The Use of a Laparoscopic Bulldog Clamp to Control the Dorsal Vein Complex During Robot-Assisted Radical Prostatectomy: A Novel Technique

Abstract

Purpose:

To describe a novel technique to control dorsal vein complex (DVC) during robot-assisted radical prostatectomy (RARP).

Patients and Methods:

We have been using a laparoscopic bulldog clamp to control DVC before apical dissection and urethral division. Data of 50 patients who underwent DVC control with laparoscopic bulldog clamp (group 1) were retrospectively compared with 50 consecutive patients in whom DVC was controlled with suture ligation (group 2). In the bulldog and suture groups, 30 and 31 patients underwent concomitant bilateral extended pelvic lymph node dissection (PLND), respectively. Operative and anastomosis time, estimated blood loss (EBL), apical surgical margin positivity, and early continence rates were evaluated.

Results:

Patients in the bulldog group had significantly shorter operative time compared with patients in the suture group (146.8 vs 178.4 min, P=0.0005). Anastomosis time was significantly shorter in the bulldog group (12.3 vs 15.5 min, P=0.002). There was no difference in EBL between the groups (185 vs 184.2 mL). Immediate, postoperative first and third month continence rates were 62% vs 44%, 74% vs 60%, 90% vs 74% in groups 1 and 2, respectively. Although continence rates were better in favor of the bulldog group at each evaluation period, the difference did not reach statistical difference. None of the patients in both groups had apical surgical margin positivity.

Conclusions:

The use of a laparoscopic bulldog clamp to control DVC was associated with shorter operation and anastomosis time and a trend toward quicker recovery of continence. This technique provides clear vision during apical dissection and urethral division while potentially minimizing the external sphincteric trauma. Prospective randomized trials are needed for better evaluation of this technique.

Introduction

P rostate cancer is the most common solid tumor in men both in the United States and Europe. After its introduction in 2000, robot-assisted radical prostatectomy (RARP) gradually has become the technique of choice for treatment of patients with organ-confined prostate cancer.¹ Today, the majority of radical prostatectomies are performed using the da Vinci robotic system (Intuitive Surgical, Sunnyvale, CA) in the United States.²

Efforts continue to have better perioperative and postoperative results while maintaining optimal oncologic and functional outcomes. The most common site for a positive surgical margin is the apex, which makes the apical dissection one of the most crucial steps of surgery.^3,4 The dorsal vein complex (DVC) is commonly controlled by a single suture before apical dissection.^5,6 Ahlering and associates⁷ described the use of a vascular stapling device for DVC control, while some authors have preferred athermal division and selective suture ligation.^8,9

Suture ligation of the DVC may injure the urethra and external sphincter and decrease the functional urethral length.^10,11 Sometimes a DVC stitch may loosen and be dislocated during apical dissection and surgeons continue dissection of the dorsal vein, which may result in shortening of the urethral stump. On the other hand, control of the DVC with a laparoscopic bulldog clamp allows precise and bloodless apical dissection, preservation of urethral length beyond the apex of the prostate, and avoids distal sphincter mechanism injury.

In this study, we present the use of a laparoscopic bulldog clamp to control the DVC during RARP. Perioperative, oncologic, and early functional outcomes of the technique are compared with conventional suture ligation.

Patients and Methods

Between February 2005 and September 2011, 500 consecutive RARPs were performed. We started to use a laparoscopic bulldog clamp to control DVC before apical dissection and urethral transection in March 2011. As of now, the technique was used in the last 70 patients in our series. Data of the 50 patients who already completed 4 weeks of follow-up (group 1) were retrospectively reviewed and compared with the data of the last consecutive 50 patients in whom DVC was controlled with suture ligation (group 2). All patients were operated on by the same surgeon (ARK). In group 1, 30 patients, and in group 2, 31 patients underwent concomitant bilateral extended pelvic lymph node dissection (PLND).

Surgical technique

The procedure was started with incision of the peritoneum and entrance into the Retzius space by using a 0-degree scope. Subsequently, the endopelvic fascia was opened and the levator ani muscles were pushed away from the prostate. Puboprostatic ligaments were divided on both sides.

