Ligation Of Dorsal Venous Complex Research Articles

Impact of Early Dorsal Venous Complex Ligation on Urinary Continence Recovery after Robot-assisted Radical Prostatectomy: Results from a Phase 3 Randomized Controlled Trial

BackgroundWhether early ligation of the dorsal venous complex (DVC) might improve recovery of urinary continence (UC) after robot-assisted radical prostatectomy (RARP) has never been investigated in a prospective randomized study. ObjectiveTo assess whether early DVC ligation might affect UC recovery after RARP. InterventionDVC ligation (early vs standard). Design, setting, and participantsA total of 312 patients with prostate cancer underwent primary RARP at a tertiary care institution. Outcome measurements and statistical analysisThe primary outcome was UC recovery at 1 and 4 mo after RARP. UC was defined as 0 pads/1 safety pad per day. All patients completed the International Prostate Symptom Score (IPSS) and International Consultation of Incontinence Questionnaire (ICIQ)-Short Form questionnaires. Secondary outcomes were early (≤4 mo) erectile function recovery, the positive surgical margin (PSM) rate, 30-d Clavien-Dindo complications, and biochemical recurrence rates. Quality of life was assessed using the EQ-5D-5L questionnaire. The association between treatment arm and UC recovery was also tested using multivariable regression models. Results and limitationsAfter surgery, 23 patients withdrew their consent and 29 were lost to follow-up, leaving 261 patients available for per-protocol analyses. Of these, 32 patients (24%) in the experimental group and 37 (29%) in the control group used no pad/one safety pad at 1 mo after RARP, whereas 96 (72%) in the control group versus 83 (65%) in the control group were continent at 4-mo follow-up (both p = 0.3). Median ICIQ and IPSS scores did not differ between the groups at both time points. The results were confirmed on multivariable regression analyses. PSMs were observed for 32 patients (25%) in the experimental group versus 30 (22%) in the control group (p = 0.6). The incidence of postoperative complications (17% experimental vs 13% control) and the 1-yr biochemical recurrence–free survival did not differ between the groups. ConclusionsIn this randomized clinical trial, we did not find evidence that early ligation of the DVC during RARP was associated with better UC recovery after surgery in comparison to the standard technique. Given its safety in terms of surgical margins and complications, this technique may be considered as an option for surgical dissection according to the physician’s preference. Patient summaryOur trial showed that for patients undergoing robot-assisted surgical removal of the prostate, the timing of a specific step to control bleeding from a network of veins draining the prostate did not affect recovery of urinary continence after surgery. The results indicate that earlier control of these veins may be considered as an option according to the surgeon’s preference.

