Robot-assisted versus three-dimensional laparoscopic radical prostatectomy: 12-month outcomes of a randomised controlled trial

Objectives

To compare functional and oncological outcomes of robot-assisted laparoscopic prostatectomy (RALP) to three-dimensional laparoscopic radical prostatectomy (3D-LRP) at 12 months after surgery.

Patients and methods

Prospective randomised single-centre study of 145 consecutive men referred to radical prostatectomy in a tertiary referral centre in Finland. Patients were randomised 1:1 to the RALP (N = 75) and 3D-LRP (N = 70) groups. The primary outcome was urinary continence evaluated with the Expanded Prostate Cancer Index Composite 26-item version (EPIC-26) incontinence domain score at 12 months after surgery. Secondary outcomes included the use of protective pads at 12 months after surgery, EPIC-26 domain scores of irritative/obstructive, bowel, sexual and hormonal symptoms, positive surgical margin (PSM) rate, and biochemical recurrence (BCR). Complication frequency within the 3-month period after surgery was evaluated according to Clavien–Dindo classification. Statistical significance between groups was analysed using Mann–Whitney, chi-square and Fisher's exact tests. The trial was terminated after interim analysis based on no statistically significant difference in EPIC-26 urinary incontinence domain scores. Altogether 145 patients of the target accrual of 280 patients were recruited.

Results

Postoperative continence at 12 months after surgery according to the EPIC-26 incontinence domain was 79.25 in both groups (P = 0.4). Between group difference was −5.8 (95% confidence interval –15.2 to 3.6). There was no statistically significant difference in the rates of PSM or BCR between the two surgical modality groups.

Conclusion

We were unable to demonstrate a difference between the RALP and 3D-LRP groups for functional and oncological outcomes at 12 months after surgery.     

Knotless “three‐U‐stitches” technique for urethrovesical anastomosis during laparoscopic radical prostatectomy

We describe a new technique for urethrovesical anastomosis that consists of placing three “U” stitches of Monocryl 2‐0 to connect the bladder neck and urethral stump together. The margins are united by a double passage of the suture, without tying any knots. The sutures are tied on the bladder's surface using Lapra‐Ty clips fixed at a certain distance from where to two mucosal margins have been joined. We carried out this technique on 90 patients who underwent laparoscopic extraperitoneal radical prostatectomy. The good joining of the margins, the absence of knots and the minimum trauma to the urethral wall together enable to create an anastomosis that is both “sealed” and “tension free”, allowing a quick “welding” of the margins and an early catheter removal. Regarding urinary continence, 56.6% (51) of patients were continent at catheter removal, 87.6% (78) were continent 3 months later and 98.9% (89) were continent after 6 months. In nine patients (10%), an episode of acute urinary retention occurred within 24 h after the removal of the catheter. We did not encounter any cases of vesicourethral anastomosis stenosis.     

Delayed recovery of urinary continence after laparoscopic radical prostatectomy

AIM: To study the rate at which patients regained urinary continence during our institution's early experience with laparoscopic radical prostatectomy. METHODS: The urinary continence of 34 patients was recorded at various intervals following laparoscopic radical prostatectomy. These data were compared with those from 49 patients who had undergone radical retropubic prostatectomy. RESULTS: For laparoscopic prostatectomy patients, 2.9% had regained urinary continence at 1 month, 29.4% at 3 months, 46.9% at 6 months, 56.0% at 9 months and 60.0% at 12 months. For retropubic prostatectomy patients, the corresponding rates were 22.4% at 1 month, 63.3% at 3 months, 84.1% at 6 months, 92.9% at 9 months and 92.9% at 12 months. Backward stepwise logistic regression analysis indicated that laparoscopic surgery itself significantly predicted urinary incontinence at every interval from 1 to 9 months following surgery (P < 0.05). CONCLUSION: Patients' postoperative recovery of urinary continence was not satisfactory in our early experience with laparoscopic radical prostatectomy. Further efforts to elucidate the reason for this poor functional outcome are mandatory before the procedure is accepted as part of standard practice.     

