title: Lateral pedicle control during laparoscopic radical prostatectomy: refined technique.
abstract: OBJECTIVE
  To report a technique of lateral pedicle control during laparoscopic radical prostatectomy that completely eliminates any form of electrocautery, ultrasonic thermal energy, clips, or bioadhesives.
  
  
  METHODS
  The technique was used in 25 men undergoing nerve-sparing laparoscopic radical prostatectomy. Our antegrade technique involves transient control of the lateral prostate pedicles with an atraumatic vascular bulldog clamp. The pedicles were divided by precise cold cutting, and the neurovascular bundles (NVBs) were teased away with gentle blunt and sharp dissection. Hemostasis was secured with meticulous, superficial suturing of transected blood vessels with 4-0 Vicryl. Real-time transrectal ultrasound monitoring was performed preoperatively, during bulldog clamp application, and postoperatively.
  
  
  RESULTS
  The mean bulldog clamp time for the right and left prostate pedicles was 11.1 and 11.2 minutes, respectively. Transrectal ultrasonography confirmed continued arterial blood flow within NVB during active bulldog clamping. Before clamping, during clamping, and after prostatectomy, the mean number of visible blood vessels within each NVB was 3.4, 2.2, and 2.1 (P <0.001 before versus during or after), and the mean resistive index of arterial blood flow was 0.86, 0.85, and 0.85, respectively. Positive surgical margins occurred in 1 patient (4%). Potency and continence data are awaited.
  
  
  CONCLUSIONS
  We describe a technique of lateral pedicle ligation during laparoscopic radical prostatectomy using monitored cold cutting and delicate 4-0 hemostatic suturing that completely eliminates all electrocautery, ultrasound thermal energy, clips, and bioadhesives. Bulldog clamp placement on the lateral prostate pedicles did not interrupt blood flow within the NVB.
authors.affiliation: Section of Laparoscopic and Robotic Surgery, Glickman Urological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA. gilli@ccf.org
authors.forename: Inderbir S
authors.initials: IS
authors.lastname: Gill
authors.forename: Osamu
authors.initials: O
authors.lastname: Ukimura
authors.forename: Mauricio
authors.initials: M
authors.lastname: Rubinstein
authors.forename: Antonio
authors.initials: A
authors.lastname: Finelli
authors.forename: Alireza
authors.initials: A
authors.lastname: Moinzadeh
authors.forename: Dinesh
authors.initials: D
authors.lastname: Singh
authors.forename: Jihad
authors.initials: J
authors.lastname: Kaouk
authors.forename: Tsuneharu
authors.initials: T
authors.lastname: Miki
authors.forename: Mihir
authors.initials: M
authors.lastname: Desai
mesh_terms: D006488:Hemostasis, Surgical; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D008875:Middle Aged; D011468:Prostatectomy / Q000295:instrumentation / Q000379:methods*; D013536:Suture Techniques; D016896:Treatment Outcome; D018084:Ultrasonography, Interventional