Vol. 118,July,Part2 Printed in U.S.A.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Vvilliams & Wilkins Co.
VESICOURETHRAL ANASTOI\tIOSIS AFTER RADICAL EXPERIENCE "\VITH THE JEWETT MODIFICATION CLARENCE V. HODGES From the Division of Urology, University of Oregon Health Sciences Center, Portland, Oregon
ABSTRACT
The author's experience with the Jewett method of vesicourethral anastomosis after radical ~N,~~~~,,-~" is described. 1 instance of stress incontinence has been encountered in more is described in detail. cases. The cnAHH'4 As a resident and instructor in Urology at the UroInstitute in Baltimore in the late 1940s, it was my to assist Dr. J. Jewett on many occasions with prostatectomies. During my entire professional career of 30 years since that time, I have persisted in the use of the method learned from Doctor Jewett for r-c, ,,1·,na the vesicourethral anastomosis after removal of the prostate gland. Like Doctor Jewett, who has recorded only 1 case of stress incontinence in 106 personal cases, I am aware of 1 similar complication in more than 200 cases. experience at postgraduate courses and in talking to Since other indicates that the details of the technique are well known or as frequently taught in these radical retropubic approach, I modification of the Vest method as I learned it from him. I\/Iost urologists believe that the appropriate method to handle cancer in stage A 2 and B, is by radical prostatectomy, While there is, unfortunately, a small of with prostatic cancer whose disease is early for radical surgical cure, Jewett's figures of 33 per cent tumor-free survival after radical perineal tomy in µa,cn,.uc" whose carcinoma was confined to prostate have not been matched by any other modality to date.' Radical OS'.cat;ectmny has these main vv,u,-ouvuo,,v",0 and rectal injury, postoperative inconti0 ="ff1-A~ nence and We are unable to preserve potency at the present time after radical roc•,m-n" but we can achieve near records for preventing incontinence. Some have recommended conserving either a portion of the apex of the or of the bladder neck; either of improve continence. There is , however, that the entire prosalong with enough of the vesical neck to ensure as complete a removal of the cancer as is Removal of the distal portion of the vesical neck up to 1 cm, from the ureteral orifices results in a which must be tailored to fit defect at the vesical membranous urethra when these structures are anastomosed and also to obtain a watertight repair of the large vesical defect remaining, Our final objective is to ntoirtnrm an anastomosis that will prevent undue strain on rethe external urethral structure. f--Tistorical note. Dr. Hugh H. Young described the vesicourethral anastomosis, ~v,"U'V""""' of approximation of bladder to urethra, as follows: "a.fter removal of the entire , there remains a very large open wound in the which must be down and anastomosed with the membranous urethra. It possible traction with clamps to ~""-'"""""" anterior part of the vesical wall to the of the membranous urethra, . Heavy chromic the suture being so as to include mucous mern.brane and tied boomerang needle-holder 0
is of great assistance in placing these sutures which are serted alternately on each side until the entire circumference of the urethra has been approximated to the bladder wall (the anastomosis being completed by a figure-of-8 stitch in the median line posteriorly). Eight or 10 sutures are generally necessary to make this anastomosis satisfactorily. should be placed deeply through adjacent muscular structures and tied not too tightly. During this procedure, a urethral catheter remains within the point of anastomosis and into the bladder, where it remains for drainage after tion. The rest of the bladder opening is closed continuous chromic catgut suture which does not mucous membrane."" Of 24 cases reported by only 3 patients were incontinent postoperatively, an of about 12 per cent. In 1940 Vest reported his new method of making the anastomosis so that the strain would be taken off the external urethral sphincter by using traction sutures to pull the blad-, der neck firmly against the urogenital diaphragm, the sutures out through the perineum to prevent or distortion of the external urinary sphincter. 3 His consisted of 4 quadrantal sutures: with 3 sutures, anteriorly and laterally, coming into the urethral "f-'"''"''-'vc1 and a fourth figure-of-8 suture being placed anastomosis is described by Weyrauch, "take bites in the vesical neck with sutures of No. 1 chromic catgut. Lead these out to the surface of the perineum and tie them over buttorn:;; place the initial suture in the midanterior of the vesical neck After leaving the bladder margin, continue the suture beneath the mucosa of the membranous urethra within the external sphincter, on through the triangular H1",au1ei1c and through the bulb of the urethra to emerge in subcutaneous tissues at the anterior margin of the perineal incision, Next, pass the ends through the skin in the midline, at a level between the scrotum and perineal incision, Place similar sutures laterally and tie these first .. , , A catheter from the membranous urethra facilitates introducing the sutures. To complete the anastomosis, take a figure-of-8 riorly from the vesical neck to the urogenital diaphragm, Jewett's modification includes substituting simple sutures for Vest's anterior and lateral mattress sutures, which were tied over buttons on the perineal skin, These simply anterior and lateral margins of the appropriate portion anterior bladder lumen defect to the membranous urethra. A fourth suture, placed in the area of the bladder neck below the coaptionjust described as a mattress suture, the bladder wall on each side, enters the bladder defect lumen briefly to enter the urethral lumen for a distance of about l cm. distally (part A of figure), Each end emerges urethral wall posteriorly and is brought through the nor,r,oc, body to be tied ultimately just under the perineal closing the remainder of the bladder defect, with enough tension to take the strain off the vesicourethral anastomosis.
