exposure is particularly. helpful for the dorsal sutures (5 and 7 o’clock positions). An advantage over grooved sounds is the ability to use a narrower shaft (24F) but with
larger tips that do not have to traverse the pendulous urethra. The 28F tips allow b’etter purchase on the urethral wall to prevent retraction. The 360-degree tip rotation with simple bayonet attachment facilitates varied positioning and tip exchange. Occasionally, the urethral stump is particularly short or retracted or has been torn during dissection or attempted suture placement. Adequate suture placement in these circumstances may be difficult or impossible. However, either the slotted tip (1) or slotted spoon tip (:3) may be used to achieve a deeper pass of the needle encompassing portions of periurethral tissue to give added support. Three different tips are currently available, but as suggestions from the urologic community are received undoubtedly more configurations will be provided. 1221 Madison, Suite 1210 Seattle, Washington 98104 References 1. Lang? PM, and Reddy PK: Technical nuances and surgical results of iadical retropubic prostatectomy in 150 patients, J ‘hrol 138: 348 (19871. 2. Rotd RA: and Janeiro J: Urethral suture guide for radical prostatectomy, Urology 31: 267 (1988). 3. Roth RA: An improved expanding tip urethral suture guide for use in radical prostatectomy, J Ural 146: 390 (1991). 4. Walsh PC: Radical retropubic prostatectomy, in Campbell’s Urology, ed 5, Philadelphia, W.B. Saunders company, ~013, 1986, p 2786. 5. Parry WL: Prostate malignancies, in Urologic krgery, ed 2, Hagerstown, Harper and Row, 1975, p 568.
383
IMPROVED TECHNIQUE FOR URETHRAL SUTURING IN RADICAL RETROPUBIC PROSTATECTOMY: “THE SEATTLE SOUND” JAMES E. GOTTESMAN,
From the Department Seattle, Washington
M.D.
of Urology, The Swedish Hospital Medical Center,
The placement of sutures into the urethral stump during radical retropubic prostatectomy is among the more difficult technical maneuvers facing the urologist. The ever-present bloody periurethral ooze, the retraction and exit angle of the urethral stump, and the depth and poor illumination of the pelvis make passage of suture into the urethra a test of surgical skill. To facilitate placement of urethral sutures during radical retropubic prostatectomy a specially constructed sound with interchangeable rotating tips* has been developed.
stump and the slotted sound at the same time. The suture passes from outside-in at the 9 o’clock urethral position, then through the slot in the sound, then from inside-out at the 3 o’clock urethral position (Fig. 3). (Note: Only the urethral wall need be included in the suture. Periurethral tissue may be included if the operator so desires by starting the suture deeper or by necessity if the stump is too short or retracted.) The suture is drawn through the urethra until both ends are equal in length. The needle is removed. The sound is advanced until
Material and Methods The “Seattle Sound’ system consists of a 24F sound shaft with variable size and shape sound tips (Figs. 1, 2). The sound is used as follows. Shaft placement The sound with 24F shaft, mounted with the “atraumatic” standard 24F sound tip, is placed through the urethra into the pelvis until the sound tip is visualized (Fig. 2). At this point the surgeon removes the “atraumatic” tip and has the current option of three different sound configurations to allow placement of the urethral sutures (Fig. 2). Upward perineal pressure with a sponge stick may be used adjunctively to better visualize the urethral stump. Slotted tip (#I). The 28F slotted tip can be rotated into any orientation, but I have found the horizontal orientation to be the most useful as the first step in the urethral anastomosis. This step allows simultaneous placement of sutures at the 3 and 9 o’clock positions. The suture is passed through and through the urethral FIGURE1. 24F sound shaft with variably sized in*Cook Urological,
380
Inc.,
Spencer,
Indiana
terchangeable
UROI,OCY
and rotating
/ APRIL 1992
!
tips.
\‘OI.UME
SXXIX,
NUhlBER
1
7
FI(:URE 2. Urethral stump: sound passed with standard “atraumatic” tip. “Atraumatic” tip removed and exchanged for desired tip configuration. Slotted, spoon. and slotted spoon tips shown.
Flc:rlRl~: 3. Slotted position:;. Sllturc rlrethral .stump and position .and exiting
tip oriented in 3 and 9 o’clock pa,ssed through and through slotted tip starting at 9 o’clock urethra at 3 o’clock po,sition.
