Editorial Comment for Tüfek et al.

I n the preceding article, the authors describe a technique for temporary control of the dorsal vein using a bulldog clamp. This technique allows the apical dissection to proceed in a bloodless field and subsequent suturing of the dorsal vein after completion of the apical dissection. Certainly the step of controlling the dorsal vein is one of the key steps in radical prostatectomy. As the authors point out, indiscriminate placement of sutures in an attempt to control the dorsal vein could result in sphincteral injury, and poor visualization during the apical dissection could compromise the apical margin.

There is some evidence to suggest a decreased positive margin rate when suture ligation of the dorsal vein is avoided. Ahlering and associates ¹ first showed a decreased positive margin rate from 36% to 16.7% with stapling compared with suturing of the dorsal vein. The positive margin rate for pT₂ tumors decreased from 27.3% to 4.7% (P=0.003). Similarly, Wu and colleagues ² in a retrospective single surgeon comparison reported decreased blood loss (288 vs 495 mL; P<0.001) and a trend toward a decreased positive apical margin rate (2.1% vs 13.4%; P<0.056) when the dorsal vein was stapled compared with sutured. No difference in PSA recurrence, continence, or Sexual Health Inventory for Men scores was reported.

The use of the bulldog clamp could provide the advantages of the stapling device such as dissection in a bloodless field and preservation of the sphincter without the additional cost of the disposable stapling device. As with all procedural modifications, the ultimate success of this new technique will be best evaluated by comparing outcomes using a prospective randomized trial.