Athermal division and selective suture ligation of the dorsal vein complex during robot-assisted laparoscopic radical prostatectomy: description of technique and outcomes.
BACKGROUND
Apical dissection and control of the dorsal vein complex (DVC) affects blood loss, apical positive margins, and urinary control during robot-assisted laparoscopic radical prostatectomy (RALP).


OBJECTIVE
To describe technique and outcomes for athermal DVC division followed by selective suture ligation (DVC-SSL) compared with DVC suture ligation followed by athermal division (SL-DVC).


METHODS
Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures.


METHODS
RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection.


METHODS
Blood loss, transfusions, operative time, apical and overall positive margins, urine leaks, catheterization duration, and urinary control at 5 and 12 mo evaluated using 1) the Expanded Prostate Cancer Index (EPIC) urinary function scale and 2) continence defined as zero pads per day.


CONCLUSIONS
Men who underwent DVC-SSL versus SL-DVC were older (mean: 59.9 vs 57.8 yr, p<0.001), and relatively fewer white men underwent DVC-SSL versus SL-DVC (87.5% vs 96.7%, p<0.001). Operative times were also shorter for DVC-SSL versus SL-DVC (mean: 132 vs 147 min, p<0.001). Men undergoing DVC-SSL versus SL-DVC experienced greater blood loss (mean: 184.3 vs 175.6 ml, p=0.033), and one DVC-SSL versus zero SL-DVC were transfused (p=0.442). Overall (12.2% vs 12.0%, p=1.0) and apical (1.3% vs 2.7%, p=0.361) positive surgical margins were similar for DVC-SSL versus SL-DVC. Although 5-mo postoperative urinary function (mean: 72.9 vs 55.4, p<0.001) and continence (61.4% vs 39.6%, p<0.001) were better for DVC-SSL versus SL-DVC, 12-mo urinary outcomes were similar. In adjusted analyses, DVC-SSL versus SL-DVC was associated with shorter operative times (parameter estimate [PE]±standard error [SE]: 16.84±2.56, p<0.001), and better 5-mo urinary function (PE±SE: 19.93±3.09, p<0.001) and continence (odds ratio 3.39, 95% confidence interval 2.07-5.57, p<0.001).


CONCLUSIONS
DVC-SSL versus SL-DVC improves early urinary control and shortens operative times due to fewer instrument changes with late versus early DVC control.
Lei
Yin
Y
Division of Urologic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Alemozaffar
Mehrdad
M
Williams
Stephen B
SB
Hevelone
Nathanael
N
Lipsitz
Stuart R
SR
Plaster
Blakely A
BA
Amarasekera
Channa A
CA
Ulmer
William D
WD
Huang
Andy C
AC
Kowalczyk
Keith J
KJ
Hu
Jim C
JC
D000368:Aged; D016063:Blood Loss, Surgical / Q000517:prevention & control; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008026:Ligation / Q000379:methods; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000517:prevention & control*; D011467:Prostate / Q000098:blood supply / Q000601:surgery; D011468:Prostatectomy / Q000295:instrumentation / Q000379:methods*; D020127:Recovery of Function; D012189:Retrospective Studies; D012371:Robotics / Q000379:methods*; D013536:Suture Techniques; D016896:Treatment Outcome; D014554:Urination; D014680:Veins / Q000601:surgery*