Externalized urachal suture: Novel approach to bowel and bladder retraction during transperitoneal laparoscopic radical prostatectomy

Introduction. Although laparoscopic radical prostatectomy (LRP) has emerged as a legitimate minimally invasive surgical alternative to open radical retropubic prostatectomy, the technical difficulty of this advanced laparoscopic procedure remains an obstacle to its widespread use. We report a novel surgical technique for the purpose of bowel and bladder retraction during transperitoneal LRP that improves visualization and negates the need for additional working ports or steep Trendelenburg positioning. Technical Considerations. A 35-cm absorbable suture is secured intracorporeally to the urachus. The distal end of the suture is then pulled out through the left subcostal abdominal wall in the midaxillary line using a Carter-Thomason CloseSure device. Application of tension on the suture retracts the bladder superiorly and prevents bowel from entering the surgical field. This maneuver provides excellent exposure of the bladder neck and prostate and minimizes the need for additional fan retraction or steep Trendelenburg positioning. In 20 consecutive procedures, this step added an average of 2.2 minutes to the operative time, which averaged 169 minutes overall. Conclusions. Incorporation of an adjustable externalized urachal suture allows for excellent retraction of both bowel and bladder. This allows transperitoneal LRP to be performed using a four-port approach with minimal need for additional retraction or steep Trendelenburg positioning. In light of these benefits, the urachal suture has been incorporated as a routine step in transperitoneal LRP at our institution.