Surgical margin status of open versus laparoscopic radical prostatectomy specimens

Objectives:   To compare the surgical margin (SM) status between open and laparoscopic radical prostatectomy (RRP and LRP, respectively) specimens.
Methods:   Surgical specimens from 137 patients undergoing LRP and 220 patients undergoing RRP for clinically localized prostate cancer were included in the analysis. SM status in each resected specimen, including the number of positive SM as well as their location, was examined.
Results:   The incidence of positive SM in the LRP group was significantly greater than that in the RRP group. Despite the lack of significant difference in the proportion of solitary positive SM between these two groups, the proportion of multiple positive SM in the LRP group was significantly greater than that in the RRP group. There was no significant difference in the incidence of anterior positive SM between the two groups, while the incidences of positive SM at the apex, posterior site and bladder neck in the LRP group were significantly greater than those in the RRP group. Furthermore, there were no significant preoperative parameters predicting positive SM in the LRP group. On the other hand, the biopsy Gleason score and clinical T stage were identified as significant predictors of positive SM in the RRP group, of which the biopsy Gleason score was independently related to the presence of positive SM.
Conclusions:   Clinical T stage and Gleason score could be useful predictors of SM status following RRP, while positive SM in LRP specimens were detected irrespective of preoperative parameters, suggesting the need for an effort for further refining the LRP procedure.     

腹腔镜下根治性前列腺切除术治疗TURP术后偶发前列腺癌的配对分析

目的探讨经尿道前列腺切除术(TURP)后偶发前列腺癌行腹腔镜根治性前列腺切除术(LRP)在外科手术、肿瘤学及尿控等方面的影响。方法回顾性分析自2012年1月至2017年12月北部战区总医院泌尿外科285例接受了LRP治疗的男性患者的临床资料。其中37例患者术前已接受过TURP治疗(TURP组),另外选取37例没有接受过TURP的患者与之配对(对照组)。运用相关统计学方法比较两组患者在围手术期并发症、外科手术、肿瘤及尿控等方面的差异。结果两组患者在年龄、体质指数、血清前列腺特异性抗原(PSA)水平以及术前和术后Gleason评分等方面无统计学差异。TURP组与对照组相比患者出血量较多[(555.4±238.4)vs.(237±111.3)mL,P<0.05]、手术时间较长[(256.7±65.3)vs.(215.2±62.3)min,P<0.05]、输血概率大(5.4%vs.0.0%,P<0.05)、并发症发生率较高(43.2%vs.13.5%,P<0.05)。TURP组的手术阳性切缘率与对照组相比(35.1%vs.24.3%)差异无统计学意义(P=0.353)。手术后12个月的尿控率两组相似,但在3个月时TURP组的尿控率较低(40.5%vs.70.2%)。在平均随访36.5个月后,TURP组和对照组分别有10.8%和8.1%的患者出现生化复发,差异无统计学意义。结论TURP后LRP需要更长的手术时间、失血更多、并发症发生率更高和更差的短期尿控,但两组患者远期肿瘤切除效果及远期尿控没有差异,所以TURP后行LRP的疗效是安全可靠的。     

经腹膜外途径腹腔镜前列腺癌根治术的临床疗效观察及并发症处理分析(附15例报告)

