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Asian J Endosc Surg ISSN 1758-5902
O R I G I N A L A RT I C L E
Unidirectional barbed suture for vesicourethral anastomosis during laparoscopic radical prostatectomy Toshikazu Takeda, Akira Miyajima, Gou Kaneko, Masanori Hasegawa, Eiji Kikuchi & Mototsugu Oya Department of Urology, Keio University School of Medicine, Tokyo, Japan
Keywords Laparoscopic radical prostatectomy; unidirectional barbed suture; vesicourethral anastomosis Correspondence Akira Miyajima, Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. Tel: +81 3 5363 3825 Fax: +81 3 3225 1985 Email: [email protected] Received: 23 October 2013; revised: 17 January 2014; accepted: 14 April 2014 DOI:10.1111/ases.12115
Abstract Introduction: We investigated the impact of unidirectional barbed suture (UBS) for vesicourethral anastomosis (VUA) during laparoscopic radical prostatectomy. Methods: The polyglyconate UBS V-Loc 180 was used for VUA during laparoscopic radical prostatectomy in 30 consecutive patients who were diagnosed with organ-confined prostate cancer between January and October 2012. The operative and postoperative parameters were then compared with those of 30 consecutive patients who had previously undergone the same procedure but with the monofilament poliglecaprone suture Monocryl. All procedures were performed by the same experienced surgeon. Results: VUA time was significantly shorter in the V-Loc group (13.2 ± 2.3 min) than in the Monocryl group (19.1 ± 3.3 min) (P < 0.001). The V-Loc group required significantly more stitches than the Monocryl group (11.4 ± 1.3 vs 10.6 ± 1.6 stitches; P = 0.031). The percentage of patients who required no more than one pad per day at 3 months postoperatively was significantly higher in the V-Loc group (63.3%) than in the Monocryl group (23.3%) (P = 0.020). No significant differences in other perioperative parameters were observed between the two groups. Conclusion: Using UBS prevents suture slippage and enables tieless anastomosis. VUA using a UBS may relieve surgeon stress because a rapid and secure anastomosis is achievable.
Introduction Laparoscopic radical prostatectomy (LRP) is one of the most common surgical approaches for the treatment of patients with localized prostate cancer. Vesicourethral anastomosis (VUA) is necessary after prostate removal, but an insecure VUA can lead to a longer catheterization time and a decreased quality of life for the patient. Numerous modifications have been described to make VUA technically easier, prevent urinary leaks, and improve continence outcomes. VUA was initially performed in an interrupted fashion, after which running anastomosis was reported by Gill and Zippe (1). Later, the so-called running Van Velthoven suture technique was introduced by Van Velthoven et al. (2). Monofilament suture use has increased recently because
a smooth texture for VUA can be produced. However, one of its main limitations is the loss of tension due to suture loosening. Unidirectional barbed sutures (UBS) have been studied and reported extensively in the plastic and reconstructive surgery literature (3,4). The initial application of UBS in the field of urology was reported during laparoscopic pyeloplasty (5). The polyglyconate UBS V-Loc 180 (Covidien, Mansfield, USA) has a loop on the free end through which the suture is passed, allowing for knotless security during initiation of the stitch. Similarly, knot tying is not necessary to secure the anastomosis when stitching is complete. Although some previous reports described UBS for VUA during robot-assisted radical prostatectomy (RARP) (6–13), the purpose of the present study was to
Asian J Endosc Surg 7 (2014) 241–245 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
241
Barbed suture for anastomosis of LRP
T Takeda et al.
determine the feasibility and efficacy of this technique for VUA during conventional LRP with a minimum follow-up of 3 months.