In the suture group, the DVC was ligated using a 2/0 polyglactin suture with sliding knot technique. After ligating the DVC, the same suture was passed through the periosteum of the symphisis pubis to create anterior reconstruction. Following this, the scope was changed to 30-degree down. The bladder neck was divided, seminal vesicles were dissected, and a nerve-sparing technique was performed when indicated. After division of the DVC and the urethra, apical dissection was performed. A modified Rocco stitch was placed on the midline for posterior reconstruction. Finally, urethrovesical anastomosis was performed by using two 18-cm 2/0 Biosyn™ sutures with the van Velthoven technique.¹²

In the bulldog clamp group, the scope was changed to 30-degree down for bladder neck dissection. During seminal vesicle isolation and control of the lateral pedicle, athermal dissection was performed for neurovascular bundle-sparing technique. Then the DVC was controlled with a vascular bulldog clamp (Solos Endoscopy, Inc, Boston, MA) (Figs. 1A, 1B). This was followed by division of the DVC and urethra and apical dissection under bloodless clear vision. Maryland bipolar forceps and monopolar scissors were switched to the needle drivers. After removal of the bulldog clamp, the DVC was selectively sutured with 2/0 polyglactin suture. The same suture was then passed through the periosteum of the symphisis pubis for periurethral suspension. A modified Rocco stitch was placed on the midline for posterior reconstruction. Finally, urethrovesical anastomosis was performed by using two 18-cm 2/0 Biosyn sutures with the van Velthoven technique.¹²

FIG. 1.

DVC control with laparoscopic vascular bulldog clamp.

Extended PLND was performed in intermediate- and high-risk patients (prostate-specific antigen [PSA] ≥10 ng/mL and/or Gleason score ≥7 and/or ≥50% of biopsy cores involved).

Statistical analysis

All data were prospectively entered into a database for statistical analysis using GraphPad Prism Software (GraphPad Software, San Diego, CA). The Mann-Whitney U test was used to compare the demographic data of the groups as well as perioperative data (operative time, anastomosis time, and estimated blood loss [EBL]). The Fisher exact test was used to compare the outcomes of the bulldog clamp technique in terms of continence status.

Results

There was no difference in terms of age, PSA level, prostate volume, body mass index, and the rate of patients who had undergone PLND between the two groups (Table 1).

Table 1.

Demographic Characteristics of the Patients

Variable (mean±SD)	Group 1 (bulldog)	Group 2 (suture)	P
Patient group characteristics	50	50
Age (years)	61.75±7.7	60.16±7.8	0.25^a
Prostate volume (cc)	41.94±19	45.73±18	0.51^a
PSA (ng/mL)	7.1±6.4	8.3±5.8	0.19^a
BMI (kg/m²)	26.48±3.1	27.32±2.7)	0.35^a
PLND (+) patients (%)	30 (60%)	31 (62%)	1^b

SD=standard deviation; PSA=prostate-specific antigen; BMI=body mass index; PLND=pelvic lymph node dissection.

Mann-Whitney U test; ^bFisher exact test.

Patients in the bulldog group had shorter operative time compared with patients in the suture group (146.8 vs 178.4 min). The difference in operative time was approximately 32 minutes and statistically significant (P=0.0005). When patients are stratified according to PLND, both PLND (+) and (−) patients in the bulldog group had significantly shorter operative time compared with the patients in the suture group (PLND (+), 167 vs 201.4 minutes; P<0.0001, PLND (−), 119 vs 139.1 minutes; P=0.03). Patients in the bulldog group had significantly shorter anastomosis time compared with the suture group (12.3 vs 15.5 minutes; P=0.002). EBL was similar in both groups (185 vs 184.2 mL) (Table 2).

Table 2.

Perioperative Data of the Patients

Variable (mean±SD)	Group 1 (bulldog)	Group 2 (suture)	P
Operation time (min)	146.8±38.01	178.4±45.02	=0.0005^a
Operation time (min) (with PLND)	167±28.9	201.4±3 3.8	<0.0001^a
Operation time (min) (without PLND)	119±3 2.9	139.1±35.2	0.03^a
Anastomosis time (min)	12.3±4.07	15.5±7.48	=0.002^a
Estimated blood loss (mL)	185±115.7	184.2±115.8	=0.92^a

SD=standard deviation; PLND=pelvic lymph node dissection.

Mann-Whitney U test.