目的:探讨经腹膜外途径腹腔镜下前列腺癌根治术(LRP)中及术后并发症的处理对策。方法:局限性前列腺癌患者15例,年龄60~78岁,平均67岁。前列腺特异性抗原(PSA)为8.6~37.4μg/L。TNM分期均≤T2CN0M0。所有患者术前均行经直肠前列腺穿刺活检,病理明确诊断证实为前列腺癌,15例患者均行经腹膜外途径LRP。结果:15例患者均顺利完成手术,手术时间170~410min,平均(230±90)min;术中出血量为420~1 100ml,平均(500±220)ml,术中输血2例均为出血量800ml。术后病理结果:切缘阳性1例,Gleason评分≤6分的患者4例,7分的患者7例,≥8分的患者4例。所有患者均于术后2周拔除导尿管,1例术后出现轻度尿失禁,经提肛训练等辅助治疗1个月后尿失禁痊愈,能自主排尿。1例患者出现出现尿道直肠瘘,给予留置尿管3个月、半流质饮食,3个月后肠漏消失,拔除尿管痊愈;15例患者均定期随访,随访至今;术后3个月时PSA0.001~0.080μg/L,平均(0.040±0.016)μg/L,无一例生化复发。结论:经腹膜外途径LRP安全、有效,对膀胱颈分离、前列腺游离及后尿道吻合技术、技巧的提高可以明显缩短手术时间及术后并发症的发生。     

Evaluation of operative complications related to laparoscopic radical prostatectomy

Objectives:   In this decade, there have emerged many alternatives for the therapy of localized prostate cancer, such as brachytherapy, intensity modulated radiation therapy, high intensity focused ultrasound, and retropubic radical prostatectomy. In this retrospective study, we reviewed cases of complications related to laparoscopic radical prostatectomy (LRP) from our institution only, and we evaluated whether this procedure was minimally invasive or not.
Methods:   Between August 2000 and December 2006, a total of 160 patients in our institution underwent LRP as the definitive treatment for clinically localized prostate cancer. We analyzed not only the complications but also the operative time and blood loss to clarify the indications of LRP.
Results:   Major complications were defined as those requiring surgical intervention including laparoscopic repair. A total of nine major complications (5.63%) occurred in six patients (3.75%). In a Cox regression analysis, the estimated blood loss ( P  = 0.0069) and neoadjuvant hormonal therapy ( P  = 0.0019) were significant predictors of long operative time (>6 h) of LRP.
Conclusion:   The indication of LRP in this study was localized prostate cancer at the T1 or T2 stage for which neoadjuvant hormonal therapy had not been administered. We concluded that the operative and postoperative morbidities of LRP are low and that LRP can be routinely carried out by an experienced team.     

Feasibility and usefulness of laparoscopic radical prostatectomy: Kobe University experience

OBJECTIVES: The objective of this study was to present the clinical outcomes of 26 patients who underwent laparoscopic radical prostatectomy at our institution. METHODS: We performed laparoscopic prostatectomy on patients who were clinical stage T1 or T2. The mean age was 70 years old (range: 52-76). The mean level of pre-treatment prostate-specific antigen (PSA) was 8.7 ng/mL (range: 3.3-45). The Gleason score of the needle biopsy was < 7 in 21 patients and > or = 7 in five patients. Clinical stage was T1c in 17 patients, T2a in 6 patients and T2b in 3 patients. Operative techniques followed those of the French groups. Five trocars were introduced into the peritoneal cavity. The vas deferens and seminal vesicles were dissected to reach the posterior wall of the prostate and the retroperitoneal space was dissected around the urinary bladder. Incision of endopelvic fascia and dorsal vein complex (DVC) ligation were performed. The bladder neck and prostate were divided, then the distal urethra was cut. The lateral pedicles of the prostate were cut and the entire prostate was removed. Vesico-urethral anastomosis was performed at eight points. RESULTS: Mean operation time was 7 h 30 min. Mean bleeding volume (including urine volume) was 850 mL (range: 32-3135). All patients underwent autologous blood transfusion. Only one patient required further blood transfusion. Gleason scores of resected specimens were < 7 in 10 patients, and > or = 7 in 16 patients. Pathological stage was T0 in 1 patient, T2a in 6 patients, T2b in 13 patients, T3a in 5 patients and T3b in 1 patient. The PSA value was undetectable in all patients one month after surgery. Ten patients who survived for 6 months after surgery had complete urinary continence without a pad. In 7 of the 12 patients who were potent before surgery, neurovascular bundles were preserved, and 5 of them (71%) achieved complete or incomplete erection 3 months after surgery. However, only one patient (14%) could have sexual intercourse. CONCLUSION: Although longer follow-up is necessary to evaluate this surgical technique, laparoscopic prostatectomy seems to be a reasonable option in the treatment of organ-confined prostate cancer.     