PD61-09 FINAL RESULTS OF A PROSPECTIVE, RANDOMIZED CONTROLLED TRIAL ASSESSING THE IMPACT OF EARLY DORSAL VENOUS COMPLEX (eDVC) LIGATION ON URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Cancer: Localized: Surgical Therapy V (PD61)1 Sep 2021PD61-09 FINAL RESULTS OF A PROSPECTIVE, RANDOMIZED CONTROLLED TRIAL ASSESSING THE IMPACT OF EARLY DORSAL VENOUS COMPLEX (eDVC) LIGATION ON URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY Francesco Montorsi, Giuseppe Cirulli, Gabriele Sorce, Andrea Gallina, Marco Moschini, Giorgio Gandaglia, Francesco Pellegrino, Luigi Nocera, Nicola Fossati, Armando Stabile, Simone Scuderi, Francesco Barletta, Elio Mazzone, Andrea Salonia, Carlo Andrea Bravi, Giuseppe Rosiello, and Alberto Briganti Francesco MontorsiFrancesco Montorsi More articles by this author , Giuseppe CirulliGiuseppe Cirulli More articles by this author , Gabriele SorceGabriele Sorce More articles by this author , Andrea GallinaAndrea Gallina More articles by this author , Marco MoschiniMarco Moschini More articles by this author , Giorgio GandagliaGiorgio Gandaglia More articles by this author , Francesco PellegrinoFrancesco Pellegrino More articles by this author , Luigi NoceraLuigi Nocera More articles by this author , Nicola FossatiNicola Fossati More articles by this author , Armando StabileArmando Stabile More articles by this author , Simone ScuderiSimone Scuderi More articles by this author , Francesco BarlettaFrancesco Barletta More articles by this author , Elio MazzoneElio Mazzone More articles by this author , Andrea SaloniaAndrea Salonia More articles by this author , Carlo Andrea BraviCarlo Andrea Bravi More articles by this author , Giuseppe RosielloGiuseppe Rosiello More articles by this author , and Alberto BrigantiAlberto Briganti More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002098.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: The ligation of the dorsal venous complex (DVC) and the approach to the prostatic apex represent crucial steps of robot-assisted radical prostatectomy (RARP) which may affect urinary continence (UC) recovery. We hypothesized that the early ligation of the DVC during RARP might allow for a better preservation of urethral sphincter and thus improved continence recovery over the traditional technique. METHODS: In this randomized controlled trial (RCT - NCT03368378) a total of 312 consecutive prostate cancer (PCa) patients were randomly assigned to the experimental group (early DVC ligation, before the bladder neck incision and nerve-sparing lateral dissection) vs. control group (standard DVC ligation after the bladder neck). The minimum number of subjects for an 80% study power has been calculated considering an alfa-error of 5% and a UC recovery of 26% at 4 weeks obtained with the standard treatment. The hypothesis was that the early DVC ligation could improve UC recovery by 15% at 4-month after RARP. Primary endpoint was continence recovery at 1 and 4 months from surgery. UC was defined as 0/1 protective pad over 24-hour. Secondary outcomes were positive surgical margins (PSM), erectile function (IIEF-6), and 30-day complications (Clavien-Dindo classification). RESULTS: The per-protocol analyses included 276 patients. At 1 and 4 months after surgery, the percentage of patients who recovered continence in the experimental vs. control group was 23% vs. 28% and 71% vs. 64%, respectively (both p ≥0.2). Similar results were found at 1-year follow-up (90% vs. 91%; p=0.6). The percentage of PSM at final pathology did not differ between the groups (22% vs 24%; p=0.7). This finding was not affected by pathologic stage (PSM rate in organ-confined for experimental vs. control group: 12% vs. 18%; non-organ confined: 29% vs. 27%; both p ≥0.4). One year after surgery, there was no significant difference in median postoperative IIEF-6 between patients receiving early DVC ligation and the control group (p=0.07). The rate of Clavien-Dindo ≥2 complications during hospital stay did not differ between the experimental vs. control group (12% vs 11%, p=0.7). CONCLUSIONS: Although an early DVC ligation during RARP is safe and not associated with an increased risk of PSM or complications, our RCT demonstrated that this approach did not improve UC recovery at 4-months. These results were maintained at 1-year follow-up. Thus, early DVC has no impact on either functional or oncological outcomes. Source of Funding: None © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e1069-e1070 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Francesco Montorsi More articles by this author Giuseppe Cirulli More articles by this author Gabriele Sorce More articles by this author Andrea Gallina More articles by this author Marco Moschini More articles by this author Giorgio Gandaglia More articles by this author Francesco Pellegrino More articles by this author Luigi Nocera More articles by this author Nicola Fossati More articles by this author Armando Stabile More articles by this author Simone Scuderi More articles by this author Francesco Barletta More articles by this author Elio Mazzone More articles by this author Andrea Salonia More articles by this author Carlo Andrea Bravi More articles by this author Giuseppe Rosiello More articles by this author Alberto Briganti More articles by this author Expand All Advertisement Loading ...

Improved Apical Margins with Use of Periurethral Suspension Stitch in Robotic Assisted Radical Prostatectomy

Introduction: Robotic surgery has transformed the standard treatment for localized prostate cancer. Oncologic control is at the foremost concern when treating prostate cancer. Previous studies have detailed the use of a periurethral suspension stitch during robotic assisted radical prostatectomy (RARP), but none have demonstrated significant improvement in surgical margins. Objective: The purpose of this study is to illustrate the use of a periurethral suspension stitch during RARP and its impact on apical surgical margin status. Methods: This study retrospectively analysed 97 patients who underwent RARP by a single high-volume robotic surgeon (TJM) between November 2011 and February 2014. The patients were split into two cohorts with one group (Suspended Stitch) having the dorsal venous complex (DVC) ligation stitch suspended while the second group having the DVC ligation stitch unsuspended (Unsuspended Stitch). Results: Positive margins were seen in 39.6% of patients in the Unsuspended Stitch group and 20.4% of patients in the Suspended Stitch group (p=0.04). Patients in the Unsuspended Stitch group had a Gleason score > 7 in 33.3% of cases, where patients in the Suspended Stitch group had a Gleason score > 7 in 57.1% of cases. Conclusion: Localized prostate cancer treatment has significantly changed with RARP. This study provides an additional technique for achieving improved oncologic control.

MP74-09 A PROSPECTIVE, RANDOMIZED, PHASE 3 TRIAL ASSESSING THE IMPACT OF EARLY DORSAL VENOUS COMPLEX LIGATION ON URINARY CONTINENCE RECOVERY AFTER ROBOT-ASSISTED RADICAL PROSTATECTOMY. RESULTS OF AN INTERIM ANALYSIS ON EARLY POST-OPERATIVE OUTCOMES

INTRODUCTION AND OBJECTIVE:The ligation of the dorsal venous complex (DVC) is a key step during robot-assisted radical prostatectomy (RARP) and it may affect urinary continence (UC) recovery. We hy...