Materials and Methods V-Loc 180 was used for VUA during LRP in 30 consecutive patients who were diagnosed with organ-confined prostate cancer between January and October 2012. The results were then compared with those from 30 consecutive patients who had previously undergone the same procedure but with a monofilament polyglicaprone suture (Monocryl; Ethicon Endo-Surgery, Cincinnati, USA). All procedures were performed by the same experienced surgeon. For the V-Loc group, a 30-cm 2-0 V-Loc 180 on a tapered 26-mm needle was used. The first suture was placed at the 5 o’clock position outside-in on the bladder neck and inside-out on the urethra, and then the needle was passed through the looped end. Next, the anastomosis was continued in a clockwise fashion, and the suture was run to the initial 5 o’clock position. Upon conclusion of the anastomosis, it was unnecessary to tie a knot, and the needle was simply cut. For the Monocryl group, a 35-cm 2-0 Monocryl on a tapered 26-mm needle was used. The first suture was placed at the 5 o’clock position outside-in on the bladder neck and inside-out on the urethra, and then the knot was tied. Next, the anastomosis was continued in a clockwise fashion and the suture was run to the initial 5 o’clock position. Absorbable Lapra-Ty clips made from Vicryl (Ethicon Endo-Surgery) were used to maintain the tension. Upon conclusion of the anastomosis, the knot was also tied. In both groups, integrity of the anastomosis was tested intraoperatively by instilling 120-mL saline into the bladder. Cystography was performed at 2–4 days after the operation. If any extravasation of contrast was noted, cystography was performed again after a few days. If urinary retention was noted, the catheter was re-inserted. During the hospital stay, the urine loss ratio, which is defined as the weight of urine loss in the pad divided by daily micturition volume, was calculated (14). In the follow-up, patients were asked how many pads they required daily. The urine loss ratio on the last day of hospitalization and number of pads at 1 and 3 months postoperatively were analyzed. The two groups were compared at baseline for age, BMI, preoperative prostate-specific antigen, clinical stage, biopsy Gleason score, and prostate volume, which was measured by transrectal ultrasound preoperatively. Total operative time, VUA time, estimated blood loss, number of stitches, cystogram leak, urinary retention,
242
Table 1 Comparison of baseline patient characteristics
Patients (n) Age, mean ± SD (years) BMI, mean ± SD (kg/m2) PSA, mean ± SD (ng/mL) Biopsy Gleason score (n) ≤6 7 ≥8 Clinical stage (n) cT1 cT2 Prostate volume, mean ± SD (mL)
Monocryl group
V-Loc group
P-value
30 64.7 ± 4.9 24.4 ± 2.3 8.4 ± 5.4
30 66.3 ± 5.4 23.5 ± 2.7 9.0 ± 10.1
0.134 0.149 0.892
5 19 6
7 19 4
0.390
12 18 30.5 ± 13.1
2 28 27.3 ± 8.3
0.002 0.355
PSA, prostate-specific antigen.
catheter duration, length of hospital stay, and continence were also analyzed for each individual patient. The associations between the Monocryl group or the V-Loc group and these parameters were assessed with the χ2 test and Mann–Whitney U-test. Differences between the groups were regarded as significant when P < 0.05. These analyses were performed with the STATA version 7.0 statistical software package (Stata Corporation, College Station, USA).
Results The mean age of the patients was 65.5 years and the median follow-up interval was 6.5 months. Baseline characteristics were similar between the Monocryl group and the V-Loc group (Table 1). We also evaluated the differences in perioperative parameters between the two groups (Table 2). Total operative time was 177.1 ± 29.4 min in the V-Loc group and 184.2 ± 40.3 min in the Monocryl group, and there was no statistically significant difference (P = 0.405). VUA time was significantly shorter in the V-Loc group (13.2 ± 2.3 min) than in the Monocryl group (19.1 ± 3.3 min) (P < 0.001). Estimated blood loss was 182.7 ± 183.9 mL in the V-Loc group and 182.2 ± 209.5 mL in the Monocryl group, and there was no statistically significant difference (P = 0.421). The V-Loc group required significantly more stitches than the Monocryl group (11.4 ± 1.3 vs 10.6 ± 1.6 stitches; P = 0.031). The mean number of Lapra-Ty clips used to maintain the suture tension during VUA in the Monocryl group was 5.4. No intraoperative leak was observed, although cystogram leak was observed in one patient in the V-Loc group on postoperative day 2, necessitating delayed catheter removal on postoperative day 4. Urinary retention
Asian J Endosc Surg 7 (2014) 241–245 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Barbed suture for anastomosis of LRP
T Takeda et al.