Immediate Continence Rates in RALRP: A Comparison of Three Techniques

Methods:We retrospectively analyzed the patients who underwent RALRP for localized prostate cancer by a single surgeon in our clinic from January 1, 2009–February 1, 2016. Continence was defined as no leakage or use of a safety pad for minimal leakage. The main outcome measure was continence at postoperative week 1 and months 1, 6, and 12.Results:Between 2009 and 2016, 239 patients underwent RALRP for localized prostate disease. Seventy-four patients underwent a standard approach (group 1), 88 had posterior reconstruction (group 2), and 77 had posterior reconstruction with total anatomic restoration (group 3). After 1 week, 24.3% of the patients in group 1 (18/74), 31.8% in group 2 (28/88), and 45.8% in group 3 (33/72) were continent (P = .02). One month after the surgery, continence rates for groups 1, 2, and 3 were 56.7, 67, and 75%, respectively (0.065). After 6 and 12 months, continence rates for groups 1, 2, and 3 were 72.9 and 87.8%, 81.8 and 89.7%, and 84.7 and 91.6%, respectively (P = .178 and .7484).Conclusion:Anatomic restoration improves continence rates in the early period after RALRP. Even though other parameters were higher in the total restoration group, immediate continence (at 1 week) was significantly better.     

Laparoscopic radical prostatectomy: introduction of training during our first 50 cases

Background: The study aims to assess the initial experience of laparoscopic radical prostatectomy (LRP) in a regional centre in Australia which includes Fellowship training during our first 50 cases. Methods: Data were collected prospectively from our first 50 consecutive patients who underwent LRP for localized prostate cancer between September 2009 and October 2010. All cases were performed or supervised by the primary surgeon. Patient details, operative details, complications, early oncological and functional outcomes were analysed. Results: The median age was 65 (45–76) years and median preoperative prostate‐specific antigen was 7.5 (2.5–23) ng/mL, with palpable disease present in 48%. Using D'Amico's risk stratification, 14%, 74% and 12% were in low, intermediate and high‐risk categories, respectively. Forty percent of cases were training cases with a median of 5 (2–8) of 10 operative steps performed by the Fellow. There was one open conversion and no rectal injuries. Mean operative time was 288 (175–440) min and with blood transfusion rate of 6%. Mean length of stay was 2.5 (1–6) days. Positive surgical margin rates for pT2 and pT3 disease were 14% and 52%, respectively, although for the last 25 cases they were 7% and 30%, respectively. Continence rate was 86% at 6 months, and 45% and 33% of preoperatively potent patients were potent after bilateral and unilateral nerve preservation at 6 months. Conclusion: LRP has been safely introduced in a regional centre with establishment of a Fellowship training programme, with early results comparable with other open, laparoscopic and robotic series.     

机器人辅助完全后入路筋膜内前列腺癌根治术5例经验总结

目的简要介绍机器人辅助完全后入路筋膜内前列腺癌根治术的初步经验。方法回顾性分析浙江大学医学院附属邵逸夫医院泌尿外科2016年8月至10月间5例机器人辅助完全后入路筋膜内前列腺癌根治术患者的临床资料。结果所有手术均顺利完成,手术时间为124~155分钟,平均(139.8±13.9)分钟;术中出血量30~80ml,平均(52.0±19.2)ml。无切缘阳性患者。术后6周复查PSA均达到根治标准。3例患者术后拔除导尿管后即能完全控尿,未使用尿垫,其余2例在术后1个月内控尿完全恢复。2例患者术后1个月内恢复勃起功能,其余3例随访1个月未见明显性功能恢复。结论机器人辅助完全后入路筋膜内前列腺癌根治术是可行的。患者的肿瘤控制、术后尿控以及性功能恢复均较为满意。有条件的单位可选择合适患者施行。     