209
210
HODGES
B
A, anterior and lateral sutures of 2-zero chromic catgut, labeled 1, 2 and 3, unite 3 quadrants of stump of membranous urethra to anterior portion of bladder defect. Placement of mattress suture labeled 4 to approximate posterior portion of newly fashioned bladder neck to membranous urethra. Suture ends emerge through urethral wall and course upward through perineal body to be tied under perineal skin. B, running 2-zero chromic catgut suture labeled 5 closes posterior remaining portion of bladder defect before suture labeled 4 is drawn up. Suture labeled 4 relieves any posterior strain on vesicourethral anastomosis.
The posterior limb of the bladder defect is closed, starting posteriorly, with a running suture of 2-zero atraumatic chromic catgut (partB of figure). Care is taken at the start to avoid the ureteral orifices (only 1 cm. away!), coapting bladder wall to bladder wall, after identification of the ureteral orifices with indwelling catheters. Parenthetically, when doing a radical retropubic prostatectomy, we have been able to duplicate Mittemeyer's observation that the same principle, applied in reverse with closure of the posterior bladder defect first and then coaption of the appropriate anterior portion of the defect to the membranous urethra will improve the urinary incontinence results from approximately 10 to less than 1 per cent. 4 The usual problem has been an inability to place the approximating sutures carefully or at all in the proximal end of the membranous urethra, once it has retracted into the depths of the pelvis and
the urogenital diaphragm. However, if the surgeon can place a single approximating suture at 3 or 4 points in this end of the membranous urethra in succession, each just before the urethra is cut away from the prostate, these sutures will remain for accurate approximation when the apposing portion at the anterior end of the bladder defect has been prepared. REFERENCES
1. Jewett, H. J., Bridge, R. W., Gray, G. F., Jr. and Shelley, W.
M.: The palpable nodule of prostatic cancer. Results 15 years after radical excision. J.A.M.A., 203: 403, 1968. 2. Young, H. H. and Davis, D. M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., vol. 2, p. 468, 1926. 3. Weyrauch, H. M.: In: Surgery of the Prostate. Philadelphia: W. B. Saunders Co., p. 221, 1959. 4. Mittemeyer, B.: Personal communication.
THE JOURNAL OF UROLOGY
Copyright © 1977 by The Vvilliams & Wilkins Co.
VESICOURETHRAL ANASTOI\tIOSIS AFTER RADICAL EXPERIENCE "\VITH THE JEWETT MODIFICATION CLARENCE V. HODGES From the Division of Urology, University of Oregon Health Sciences Center, Portland, Oregon
ABSTRACT
The author's experience with the Jewett method of vesicourethral anastomosis after radical ~N,~~~~,,-~" is described. 1 instance of stress incontinence has been encountered in more is described in detail. cases. The cnAHH'4 As a resident and instructor in Urology at the UroInstitute in Baltimore in the late 1940s, it was my to assist Dr. J. Jewett on many occasions with prostatectomies. During my entire professional career of 30 years since that time, I have persisted in the use of the method learned from Doctor Jewett for r-c, ,,1·,na the vesicourethral anastomosis after removal of the prostate gland. Like Doctor Jewett, who has recorded only 1 case of stress incontinence in 106 personal cases, I am aware of 1 similar complication in more than 200 cases. experience at postgraduate courses and in talking to Since other indicates that the details of the technique are well known or as frequently taught in these radical retropubic approach, I modification of the Vest method as I learned it from him. I\/Iost urologists believe that the appropriate method to handle cancer in stage A 2 and B, is by radical prostatectomy, While there is, unfortunately, a small of with prostatic cancer whose disease is early for radical surgical cure, Jewett's figures of 33 per cent tumor-free survival after radical perineal tomy in µa,cn,.uc" whose carcinoma was confined to prostate have not been matched by any other modality to date.' Radical OS'.cat;ectmny has these main vv,u,-ouvuo,,v",0 and rectal injury, postoperative inconti0 ="ff1-A~ nence and We are unable to preserve potency at the present time after radical roc•,m-n" but we can achieve near records for preventing incontinence. Some have recommended conserving either a portion of the apex of the or of the bladder neck; either of improve continence. There is , however, that the entire prosalong with enough of the vesical neck to ensure as complete a removal of the cancer as is Removal of the distal portion of the vesical neck up to 1 cm, from the ureteral orifices results in a which must be tailored to fit defect at the vesical membranous urethra when these structures are anastomosed and also to obtain a watertight repair of the large vesical defect remaining, Our final objective is to ntoirtnrm an anastomosis that will prevent undue strain on rethe external urethral structure. f--Tistorical note. Dr. Hugh H. Young described the vesicourethral anastomosis, ~v,"U'V""""' of approximation of bladder to urethra, as follows: "a.fter removal of the entire , there remains a very large open wound in the which must be down and anastomosed with the membranous urethra. It possible traction with clamps to ~""-'"""""" anterior part of the vesical wall to the of the membranous urethra, . Heavy chromic the suture being so as to include mucous mern.brane and tied boomerang needle-holder 0