Table 2 Comparison of perioperative parameters
Total operative time, mean ± SD (min) VUA time, mean ± SD (min) EBL, mean ± SD (mL) Stitches, mean ± SD (n) Cystogram leak (n) Urinary retention (n) Catheter duration, mean ± SD (days) Length of hospital stay, mean ± SD (days) Urine loss ratio, mean ± SD (%) Pad requirement at 1 month (n) ≤1 2 ≥3 Pad requirement at 3 months (n) ≤1 2 ≥3
Monocryl group
V-Loc group
P-value
184.2 ± 40.3 19.1 ± 3.3 182.2 ± 209.5 10.6 ± 1.6 0 3 3.0 ± 0.4 5.4 ± 1.1 28.8 ± 30.0
177.1 ± 29.4 13.2 ± 2.3 182.7 ± 183.9 11.4 ± 1.3 1 2 3.0 ± 1.0 5.5 ± 1.1 18.1 ± 23.9
0.405
Asian J Endosc Surg ISSN 1758-5902
O R I G I N A L A RT I C L E
Unidirectional barbed suture for vesicourethral anastomosis during laparoscopic radical prostatectomy Toshikazu Takeda, Akira Miyajima, Gou Kaneko, Masanori Hasegawa, Eiji Kikuchi & Mototsugu Oya Department of Urology, Keio University School of Medicine, Tokyo, Japan
Keywords Laparoscopic radical prostatectomy; unidirectional barbed suture; vesicourethral anastomosis Correspondence Akira Miyajima, Department of Urology, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo 160-8582, Japan. Tel: +81 3 5363 3825 Fax: +81 3 3225 1985 Email: [email protected] Received: 23 October 2013; revised: 17 January 2014; accepted: 14 April 2014 DOI:10.1111/ases.12115
Abstract Introduction: We investigated the impact of unidirectional barbed suture (UBS) for vesicourethral anastomosis (VUA) during laparoscopic radical prostatectomy. Methods: The polyglyconate UBS V-Loc 180 was used for VUA during laparoscopic radical prostatectomy in 30 consecutive patients who were diagnosed with organ-confined prostate cancer between January and October 2012. The operative and postoperative parameters were then compared with those of 30 consecutive patients who had previously undergone the same procedure but with the monofilament poliglecaprone suture Monocryl. All procedures were performed by the same experienced surgeon. Results: VUA time was significantly shorter in the V-Loc group (13.2 ± 2.3 min) than in the Monocryl group (19.1 ± 3.3 min) (P < 0.001). The V-Loc group required significantly more stitches than the Monocryl group (11.4 ± 1.3 vs 10.6 ± 1.6 stitches; P = 0.031). The percentage of patients who required no more than one pad per day at 3 months postoperatively was significantly higher in the V-Loc group (63.3%) than in the Monocryl group (23.3%) (P = 0.020). No significant differences in other perioperative parameters were observed between the two groups. Conclusion: Using UBS prevents suture slippage and enables tieless anastomosis. VUA using a UBS may relieve surgeon stress because a rapid and secure anastomosis is achievable.
Introduction Laparoscopic radical prostatectomy (LRP) is one of the most common surgical approaches for the treatment of patients with localized prostate cancer. Vesicourethral anastomosis (VUA) is necessary after prostate removal, but an insecure VUA can lead to a longer catheterization time and a decreased quality of life for the patient. Numerous modifications have been described to make VUA technically easier, prevent urinary leaks, and improve continence outcomes. VUA was initially performed in an interrupted fashion, after which running anastomosis was reported by Gill and Zippe (1). Later, the so-called running Van Velthoven suture technique was introduced by Van Velthoven et al. (2). Monofilament suture use has increased recently because
a smooth texture for VUA can be produced. However, one of its main limitations is the loss of tension due to suture loosening. Unidirectional barbed sutures (UBS) have been studied and reported extensively in the plastic and reconstructive surgery literature (3,4). The initial application of UBS in the field of urology was reported during laparoscopic pyeloplasty (5). The polyglyconate UBS V-Loc 180 (Covidien, Mansfield, USA) has a loop on the free end through which the suture is passed, allowing for knotless security during initiation of the stitch. Similarly, knot tying is not necessary to secure the anastomosis when stitching is complete. Although some previous reports described UBS for VUA during robot-assisted radical prostatectomy (RARP) (6–13), the purpose of the present study was to
Asian J Endosc Surg 7 (2014) 241–245 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
241
Barbed suture for anastomosis of LRP
T Takeda et al.
determine the feasibility and efficacy of this technique for VUA during conventional LRP with a minimum follow-up of 3 months.