Impact of surgical technique (open vs laparoscopic vs robotic-assisted) on pathological and biochemical outcomes following radical prostatectomy: an analysis using propensity score matching

Study Type – Therapy (case series) Level of Evidence 4 What’s known on the subject? and What does the study add? Thus far, no institution has investigated the impact of the most commonly used surgical techniques – open, laparoscopic and robotic radical prostatectomy – on biochemical outcome. However, recent data from large meta‐analysis suggest that the impact of the chosen surgical technique on biochemical outcome is minimal and statistically not relevant. We are the first to apply the method of propensity score matching in the urology literature to compare three different surgical techniques. This method is intended to simulate a randomized trial which is unlikely to be undertaken for radical prostatectomies. We confirmed previous data that the surgical technique does not seem to have an impact on biochemical outcome following radical prostatectomy.

OBJECTIVE

? To investigate a single institution experience with radical retropubic prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot‐assisted radical prostatectomy (RARP) with respect to pathological and biochemical outcomes.

PATIENTS AND METHODS

? A group of 522 consecutive patients who underwent RARP between 2003 and 2008 were matched by propensity scoring on the basis of patient age, race, preoperative prostate‐specific antigen (PSA), biopsy Gleason score and clinical stage with an equal number of patients who underwent LRP and RRP at our institution. ? Pathological and biochemical outcomes of the three cohorts were examined.

RESULTS

? Overall positive surgical margin rates were lower among patients who underwent RRP (14.4%) and LRP (13.0%) compared to patients who underwent RARP (19.5%) (P= 0.010). There were no statistically significant differences in positive margin rates between the three surgical techniques for pT2 disease (P= 0.264). ? In multivariate logistic regression analysis, surgical technique (P= 0.016), biopsy Gleason score (P < 0.001) and preoperative PSA (P < 0.001) were predictors of positive surgical margins. ? Kaplan–Meier analysis did not show any statistically significant differences with respect to biochemical recurrence for the three surgical groups.

CONCLUSIONS

? RRP, LRP and RARP represent effective surgical approaches for the treatment for clinically localized prostate cancer. A higher overall positive SM rate was observed for the RARP group compared to RRP and LRP; however, there was no difference with respect to biochemical recurrence‐free survival between groups. ? Further prospective studies are warranted to determine whether any particular technique is superior with regard to long‐term clinical outcomes.     

腹腔镜下经腹膜外途径前列腺癌根治术(附2例报告)

目的:探讨腹腔镜下经腹膜外途径前列腺癌根治术的手术方法和临床效果。　方法:2例前列腺癌患者, 腹腔镜下经腹膜外途径分离前列腺,切开膀胱颈部,分离前列腺尖部、游离精囊后顺行将前列腺切除,膀胱颈成形 后与后尿道吻合。　结果:手术时间分别为10、7h,出血量分别为1000、500ml。术后24h恢复肠道功能,3周后 拔除尿管,未出现并发症。　结论:腹腔镜下腹膜外途径前列腺癌根治术创伤小、视野清晰、出血少、恢复快,是早 期前列腺癌根治术的方法之一。     