is of great assistance in placing these sutures which are serted alternately on each side until the entire circumference of the urethra has been approximated to the bladder wall (the anastomosis being completed by a figure-of-8 stitch in the median line posteriorly). Eight or 10 sutures are generally necessary to make this anastomosis satisfactorily. should be placed deeply through adjacent muscular structures and tied not too tightly. During this procedure, a urethral catheter remains within the point of anastomosis and into the bladder, where it remains for drainage after tion. The rest of the bladder opening is closed continuous chromic catgut suture which does not mucous membrane."" Of 24 cases reported by only 3 patients were incontinent postoperatively, an of about 12 per cent. In 1940 Vest reported his new method of making the anastomosis so that the strain would be taken off the external urethral sphincter by using traction sutures to pull the blad-, der neck firmly against the urogenital diaphragm, the sutures out through the perineum to prevent or distortion of the external urinary sphincter. 3 His consisted of 4 quadrantal sutures: with 3 sutures, anteriorly and laterally, coming into the urethral "f-'"''"''-'vc1 and a fourth figure-of-8 suture being placed anastomosis is described by Weyrauch, "take bites in the vesical neck with sutures of No. 1 chromic catgut. Lead these out to the surface of the perineum and tie them over buttorn:;; place the initial suture in the midanterior of the vesical neck After leaving the bladder margin, continue the suture beneath the mucosa of the membranous urethra within the external sphincter, on through the triangular H1",au1ei1c and through the bulb of the urethra to emerge in subcutaneous tissues at the anterior margin of the perineal incision, Next, pass the ends through the skin in the midline, at a level between the scrotum and perineal incision, Place similar sutures laterally and tie these first .. , , A catheter from the membranous urethra facilitates introducing the sutures. To complete the anastomosis, take a figure-of-8 riorly from the vesical neck to the urogenital diaphragm, Jewett's modification includes substituting simple sutures for Vest's anterior and lateral mattress sutures, which were tied over buttons on the perineal skin, These simply anterior and lateral margins of the appropriate portion anterior bladder lumen defect to the membranous urethra. A fourth suture, placed in the area of the bladder neck below the coaptionjust described as a mattress suture, the bladder wall on each side, enters the bladder defect lumen briefly to enter the urethral lumen for a distance of about l cm. distally (part A of figure), Each end emerges urethral wall posteriorly and is brought through the nor,r,oc, body to be tied ultimately just under the perineal closing the remainder of the bladder defect, with enough tension to take the strain off the vesicourethral anastomosis.
209
210
HODGES
B
A, anterior and lateral sutures of 2-zero chromic catgut, labeled 1, 2 and 3, unite 3 quadrants of stump of membranous urethra to anterior portion of bladder defect. Placement of mattress suture labeled 4 to approximate posterior portion of newly fashioned bladder neck to membranous urethra. Suture ends emerge through urethral wall and course upward through perineal body to be tied under perineal skin. B, running 2-zero chromic catgut suture labeled 5 closes posterior remaining portion of bladder defect before suture labeled 4 is drawn up. Suture labeled 4 relieves any posterior strain on vesicourethral anastomosis.
The posterior limb of the bladder defect is closed, starting posteriorly, with a running suture of 2-zero atraumatic chromic catgut (partB of figure). Care is taken at the start to avoid the ureteral orifices (only 1 cm. away!), coapting bladder wall to bladder wall, after identification of the ureteral orifices with indwelling catheters. Parenthetically, when doing a radical retropubic prostatectomy, we have been able to duplicate Mittemeyer's observation that the same principle, applied in reverse with closure of the posterior bladder defect first and then coaption of the appropriate anterior portion of the defect to the membranous urethra will improve the urinary incontinence results from approximately 10 to less than 1 per cent. 4 The usual problem has been an inability to place the approximating sutures carefully or at all in the proximal end of the membranous urethra, once it has retracted into the depths of the pelvis and
the urogenital diaphragm. However, if the surgeon can place a single approximating suture at 3 or 4 points in this end of the membranous urethra in succession, each just before the urethra is cut away from the prostate, these sutures will remain for accurate approximation when the apposing portion at the anterior end of the bladder defect has been prepared. REFERENCES
1. Jewett, H. J., Bridge, R. W., Gray, G. F., Jr. and Shelley, W.
M.: The palpable nodule of prostatic cancer. Results 15 years after radical excision. J.A.M.A., 203: 403, 1968. 2. Young, H. H. and Davis, D. M.: Young's Practice of Urology. Philadelphia: W. B. Saunders Co., vol. 2, p. 468, 1926. 3. Weyrauch, H. M.: In: Surgery of the Prostate. Philadelphia: W. B. Saunders Co., p. 221, 1959. 4. Mittemeyer, B.: Personal communication.
