Hiroshi Sasaki md, Department of Urology, Jikei University School of Medicine, 3-25-8 Nishi-Shimbashi, Minato-ku, Tokyo 105-8461, Japan. Email: email@example.com
Laparoscopic radical prostatectomy for localized prostate cancer offers several advantages, including creation of a pneumoperitoneum that results in less blood loss than is seen with the corresponding open procedure. Transection of the deep dorsal vein complex remains among the most challenging aspects, however. Safe and secure completion of this procedure is important to minimize blood loss and maximize the chance of cure. Liberal use of coagulation for hemostasis at the dorsal vein complex (DVC) risks thermal damage to the sphincteric muscle. DVC ligation before transection, though commonly performed, can cause loss of some sphincteric fibers and potentially result in delayed recovery of urinary continence. Furthermore, ligation may at times prove difficult, especially in obese patients with a short and broad DVC, a large prostate gland, and a narrow pelvis. The presence of prominent pubic tubercles may further increase the difficulty. We have found that bleeding from the DVC is easily controlled without suture ligation through a combination of a modest pneumoperitoneum with pinpoint coagulation of one or two small arteries that are consistently found in the superficial layer of the complex. Precise, even-level transection is possible under direct vision with no more than modest blood loss. A stitch in a Z-shaped fashion is then applied to the entire transected stump of the DVC. This procedure is simple and easily performed, even by those with limited experience. Here we provide an overview of our current technique.
A five-port transperitoneal approach is used. Antegrade laparoscopic radical prostatectomy (LRP) is started, as previously described, under an ordinary pneumoperitoneal pressure of 12 mmHg and with the patient in the Trendelenburg position.1 The dissection is advanced toward the apex until it reaches a point at which only the DVC, the urethra, and the prostate gland are connected. The pneumoperitoneal pressure is then temporarily raised to 15 mmHg. The superficial layer of the mid-portion of the DVC is cut with a pair of scissors (Microline), starting from the midline (Fig. 1). No electrocautery is applied at this stage. As cutting proceeds from the midline, pulsating bleeders from one or sometimes two small arteries that run near the midline of the DVC will be encountered (Fig. 2). The transected arterial stump or stumps are handled through pinpoint monopolar coagulation using the very tip of the scissors. The rest of the DVC is easily dissected, as venous bleeding is well controlled by the pneumoperitoneum alone (Fig. 3). A stitch in a Z-shaped fashion (V-20, 2-0 1/2. polyglactin; Tyco Healthcare group LP, Norwalk, CT, USA) is then applied to the entire transected stump of the DVC (Fig. 4). The urethra is identified with the use of a 20-Fr metal sound inserted through the urethra.
Complete hemostasis after transection of DVC constitutes an extremely important step during the course of radical prostatectomy.1 The DVC is a complex structure that contains veins, arteries, sphincteric muscle fibers, and other components. Main arteries consistently lie superficially to this complex. One of the advantages of LRP is that the bleeding from veins can easily be controlled with modest peumoperitoneal pressure alone. This also applies to veins in the DVC. It is impressive that under the pneumoperitoneum, most of the bleeding from the DVC can be controlled with only pinpoint coagulation of arteries. The simultaneous transection of arteries and veins leads a surgeon to believe that bleeding from the DVC is often difficult to control even in LRP. The cardinal rule here is to identify and coagulate the arteries first. There was no difference in the amount of intraoperative bleeding either before or after we undertook the procedure (262 vs 259 mL).
In our experience, pinpoint use of monopolar scissors for electrocoagulation had no significant adverse effects on functional or pathological outcome after surgery. The recovery of urinary continence (pad-free rates) for the past 100 patients has been 71.7% by 3 months and 96.5% by 12 months.1 The overall positive surgical margin rate in pT2 disease has been 6.5%.1 We do not believe this procedure itself affected potency recovery.
A technique known as “selective ligature” has recently been reported.2,3 This method involves meticulous hemostatic suturing after dissection of the DVC and is intended to improve postoperative urinary continence. Bipolar coagulation was reported as the preferred method of coagulation, but no effort was made to find arteries. At least in theory, the use of bipolar coagulation3 may have some advantage in terms of avoiding penetrating thermal damage. However, it cannot be used in a pinpoint fashion and seems more traumatic overall than our approach. The reported continence recovery was comparable to ours: 80.0% at 3 months (24/30) and 90.0% at 12 months (27/30). Our own experience with selective ligature has not demonstrated any advantage for this technique.
The procedure we report here is simple, safe and easily applicable to any patient, even those with anatomical difficulties. Greater and more thorough understanding of DVC anatomy is important and can lead to further advances in surgical techniques.