How to Do Vesicourethral Anastomosis Using Van Velthoven Single-Knot Running Suture Technique for Robot-Assisted Radical Prostatectomy

Abstract

Introduction:

Vesicourethral anastomosis (VUA) is a critical step in robotic-assisted radical prostatectomy. A precise, watertight, and tension-free anastomosis is essential to prevent urinary leakage, reduce catheterization time, and promote early recovery of continence. This video demonstrates the standardized Van Velthoven single-knot running suture technique.

Patient and Methods:

We present a 68-year-old male with localized prostate cancer who underwent robotic-assisted radical prostatectomy. Informed consent for video recording and publication was obtained. After completion of the extirpative phase and meticulous hemostasis, posterior reconstruction and VUA were performed using a 3-0 barbed absorbable suture.

Surgical Technique:

Following prostate removal, the bladder neck is inspected for symmetry, mucosal integrity, and appropriate diameter. Irregular edges are trimmed to ensure healthy, well-vascularized margins. A 30° downward lens optimizes visualization, particularly in deep or narrow pelvises, while stable pneumoperitoneum maintains working space. Posterior reconstruction is performed according to Rocco’s principles, approximating Denonvilliers’ fascia and the posterior detrusor apron to the posterior rhabdosphincter with a 3-0 absorbable suture. This restores posterior support, reduces tension on the anastomosis, and may facilitate earlier continence recovery. Rectal tissue and excessive urethral muscle incorporation are carefully avoided. The anastomosis begins posteriorly at the 6 o’clock position. The first stitch is placed outside-in on the bladder neck and inside-out on the urethral stump, incorporating full-thickness mucosa for a watertight seal. The two suture arms are then run continuously in opposite directions from 6 to 12 o’clock. Bites are spaced 3–4 mm apart, including full-thickness bladder and urethral tissue. Urethral bites are slightly shallower laterally to avoid narrowing, while bladder bites may be wider for strength. Gradual cinching after every few throws ensures even approximation without excessive tension. The bedside assistant provides gentle bladder traction, maintains a clear field, and carefully manages the Foley catheter to prevent distortion. A 16–18F Foley catheter is inserted before or during anterior closure, ensuring correct intravesical positioning before balloon inflation with 10 mL sterile water. Anterior suturing (10–12 o’clock) is technically demanding due to limited visualization. Improved exposure is achieved with optimal camera angulation and bladder elevation. Slightly wider anterior bladder bites prevent gaps. The suture arms meet at 12 o’clock, where final cinching is performed over the catheter and secured with a single knot. Technical adjustments in narrow pelvis cases include optimized Trendelenburg positioning, reduced needle arc movements, and frequent clutching. Urethral edge tears are repaired immediately with interrupted 4-0 absorbable sutures. In cases of size mismatch, fish-mouth bladder neck reconstruction reduces the diameter before anastomosis. A saline leak test with 120–150 mL confirms watertight closure.

Results:

Total anastomosis time was 22 min. Intraoperative leak testing showed no extravasation. Recovery was uneventful, and the catheter was removed on postoperative day 10.

Conclusion:

The Van Velthoven single-knot running suture technique provides a reproducible, efficient, and secure method for VUA, supporting surgical precision and favorable functional outcomes.

Authors declare no commercial associations during the last two years that might create a conflict of interest in connection with the video.

Runtime of video: 95 sec.