The technique used to create the vesicourethral anastomosis after robot-assisted laparoscopic radical prostatectomy (RALRP) can have a marked impact on the postoperative outcome, according to a recent paper in the Journal of Endourology.

Poorly constructed anastomoses, resulting in urinary leakage and bladder neck stricture, are associated with considerable short-term morbidities, including urinary retention, sepsis and a delay in regaining continence.

A team based at the James Buchanan Brady Institute of Urology, New York, NY, carried out a retrospective study of the rates of anastomotic leaks, bladder neck strictures and time to return of continence in 1,900 patients who underwent RALRP in their institute from 2005–2009. Statistical analysis showed that the men who had anterior reconstruction (n = 303) or total anatomic restoration (n = 1,383) had a significantly reduced rate of anastomotic leakage and bladder neck contractures compared with the men who underwent conventional anastomosis (n = 214). In addition, continence rates during the first postoperative year were markedly higher in the reconstructed groups than in the conventional anastomosis group.

The authors suggest that there are four main sites at which the anastomosis can become unstable after RALRP, and that these deficiencies result in descent into the pelvis of the bladder, which presses on the anastomosis. Anterior reconstruction and total anatomic restoration address these weaknesses, reducing the likelihood of adverse sequelae.

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However, the authors of another recent article question the long-term relevance of these results. In the British Journal of Urology International, Robert Nadler and colleagues from Northwestern University Feinberg School of Medicine, Chicago, IL, report the results of their retrospective review of the long-term effects of anastomotic leak and bladder neck contracture on erectile function and continence. At 24 months follow-up, there was no difference in erectile function—as measured by Sexual Health in Men (SHIM) score—or in continence rates or bladder neck contracture rates, between patients who had a postoperative anastomotic leak and those that did not. This knowledge could be very helpful in counseling patients in the immediate postoperative period.

“While a watertight anastomosis is ideal, this study is reassuring to both physicians and patients as it shows that a postoperative complication, like a urine leak, has no long-term effect on continence, potency and bladder neck contracture”, remarks Nadler.

Thus, although anastomotic leak is associated with serious short-term effects, it would seem that the long-term outcomes following urinary leakage are less worrying. However, in terms of patient satisfaction and reduction of short-term adverse effects, total anatomic restoration would seem to be the most effective approach to formation of the anastomosis after RALRP. Prospective and randomized trials to further investigate the outcomes associated with this technique are now required.