To clamp or not to clamp?

Introduction: Radical prostatectomy (RP) is the gold-standard surgical treatment for men with clinically localized prostate cancer (PCa). Surgical techniques to minimize intra and post-operative complications are well established, but excessive bleeding during RP continues to be a concern. The objective of our study was to determine whether additional intraoperative temporary occlusion of the internal iliac arteries combined with a penile base tourniquet during open RP improves hemostasis.
 Methods: We conducted a retrospective chart review of 23 patients who underwent open RP between Jan 2014 to May 2016. Eight patients underwent open RP with additional clamping of the internal iliac arteries using bulldog vascular clamps combined with a penile base penrose drain tourniquet as temporary prostatic arterial and venous control during dorsal venous complex ligation and neurovascular bundle sparing. Our primary outcome was immediate and post-operative day 1 hemoglobin levels. Our main outcome was analyzed using Students t-test with equal variance.
 Results: We stratified participants by clamping type. Fifteen patients underwent no clamping and 8 patients had the combined temporary clamping. Primary analysis of estimated blood loss showed a reduction in average blood loss among individuals with vascular control technique versus usual technique (516 ml and 754 ml respectively, p= 0.021). There were no obvious intraoperative or postoperative complications noted that could have been attributable to the temporary vascular control techniques.
 Conclusion: Temporary vascular control with the addition of minor surgical techniques during open RP may improve an objective measure of blood loss immediately after surgery.

A technique of pretightening dorsal vein complex can facilitate laparoscopic radical prostatectomy.

The ligation of dorsal venous complex (DVC) is a very important procedure during laparoscopic radical prostatectomy (LRP). Inaccurate DVC ligation may lead to severe bleeding or postoperative incontinence. We, therefore, designed the DVC pretightening technique to facilitate this procedure. The 32 involved patients with localized prostate cancer underwent LRP between July 2017 and October 2018. All of the patients received DVC pretightening technique. A laparoscopic intestinal clamp was used to narrow and strain DVC. The needle passage was limited between the bone and clamp. The ligation time, DVC-related blood loss, and continence data were recorded. The ligation of DVC in 32 patients was performed with DVC pretightening technique. Every suture was completed with one attempt. The mean ligation time was 2.7 ± 1.0 min. The DVC-related blood loss was 2.0 ± 1.3 ml. The 3-month continence rate was 81.3% (26/32). Positive margin rate was 9.4% (3/32). In conclusion, the DVC pretightening technique simplified the ligation of DVC during LRP. It is a safe and reliable technique. However, large-sample randomized controlled trials are still required to confirm the advantage of the new method in improving mean ligation time, DVC-related blood loss, continence rate, and positive margin rate.

Validation of a novel, tissue-based simulator for robot-assisted radical prostatectomy.

To create a tissue-based simulator that allows practice of key steps of robot-assisted radical prostatectomy (RARP) in a sequential fashion. A model was created from female porcine genitourinary tract tissue to represent the male pelvic genitourinary anatomy. The following steps of RARP were simulated: dorsal venous complex ligation, division of bladder neck, seminal vesicle dissection, prostatic pedicle ligation with nerve sparing, urethral division, bladder neck reconstruction, and vesicourethral anastomosis. Ten novices and 10 experts performed RARP on the model. Face validity was calculated by ratings of realism. Content validity was calculated by experts' rating of usefulness of the model as a training tool. Construct validity was calculated by comparison of time to complete the simulator and rating of performance on the objective structured assessment of technical skill (OSATS) questionnaire, between novices and experts. The model was determined to have good face and content validity with an average score of 3.7/5 and 4.8/5, respectively. The mean time for completion of the simulator was 121.5 minutes for the novice and 62 minutes for the expert group (P<0.001), and the mean overall OSATS performance ratings were 4.6/5 for experts and 2.6/5 for novices (P<0.001), yielding good construct validity. We created and validated a realistic, tissue-based simulator to allow for training of key surgical steps of RARP in a sequential fashion. Ultimately, this simulator could be incorporated into urology training, credentialing, and facilitate surgeon transitioning from open prostatectomy to RARP.