机器人辅助腹腔镜根治性前列腺切除术130例

目的 评估da Vinci S机器人辅助腹腔镜根治性前列腺切除术（RARP）的疗效和安全性.方法 回顾分析2009年7月至2013年9月,复旦大学附属中山医院应用da Vinci S手术系统（da Vinci Intuitive Surgical Inc.,Sunnyvale,CA,USA.）完成RARP术130例的情况.年龄48～76岁,平均（67±6）岁;PSA水平为2.16～ 78.20 ng/ml,平均（26.05±8.41）ng/ml;Gleason评分6～10;肿瘤临床分期均为局限性前列腺癌.结果 130例均经腹腔途径,采用机器人3臂或4臂,5～6枚troc ar完成RARP,无机器人机械故障或其他原因导致的术式改变.术前机器人准备时间20 ～ 90 min,平均（48.5±15.4） min;手术时间90 ～ 300 min,平均（143.6±22.9） min;术中出血量50 ～ 600 ml,平均（158.2±59.6） ml,2例（1.5％）术后输血400ml.术后2～3d下床活动,平均（2.2±0.6）d;术后住院5～21d,平均（6.6±1.9）d;4～21d拔除导尿管,平均（6.1±2.0）d.术后主要并发症包括：漏尿6例（4.6％）,漏尿于术后3～15d停止.术后淋巴瘘8例（6.2％）,术后2～3周停止,未发现淋巴囊肿.术后下肢静脉栓塞、肺栓塞和附睾炎各1例,治疗后好转.术后病理切缘阳性12例（9.2％）,精囊见癌侵犯10例（7.7％）,闭孔淋巴结转移4例（3.1％）.术后1～12个月复查PSA均＜ 0.2 ng/ml,术后6个月和1年完全控尿率达86％和95％.结论RARP安全、可靠,具有出血更少、恢复更快等优势,是根治性前列腺切除术的首选方式.     

Final outcomes of patients with low‐risk prostate cancer suitable for active surveillance but treated surgically

OBJECTIVE

To study the outcomes of a contemporary cohort of patients referred from around the UK with low‐risk prostate cancer consistent with the UK National Institute for Health and Clinical Excellence guidelines for active surveillance but who were treated with laparoscopic radical prostatectomy (LRP) in a single surgeon series.

PATIENTS AND METHODS

From 1080 consecutive patients who underwent LRP between March 2000 and April 2008, 549 patients (51%) had low preoperative risk disease (PSA level <10 ng/mL, clinical stage ≤T2a and biopsy Gleason score ≤6). The pathological outcomes of these 549 patients as well as a subgroup of 74 patients with preoperative prediction of ‘insignificant’ disease were assessed.

RESULTS

The mean age of the patients was 61 years, the mean (range) PSA level was 6.1 (1–9) ng/mL; 38% of patients were staged as cT2a. In all, 126 patients (23%) were upgraded on final pathology to Gleason score ≥7. In all, 29 patients (5%) had extraprostatic extension with seminal vesicle invasion in five (0.9%). Of the 74 patients with preoperative prediction of insignificant disease, 61% had significant disease with 16% upgraded to an intermediate‐risk group. Overall, there were positive margins in 44 patients (8.0%) and biochemical failure occurred in six patients (1.1%) with a median follow‐up of 28 months.

CONCLUSION

In this contemporary UK cohort of patients with apparently low‐ or favourable‐risk prostate cancer, 23% will have higher grade disease than preoperatively predicted. Even though active surveillance is increasingly being recommended for managing low‐risk localized prostate cancer, patients and their physicians need to be aware of the potential for harbouring more significant disease.     