In each group, 31 (62%) patients had cancer at the apex. None of the patients had apical surgical margin positivity in both groups. Preoperative, operative, and postoperative pathologic data of the patients are presented in Table 3.

Table 3.

Preoperative, Operative, and Postoperative Pathologic Data of the Patients

	Group 1 (bulldog)	Group 2 (suture)	P
Nerve sparing (%)	47/50 (94%)	44/50 (88%)
-Bilateral	43	38
-Unilateral	4	6
Mean lymph node yield	18.79 (8–34)	17.4 (2–30)	0.64^a
Preoperative Gleason score	6.55 (6–9)	6.54 (6–9)	0.69^a
Clinical stage
-T₁	12	13
-T₂	38	36
-T₃		1
Postoperative Gleason score	6.64 (6–9)	6.98 (6–9)	0.008^a
Pathologic stage
-T₂	36	42
-T₃	14	8
Overall PSM (%)	2/50 (4%)	6/50 (12%)	0.2^b
PSM in T₂ disease (%)	1/36 (3%)	4/42 (10%)	0.3^b
PSM in T₃ disease (%)	1/14 (7%)	2/8 (25%)	0.52^b

PSM=positive surgical margin.

Mann-Whitney U test; ^bFisher exact test.

Continence was defined with strict criteria—no usage of pads and no leakage of urine. Immediate, postoperative first and third month continence rates were 62% (31/50) vs 44% (22/50), 74% (37/50) vs 60% (30/50), 90% (37/41) vs 74% (37/50) in group 1 and group 2, respectively (Table 4). Although continence rates were better in favor of the bulldog group at each evaluation period, the difference did not reach statistical difference (Fig. 2).

FIG. 2.

Postoperative continence status.

Table 4.

Continence Status of the Groups

	Immediate continence (n)	1st month continence (n)	3rd month continence (n)
Bulldog (group 1)	62% (31/50)	74% (37/50)	90% (37/41)
Suture (group 2)	44% (22/50)	60% (30/50)	74% (37/50)
P	0.1^a	0.2^a	0.06^a

Fisher exact test.

The mean follow-up period was 21 (4.4–36.7), 14 (4.4–24.2), and 28 (20–36.7) weeks in the whole series, in group 1 and in group 2, respectively.

While in group 2, three (6%) patients had perineal and/or lower scrotal ecchymosis, no patients in group 1 experienced such lesions.

Discussion

Optimal control of the DVC is a critical step for RARP. If it is controlled well, a precise apical dissection and urethral division is possible. Suture and stapled ligation are the common techniques described for dorsal vein control.^13

–16 Guru and colleagues⁹ reported cold incision of the DVC without previous suture ligation. In their study, intra-abdominal pressure was increased up to 20 mm Hg before apical dissection to maintain hemostasis. In the presence of excessive bleeding after incision of the DVC, it was oversewn before urethral division. In this comparative study, urethral division had to be postponed because of bleeding in some cases in the cold incision group. EBL was higher in this group (331 vs 268 mL, P=0.44), and one patient needed transfusion. In another study, Lei and coworkers⁸ reported higher blood loss in patients in whom DVC was not sutured before division, and one patient needed transfusion.⁸ In our technique, using the laparoscopic bulldog clamp to control the DVC enabled fine apical dissection without interfering with the anatomy. No patients needed transfusion.

Lei and associates⁸ compared the data of 303 patients who underwent suture ligation followed by athermal DVC division (SL-DVC) to 240 patients who underwent athermal DVC control followed by selective suture ligation (DVC-SSL) during RARP. They reported shorter operative time (131.8 vs 147 min, P<0.001) in the DVC-SSL group. Operative time was approximately 15 minutes shorter. They concluded that shorter operative time was related to fewer instrument changes in the DVC-SSL group. In our series, operative time was significantly shorter in the bulldog clamp group (146.8 vs 178.4 min, P=0.0005). The difference in operative time was approximately 30 minutes and twofold of the series of Lei and colleagues.⁸

We think that the shorter operative time of the bulldog group is not related to the learning curve, because 50 patients in the suture group and 50 patients in the bulldog group were operated on after 400 patients of the same surgeon. As the learning curve is completed, operative time does not seem to be positively affected by an additional 50 patients operated on before the bulldog group (suture group). Because control of the DVC with the bulldog clamp enables a bloodless and precise vision of the urethra and apical anatomy, we suppose shorter operative and anastomosis time to be related to optimal and faster dissection. As reported by Lei and coworkers,⁸ omitting the instrument change for suture ligation of the DVC may be another reason for shorter operative time.