FIGURE 4. Suture drawn through urethra both ends are equal in length. Sound advanced slot has cleared urethra.
until until
the slot has cleared the urethra and tlhe snared sutures can be identified (Fig. 4). The suture is elevated off the sound with a nerve hook or forceps and divided (Fig. 5). The two sutures are freed of the sound and drawn to give equal lengths for later vesical suturing. The tip can be rotated to other orientations for additional sutures (e.g., 6 and 12 o’clock positions for four total sutures or obliquely for six sutures). The sutures in 3 and 9 o’clock positions are the most natural first sutures and the easiest with the slotted tip. The other tips are easier to use in other orientations. Important note: A requirement for the slotted tip only is an extra-long suture to accommodate the double nature of each pass. Most suture manufacturers make rolls of suture for free ties that are 54 inches long. This will leave two 27-inch pieces, which is ideal. I prefer 2-O chromic suture with a l/2 curve #5 or #6 Ferguson needle. The standard 5/xcurve GU needle is a hindrance with this technique because the suture must traverse through the opposite urethral wall rather than exit from the lumen. Any absorbable suture material is acceptableif it is long enough. The deep grooved nature Spooned tip (#2). of the 28F “spoon” tip allows excellent exposure
FIGUKE 7.
off sound with nerve hook or forceps and divided.
Slotted spoon tip allows visualization of and deep bite of urethral wall. Suture started either from inside or outside and penetrate.s urethral wall and passe.s through sound:7 slot. Rotated in figure for suture at 9 o’clock position.
FIGURE: 6. Spoon tip: deep groove allows excellent visualization of urethral lumen. Suture started either from inside or outside. Figure shows rotation to position for 3 o’clock suture placed “outside-in.”
of the urethral lumen. The tip is rotated until the groove is opposite the desired suture site. The suture can be started either inside or outside the lumen using a 5/aor l/2 curve depending on surgeon’s preference. The tip is rotated to a different position for each suture placement (Fig. 6). Slotted spoon tip (#3). The 28F “slotted spoon” tip is beneficial in all situations, but especially when the urethral lumen is short or retracted. The spoon provides exposure of the lumen while the slot allows deeper suture penetration, even at the 5 and 7 o’clock positions, usually most difficult to visualize. The tip is rotated until the groove is adjacent to the desired suture site. The suture can be started either inside or outside the lumen using a 518or l/2 curve depending on the surgeon’ s preference. The suture is passed through and through the urethral wall and the slotted tip at the same time (Fig. 7). Whether starting inside or outside, the suture is snared by the sound. The sound is advanced until the slot has cleared the urethra and the snared suture can be identified. The suture is pulled through the slot with a nerve hook or forceps. The tip can be rotated to other orientations for additional sutures.
lumen
FIGURE
382
5.
Snared
sutures
identified
and elevated
UROLOGY
i
APRIL
1992
/ VOLUME
XXXIX, NUMBER 4
Disengagement of the tip~always should be done before final removal of the sound shaft. Although the chances of spontaneous tip disengagement are small if the tip is properly rotated away from the release point, care should be taken. In addition, the sound shaft is 24F, while the sound tips are 28F. This difference can be s:ignificant on removal, causing hang-up within the urethra. Comment Many urethral suturing techniques, tools, and tricks are available including perineal pressure,’ wedge pubectomy,’ grooved sounds with or without extension rods,2,3 Foley catheters with or without suture attached,4 and placement of sutures before cutting the urethra.5 Our technique appears to be simpler and more versatile than previous techniques. The “slotted” sounds (tips 1 and 3) allow excellent bites even when the stump is short or retracted. On occasion, after the initial placement of sutures in 3 and 9 o’clock positions, gentle upward traction may facilitate placement of the additional desired sutures without a sound or catheter. The “spooned” sounds (tips 2 and 3) allow direct exposure of the urethral lumen better than any other technique. This exposure is particularly. helpful for the dorsal sutures (5 and 7 o’clock positions). An advantage over grooved sounds is the ability to use a narrower shaft (24F) but with
larger tips that do not have to traverse the pendulous urethra. The 28F tips allow b’etter purchase on the urethral wall to prevent retraction. The 360-degree tip rotation with simple bayonet attachment facilitates varied positioning and tip exchange. Occasionally, the urethral stump is particularly short or retracted or has been torn during dissection or attempted suture placement. Adequate suture placement in these circumstances may be difficult or impossible. However, either the slotted tip (1) or slotted spoon tip (:3) may be used to achieve a deeper pass of the needle encompassing portions of periurethral tissue to give added support. Three different tips are currently available, but as suggestions from the urologic community are received undoubtedly more configurations will be provided. 1221 Madison, Suite 1210 Seattle, Washington 98104 References 1. Lang? PM, and Reddy PK: Technical nuances and surgical results of iadical retropubic prostatectomy in 150 patients, J ‘hrol 138: 348 (19871. 2. Rotd RA: and Janeiro J: Urethral suture guide for radical prostatectomy, Urology 31: 267 (1988). 3. Roth RA: An improved expanding tip urethral suture guide for use in radical prostatectomy, J Ural 146: 390 (1991). 4. Walsh PC: Radical retropubic prostatectomy, in Campbell’s Urology, ed 5, Philadelphia, W.B. Saunders company, ~013, 1986, p 2786. 5. Parry WL: Prostate malignancies, in Urologic krgery, ed 2, Hagerstown, Harper and Row, 1975, p 568.
383
