Presentation Authors: Gregory Joice*, Kevin Koo, Hiten Patel, Zeyad Schwen, Michael Gorin, Alan Partin, Mohamad Allaf, Baltimore, MD
Introduction: Urinary incontinence after Robot-Assisted Laparoscopic Radical Prostatectomy (RALRP) is rare but can result in poor patient quality of life. While only 4-6% of patients will require some form of continence procedure for many men the return to full continence can take 6-18 months. Multiple surgical maneuvers have been explored to support the vesicourethral anastomosis and prevent bladder neck descent with mixed results. Our aim was to demonstrate that using the umbilical ligaments to create an anastomotic sling is both feasible and safe.
Methods: A 58 year-old man presented with intermediate risk prostate cancer and elected for RALRP. Standard port placement was used for a transperitoneal robotic prostatectomy ensuring the camera port was supraumbilical. After the posterior dissection was performed, the bilateral umbilical ligaments were transected and dissected proximally to the level of the vas deferens. After the prostatectomy is completed and the vesicourethral anastomosis performed, the umbilical ligaments are sutured to each other posterior to the anastomosis. The anastomosis is then wrapped with the umbilical ligaments and held in place with absorbable suture. Finally, the proximal umbilical ligaments are anchored to the ipsilateral vas deferens.
Results: The umbilical ligament sling was created without any perioperative complications. Visually the sling was observed to provide gentle upward traction on the anastomosis and in theory preventing bladder neck descent. Additionally, when filling the bladder there appears to be a dynamic effect such that the sling acts to prevent opening of the bladder neck with a full bladder. The patient tolerated the procedure well and was discharged the following day. He passed a void trial nine days postoperatively and reports using zero pads at 2 months after the operation. As part of this pilot, we have performed 30 umbilical slings with no incidences of urinary retention or urine leak. Longer follow-up is needed to assess continence outcomes but preliminary subjective results from patients are encouraging.
Conclusions: Creation of a dynamic umbilical ligament anastomotic sling at the time of RALRP is both feasible and safe. Visually the sling appears to both prevent anastomotic descent and provides additional support to the bladder neck during filling to prevent premature opening. Ongoing prospective studies will determine if this technique can improve short or long term continence outcomes.