Selective Suture Ligation of the Dorsal Vein Complex During Robot-Assisted Laparoscopic Radical Prostatectomy

Indications/contraindications

Division and selective suture ligation (SSL) of the dorsal vein complex (DVC) may be used during robot-assisted laparoscopic radical prostatectomy (RALP) in healthy men with clinically significant prostate cancer.

Preoperative workup/preparation

Candidates for RALP should have a life expectancy of at least 10 years. Guidelines indicate metastatic workup should be pursued for those with a prostate-specific antigen (PSA) level greater than 20 ng/mL and T₁ disease, PSA greater than 10 ng/mL and T₂ disease, a Gleason score of 8 to 10, clinical stage T₃ or T₄, or clinical symptoms. ¹

Instrumentation

Settings

Energy: 25 W for both monopolar and bipolar currents.

Insufflation pressure and flow: 15 mm Hg and 10 L/min

Athermal division of the DVC

After performing the nerve sparing at the base and midportion of the prostate, we use the Prograsp forceps in the fourth robotic arm to bunch the detrusor apron while creating slight cephalad tension. This also allows for visualization of the anterolateral prostatic contour. After pushing levator fibers away from the prostatic apex, vascular structures between the detrusor apron and the apical prostate are divided sharply. Encountered in this region are the DVC sinuses and arterioles that course anterior to the prostatic apex. Arteriole bleeding is controlled by precise bipolar cautery. Critical to adequate visualization is maintenance of pneumoperitoneum to minimize venous bleeding. This may be accomplished with the use of the AirSeal^® (SurgiQuest, Milford, CT). ² Alternatively, the bedside assistant is instructed to use the suction sparingly, primarily with the sucker tip submerged within a puddle of blood while suctioning to prevent lowering of the pneumoperitoneum.

An anatomic plane extends sagitally from the detrusor apron's attachment to the pubic bone to the prostate-urethral junction, lying anterior to the urethra and medial to the pillars of Walsh. Identification of this avascular plane is achieved with blunt dissection after the vascular structures have been sharply divided. Once this cleavage plane is established, the ischioprostatic ligaments (Walsh pillars) are divided using circumferential sharp and blunt dissection. The exposure for the division of the remaining posterior rhabdosphincter attachments is facilitated by grasping the prostatic base with the fourth-arm Prograsp forceps and gently rotating the prostate.

Now, the anterior urethra is sharply transected. The robotic Maryland and the curved scissors are removed and replaced with needle drivers. Selective suturing of the DVC venotomies is performed using 3-0 polyglactin cut to 23 cm on a CT-3 needle (Ethicon, Somerville, NJ). Identification of the venotomies is facilitated by lowering the pneumoperitoneum by assistant suctioning the pneumoperitoneum, or setting the insufflator to <5 mm Hg. The bleeding venotomies are repaired with a mattress suture, taking thin bites of the venotomies, avoiding wider needle trajectories that may ensnare the anterior rhabdosphincter (Fig. 1). Approximately two to three venotomies are typically encountered.

OPEN IN VIEWER

FIG. 1.

Selective suture ligation of DVC venotomies.

For efficiency, the remaining suture after SSL of the DVC is used for 50% of the urethral anastomosis. The first stitch is preplaced as a posterior anastomotic suture before division of the posterior urethra. Then, the assistant divides the posterior urethra using laparoscopic scissors. This sequence prevents retraction of the urethral stump. The prostate is then placed in the laparoscopic bag, and the anastomosis is performed.

Management of intraoperative complications

Occasionally, visualization is compromised during DVC-SSL because of pooling of venous coagulum from the cut vascular structures. Use of a powerful suction apparatus (Neptune,^® Stryker, Kalamazoo, MI) that generates up to −500 mm Hg (as opposed to a traditional −80 mm Hg of wall suction) helps to maintain adequate pneumoperitoneum during sharp dissection of the DVC. This prevents clotting of the suction tip, hand piece, and/or tubing. A second suction/irrigator and tubing, however, should be readily available in the same room.