Materials and Methods V-Loc 180 was used for VUA during LRP in 30 consecutive patients who were diagnosed with organ-confined prostate cancer between January and October 2012. The results were then compared with those from 30 consecutive patients who had previously undergone the same procedure but with a monofilament polyglicaprone suture (Monocryl; Ethicon Endo-Surgery, Cincinnati, USA). All procedures were performed by the same experienced surgeon. For the V-Loc group, a 30-cm 2-0 V-Loc 180 on a tapered 26-mm needle was used. The first suture was placed at the 5 o’clock position outside-in on the bladder neck and inside-out on the urethra, and then the needle was passed through the looped end. Next, the anastomosis was continued in a clockwise fashion, and the suture was run to the initial 5 o’clock position. Upon conclusion of the anastomosis, it was unnecessary to tie a knot, and the needle was simply cut. For the Monocryl group, a 35-cm 2-0 Monocryl on a tapered 26-mm needle was used. The first suture was placed at the 5 o’clock position outside-in on the bladder neck and inside-out on the urethra, and then the knot was tied. Next, the anastomosis was continued in a clockwise fashion and the suture was run to the initial 5 o’clock position. Absorbable Lapra-Ty clips made from Vicryl (Ethicon Endo-Surgery) were used to maintain the tension. Upon conclusion of the anastomosis, the knot was also tied. In both groups, integrity of the anastomosis was tested intraoperatively by instilling 120-mL saline into the bladder. Cystography was performed at 2–4 days after the operation. If any extravasation of contrast was noted, cystography was performed again after a few days. If urinary retention was noted, the catheter was re-inserted. During the hospital stay, the urine loss ratio, which is defined as the weight of urine loss in the pad divided by daily micturition volume, was calculated (14). In the follow-up, patients were asked how many pads they required daily. The urine loss ratio on the last day of hospitalization and number of pads at 1 and 3 months postoperatively were analyzed. The two groups were compared at baseline for age, BMI, preoperative prostate-specific antigen, clinical stage, biopsy Gleason score, and prostate volume, which was measured by transrectal ultrasound preoperatively. Total operative time, VUA time, estimated blood loss, number of stitches, cystogram leak, urinary retention,
242
Table 1 Comparison of baseline patient characteristics
Patients (n) Age, mean ± SD (years) BMI, mean ± SD (kg/m2) PSA, mean ± SD (ng/mL) Biopsy Gleason score (n) ≤6 7 ≥8 Clinical stage (n) cT1 cT2 Prostate volume, mean ± SD (mL)
Monocryl group
V-Loc group
P-value
30 64.7 ± 4.9 24.4 ± 2.3 8.4 ± 5.4
30 66.3 ± 5.4 23.5 ± 2.7 9.0 ± 10.1
0.134 0.149 0.892
5 19 6
7 19 4
0.390
12 18 30.5 ± 13.1
2 28 27.3 ± 8.3
0.002 0.355
PSA, prostate-specific antigen.
catheter duration, length of hospital stay, and continence were also analyzed for each individual patient. The associations between the Monocryl group or the V-Loc group and these parameters were assessed with the χ2 test and Mann–Whitney U-test. Differences between the groups were regarded as significant when P < 0.05. These analyses were performed with the STATA version 7.0 statistical software package (Stata Corporation, College Station, USA).
Results The mean age of the patients was 65.5 years and the median follow-up interval was 6.5 months. Baseline characteristics were similar between the Monocryl group and the V-Loc group (Table 1). We also evaluated the differences in perioperative parameters between the two groups (Table 2). Total operative time was 177.1 ± 29.4 min in the V-Loc group and 184.2 ± 40.3 min in the Monocryl group, and there was no statistically significant difference (P = 0.405). VUA time was significantly shorter in the V-Loc group (13.2 ± 2.3 min) than in the Monocryl group (19.1 ± 3.3 min) (P < 0.001). Estimated blood loss was 182.7 ± 183.9 mL in the V-Loc group and 182.2 ± 209.5 mL in the Monocryl group, and there was no statistically significant difference (P = 0.421). The V-Loc group required significantly more stitches than the Monocryl group (11.4 ± 1.3 vs 10.6 ± 1.6 stitches; P = 0.031). The mean number of Lapra-Ty clips used to maintain the suture tension during VUA in the Monocryl group was 5.4. No intraoperative leak was observed, although cystogram leak was observed in one patient in the V-Loc group on postoperative day 2, necessitating delayed catheter removal on postoperative day 4. Urinary retention
Asian J Endosc Surg 7 (2014) 241–245 © 2014 Japan Society for Endoscopic Surgery, Asia Endosurgery Task Force and Wiley Publishing Asia Pty Ltd
Barbed suture for anastomosis of LRP
T Takeda et al.
Table 2 Comparison of perioperative parameters
Total operative time, mean ± SD (min) VUA time, mean ± SD (min) EBL, mean ± SD (mL) Stitches, mean ± SD (n) Cystogram leak (n) Urinary retention (n) Catheter duration, mean ± SD (days) Length of hospital stay, mean ± SD (days) Urine loss ratio, mean ± SD (%) Pad requirement at 1 month (n) ≤1 2 ≥3 Pad requirement at 3 months (n) ≤1 2 ≥3
Monocryl group
V-Loc group
P-value
184.2 ± 40.3 19.1 ± 3.3 182.2 ± 209.5 10.6 ± 1.6 0 3 3.0 ± 0.4 5.4 ± 1.1 28.8 ± 30.0
177.1 ± 29.4 13.2 ± 2.3 182.7 ± 183.9 11.4 ± 1.3 1 2 3.0 ± 1.0 5.5 ± 1.1 18.1 ± 23.9
0.405