Guru and colleagues⁹ compared the data of the patients with cold incision of the DVC without suture ligation (145 pts) to suture ligation before apical dissection (158 pts) and found decreased positive surgical margin rate of the apex in the first group. They thought that suturing the DVC tended to bunch the tissue and alter the apical anatomy. Lei and associates⁸ reported similar apical surgical margin positivity in both SL-DVC and DVC-SSL groups. In our series, no patient had a positive surgical margin at the apex. Because the number of patients is small, we cannot comment that this technique improves the apical surgical margin positivity rate.

In the literature, there are studies that compare suture and staple ligation of the DVC during laparoscopic radical prostatectomy (LRP) and RARP. Wu and coworkers¹⁷ reported staple ligation of the DVC during RARP to result in improved apical surgical margin rates, faster operative times, and less blood loss. They reported this benefit might have been related to better visualization from clearing off all the fat overlying the DVC before ligation. Contrary to this, Tewari and Tan¹⁸ reported avoidance of early staple ligation of the DVC in their series. They emphasized that firing of the bulky stapler device would not afford adequate visualization of the apex before division of DVC. Nguyen and associates¹⁰ found no difference, however, between suture and stapler ligation of the DVC during LRP regarding positive margin rate, blood loss, and operative time.

Endovascular stapler control of the DVC is somewhat blind and is not under full control of the surgeon; urethral and external sphincteric injury may occur. While suture material for bulldog clamp control and suture ligation of the DVC costs approximately $10, there would be an additional cost of $500 for each stapler device.

Menon and colleagues¹⁹ have suggested that DVC control followed by selective suture ligation be performed after blunt dissection of the levator ani fibers from the prostate and anterolateral aspects of the urethra leading to hemostasis and sphincter preservation. In some other studies, stapler ligation has been assumed to cause less damage to the external urinary sphincter compared with suture ligation.¹⁰ Nguyen and coworkers¹⁰ thought that suture ligation of the DVC could potentially decrease the functional urethral length and/or directly damage the external urinary sphincter. In studies of both Wu and colleagues¹⁷ and Nguyen and associates,¹⁰ however, there was not any difference regarding urinary continence.

In our study, the DVC was controlled with laparoscopic bulldog clamp, and urethral division was performed under clear vision. The length of the urethral stump was found to be adequate, and trauma to the external sphincter was minimized. In spite of the fact that immediate, postoperative first and third month continence rates were higher in the bulldog group, we did not find any statistically significant difference between the groups. Insignificant difference of the incontinence rates may be because of the short follow-up and low power effect.

In our series, three (6%) patients in the suture group had perineal and/or scrotal ecchymosis in the early postoperative period. In the bulldog group, however, none of the patients experienced such lesions. Suturation of the DVC after removal of the clamp enabled optimal control of the DVC with prevention of any bleeding, resulting in avoidance of perineal and/or scrotal ecchymosis.

Laparoscopic bulldog clamp with a freedom of motion within the applicator allowing for angulations according to each patient's prostate apical anatomy was used in our series. This maneuver capability of the clamp allowed optimal positioning to obtain effective control of DVC (Fig. 1B). Our novel technique providing fine dissection under clear vision eliminates inadvertent external sphincteric injury and alteration of the apical anatomy.

Potency was not evaluated because the follow-up period is short in this series. The shortcomings of this study are retrospective nonrandomized nature of the data collection, limited patient number, and short follow-up period to evaluate functional results.

Conclusion

Compared with conventional suture ligation, the use of a laparoscopic bulldog clamp to control DVC was associated with shorter operation and anastomosis time and a trend toward quicker recovery of continence. This technique provides clear vision during apical dissection and urethral division while potentially minimizing the external sphincteric trauma. There is no need to increase the intra-abdominal pressure during apical division. With the evidence from this study, however, it cannot be stated that this new technique is better than conventional suture ligation, but at least equivalent. Prospective randomized trials are needed for better evaluation of this technique.

Footnotes

Disclosure Statement

No competing financial interests exist.

Abbreviations Used

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