Energy-free nerve-sparing laparoscopic radical prostatectomy: the bulldog technique
Inderbir S. Gill, Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, A-100, Cleveland Clinic Foundation, 9500 Euclid Ave., Cleveland, Ohio 44195, USA.
Concern has been raised that the use of various haemostatic energy sources during release of the neurovascular bundles (NVB) during laparoscopic radical prostatectomy (LRP) can potentially cause collateral thermal damage to the delicate cavernous nerves . We recently described TRUS- guided energy-free lateral pedicle control [2–5] during nerve-sparing LRP that completely eliminates the use of all such electric or ultrasonic energy.
After the vas deferens and medial surface of the seminal vesicles have been mobilized, all subsequent steps of the entire LRP procedure are done with no thermal/electrical energy. The seminal vesicle artery is controlled with a Hem-o-Lock clip (Weck Closure Systems, Research Triangle Park, NC, USA) and transected with cold scissors. Typically, the right lateral pedicle and NVB are addressed initially.
An atraumatic bowel clamp introduced through the 5-mm suprapubic port is used to retract the seminal vesicles and vas deferens anterolaterally to the left side, placing the right lateral pedicle of the prostate under gentle tension. A 25-mm, atraumatic vascular bulldog clamp (CEV565, MicroFranceTM Medtronic Xomed, Inc., Jacksonville, FL, USA) is placed obliquely at 45° across the right lateral pedicle close to the bladder neck, at some distance from the right posterolateral edge of the prostate.
The lateral pedicle is carefully divided in small tissue bites, using Endoshears with no electrocautery.
TRUS and power Doppler measurements are obtained before and during application of the bulldog clamp to confirm uninterrupted blood flow through the NVB [4,5].
In this manner, a 1–2 mm edge of pedicle tissue remains protruding from the jaws of the bulldog clamp, which is then oversutured subsequently for haemostasis using a 4–0 polyglactin suture on an RB-1 needle (suture length 6–8 cm).
TRUS allows real-time monitoring of the precise dissection along the posterolateral edge of the prostate. Upon division of the last few remaining attachments of the lateral pedicle, the NVB becomes visible. Nerve-sparing is done antegradely. The NVB is released by cold cutting and blunt teasing with a soft laparoscopic Kittner along the convexity of the prostate toward the apex.
The bulldog clamp is then removed, revealing any bleeding vessels. The transected lateral pedicle is now selectively sutured superficially. Real-time TRUS monitoring confirms these haemostatic sutures to lie superficial to the NVB without compromising the blood vessels within the NVB. In similar manner, the left lateral pedicle is transected and the NVB released.
We initially reported on 25 patients undergoing nerve-sparing LRP using the bulldog technique; the mean clamping time was 11 min on each prostate pedicle, the operative duration 254 min, the estimated blood loss 334 mL, the hospital stay 1.6 days, and catheter duration 5.4 days. No patient required a blood transfusion, and there were no intraoperative complications. Arterial flow within the NVBs by spectral waveform analysis documented before, during and after pedicle clamping (using TRUS power Doppler) showed no changes in the mean arterial blood flow resistive index in the NVBs (0.86, 0.85 and 0.85 before and during clamping, and after LRP, respectively) .
More recently, we compared potency outcomes in 76 patients undergoing either the harmonic scalpel-based (group I) or the energy-free technique (group II). Within the entire group, the overall 1-year intercourse rates were better in group II (36% vs 70%; P = 0.04). In patients completely potent before LRP (Sexual Health in Men score ≥22), the 1-year intercourse rates in group I vs II were 71% vs 88%, respectively (P = 0.4) and erectile function recovered faster in group II .
One question is whether bulldog clamping of the prostate pedicle might cause trauma to the cavernous nerves within the NVB. While bulldog clamping adequately occludes blood flow in the lateral pedicle, and achieves a relatively bloodless field during pedicle transection, it did not interrupt blood flow in the underlying ipsilateral NVB. TRUS documentation of continued pulsatile blood flow within each NVB during active bulldog clamping confirms that deploying the bulldog clamp across the anteriorly located overlying, bulkier lateral pedicle was delicate enough to not compress the posteriorly located underlying thinner NVB. Doppler measurement of the arterial flow resistive index within the NVB did not change.
TRUS-monitored cold-cutting release of the lateral pedicle and NVB during nerve-sparing LRP, and delicate 4–0 haemostatic suturing, completely eliminates the need for all electrocautery, ultrasonic thermal energy, and bioadhesives close to the NVB. Placing a bulldog clamp on the lateral prostatic pedicle does not physically compress the ipsilateral NVB, nor does it interrupt blood flow within the NVB. Preliminary potency data are encouraging, indicating a 6-month advantage for earlier recovery of potency than with energy-based techniques. In men with preoperative complete potency we documented an intercourse rate of 88%, with or without sildenafil, at 1 year.