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). Design, settings, and participants: Retrospective study of prospectively collected data from February 2008 to July 2010 for 303 SL-DVC and 240 DVC-SSL procedures. Surgical procedure: RALP with comparison of DVC-SSL prior to anastomosis versus early SL-DVC prior to bladder-neck dissection. Measurements: 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. Results and limitations: 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. (C) 2010 European Association of Urology. Published by Elsevier B. V. All rights reserved.