Suture versus staple ligation of the dorsal venous complex during robot‐assisted laparoscopic radical prostatectomy

To present our operative and postoperative functional outcomes of sutured compared with endovascular staple ligation of the dorsal venous complex (DVC) during robot-assisted laparoscopic radical prostatectomy (RALP). Ligation of the DVC during RALP with an endovascular stapler has purported advantages of decreased apical positive surgical margin (PSM) rate, blood loss, and operative time when compared with suture ligation. In all, 162 patients who underwent RALP between October 2005 and April 2008 by one surgeon (R.B.N.) were assessed. We retrospectively analysed two different treatment groups: group 1 underwent DVC ligation with a single suture, while group 2 underwent endovascular staple ligation. Of the 162 patients evaluated, 67 had suture ligation (group 1) and 95 had staple ligation (group 2) of the DVC. Baseline patient characteristics (age, body mass index, biopsy Gleason score, clinical stage) and tumour characteristics (specimen weight, tumour volume, pathological Gleason score and stage) did not differ between the groups. Estimated blood loss (494 mL vs 288 mL), time to dissect out, ligate and transect the DVC (30 min vs 24 min), apical PSM rate (13.4% vs 2.1%) differed significantly between groups 1 and 2 respectively, favouring staple ligation of the DVC. At 6 months follow-up, there was no difference between the groups for PSA recurrence (3.7% vs 0%), complete continence (63.4% vs 55.7%) and Sexual Health Inventory for Men score (8.4 vs 8.6). In the present study, staple ligation of the DVC during RALP resulted in improved apical PSM rates, faster operative times and less blood loss.

Anatomical retro‐apical technique of synchronous (posterior and anterior) urethral transection: a novel approach for ameliorating apical margin positivity during robotic radical prostatectomy

To describe a novel synchronous approach to apical dissection during robotic-assisted radical prostatectomy (RARP) which augments circumferential visual appreciation of the prostatic apex and membranous urethra anatomy, and assess its effect on apical margin positivity. Positive surgical margins (PSM) during RP predispose to earlier biochemical recurrence, and occur most frequently at the prostatic apex. Conventional apical transection after early ligation of the dorsal venous complex (DVC) remains suboptimal, as this approach obscures visualization of the intersection between prostatic apex and membranous urethra, leading to inadvertent apical capsulotomy and eventual margin positivity. A synchronous urethral transection commenced via a retro-apical approach was adopted in 209 consecutive patients undergoing RARP by one surgeon (A.T.) between April to September 2009. The apical margin rates for this group were compared with those of 1665 previous patients who received conventional urethral transection via an anterior approach after DVC ligation. Outcomes were adjusted for differences in clinicopathological variables. All RP specimens were processed according to institutional protocols, and examined by dedicated genitourinary pathologists. The location of PSMs was identified as apex, posterior, posterolateral, bladder neck, anterior, base, or multifocal. Patients receiving synchronous urethral transection had significantly lower apical PSM rates than the control group (1.4% vs 4.4%, P = 0.04). This marked improvement in the retro-apical group occurred despite a significantly higher incidence of aggressive cancer (≥ pT3a) documented on final specimen pathology (16% vs 10%, P = 0.027).Technical difficulty was encountered in three of 209 study patients, in whom urethral transection had to be completed using the classic anterior approach. Improved circumferential visualization of the prostatic apex, membranous urethra and their anatomical intersection facilitates precise dissection of the apex and its surrounding neural scaffold, and optimizes membranous urethral preservation. This has significantly ameliorated apical PSM rates in patients undergoing RARP, despite having to deal with more aggressive cancer on final specimen pathology.

Feedback from Operative Performance to Improve Training Program of Laparoscopic Radical Prostatectomy

We report our preliminary experience identifying factors that contribute to differences in operative performance in laparoscopic radical prostatectomy (LRP) between trainees and experienced laparoscopic urologists based on objective and subjective feedback. Between December 2001 and May 2002, six trainees at the Institut Montsouris and Ecole Européenne de Chirurgie, Paris, were evaluated to identify the factors contributing to differences in operative performance in LRP between them and experienced laparoscopic urologists, both objectively and subjectively. Objective evaluation was done by an independent observer who was well versed in laparoscopic surgery, while all the trainees evaluated themselves subjectively. All the trainees had in vitro, in vivo, and didactic training sessions during the evaluation period. The following deficiencies were noted objectively in the trainees compared with experienced laparoscopic urologists: (1) lack of perfect knowledge of each step, (2) lack of synchronized movements of the nondominant hand; and (3) easy physical fatigue. The trainees took a long time to dissect the vas deferens, seminal vesicles, and bladder neck because they did not have perfect knowledge of each step. It was difficult for them to pass the needle for ligation of dorsal venous complex because they tried to hold the needle far away from the needle tip at the wrong angle, and the direction of movement was not correct. For the urethrovesical anastomosis, they struggled to find the right angle to pass the needle on the urethral side. Lack of synchronized movement of the nondominant hand, easy physical fatigue, and lack of perfect knowledge of operative steps are crucial limitations for live operative performance of trainees in LRP. Incorporation of intensive well-planned in vitro training into the curriculum to correct these deficiencies and feedback from the operative performance can make a significant contribute to shortening the learning curve.