Robotic-assisted laparoscopic radical prostatectomy: initial 15 cases in Japan

Recently, we have introduced robotic-assisted laparoscopic radical prostatectomy (RALP) in Japan. This article describes the details of a training program to shorten the learning curve in the absence of an urologist with expertise in robotic surgery. Five months after a 2-day training course of robotic surgery, RALP was first performed in Japan, and a total of 15 cases were performed in the subsequent 4 months. Our training program consisted of: (1) image training using surgical operation videos, (2) dry lab training using a sham pelvic cavity model, and (3) intraoperative mentoring. The operative procedure was divided into five consecutive stages, and time required to complete each stage was recorded. Robotic radical prostatectomy was completed in all patients without conversion to open surgery, except for the first patient in whom a restriction to a 2-h operation had been imposed by the ethics committee. The mean console time and the mean intraoperative blood loss (including urine) reduced from 264.2 min and 459.4 ml, respectively, in the first 11 cases, to 151 min and 133.3 ml, respectively, in the last three cases. With direct intraoperative guidance by the mentor during cases 13 and 14, the operation time was reduced at all five stages of the operative procedure. Our training program proved remarkably effective in reducing the learning curve of RALP in Japan, where there is no person with expertise in robotic surgery.     

Morbidity of laparoscopic radical prostatectomy: Summary of early multi-institutional experience in Japan

AIM: Laparoscopic radical prostatectomy is being evaluated throughout the world. The aim of the present study is to report early multi-institutional experience of the procedure in Japan. METHODS: A total of 148 men who were diagnosed with clinically localized prostate cancer underwent laparoscopic radical prostatectomy at seven different institutions in Japan. Early complications (within 30 days postoperatively) and postoperative convalescence were reviewed retrospectively. The median age of patients was 68.0 years (range, 51-80). RESULTS: The median operative time was 403 minutes (range, 167-925; average, 427). Blood loss ranged from 50 to 5000 mL (median, 540; average, 856). A total of 66 complications were reported in 55 patients (37.2%). Intraoperative complications were noted in 25 of 148 patients (16.9%): 10 rectal injuries (6.8%); five bladder injuries (3.4%); five cases of subcutaneous emphysema (3.4%); two intestinal injuries (1.4%); one major vessel injury (0.7%); one ureteral injury (0.7%); and one obturator nerve injury (0.7%). Overall, 16 of 148 patients (10.8%) required open conversion or postoperative open surgical repair. The most common postoperative complications were anastomotic leakage (6.8%), wound-related complications (4.7%) and perineal pain (4.7%). The bladder catheter was removed on day 7 or earlier in 73 cases (49.3%). The median time to ambulation was 1 day (mean 1.4, range 1-5). Oral intake was started on postoperative day 1 in 67 patients (45.2%) and on postoperative day 2 in 65 (43.9%). CONCLUSION: Although laparoscopic radical prostatectomy is technically demanding, reduced blood loss and shorter convalescence periods can be expected from the procedure. Surgeons should be aware of the disturbingly high morbidity rate related to early experience. By mastering laparoscopic skills and sharing knowledge, surgeons could reduce the impact of the learning curve required to complete this procedure competently.     

Upfront transection and subsequent ligation of the dorsal vein complex during laparoscopic radical prostatectomy

Laparoscopic radical prostatectomy for localized prostate cancer offers several advantages, including creation of a pneumoperitoneum that results in less blood loss than is seen with the corresponding open procedure. Transection of the deep dorsal vein complex remains among the most challenging aspects, however. Safe and secure completion of this procedure is important to minimize blood loss and maximize the chance of cure. Liberal use of coagulation for hemostasis at the dorsal vein complex (DVC) risks thermal damage to the sphincteric muscle. DVC ligation before transection, though commonly performed, can cause loss of some sphincteric fibers and potentially result in delayed recovery of urinary continence. Furthermore, ligation may at times prove difficult, especially in obese patients with a short and broad DVC, a large prostate gland, and a narrow pelvis. The presence of prominent pubic tubercles may further increase the difficulty. We have found that bleeding from the DVC is easily controlled without suture ligation through a combination of a modest pneumoperitoneum with pinpoint coagulation of one or two small arteries that are consistently found in the superficial layer of the complex. Precise, even‐level transection is possible under direct vision with no more than modest blood loss. A stitch in a Z‐shaped fashion is then applied to the entire transected stump of the DVC. This procedure is simple and easily performed, even by those with limited experience. Here we provide an overview of our current technique.