Ligation of the Dorsal Venous Complex in a Robot-Assisted Radical Prostatectomy

Abstract

Introduction:

Several methods of dorsal venous complex (DVC) ligation have been described during a robot-assisted radical prostatectomy. These include suture and stapler ligation. In this video, we demonstrate two methods of suture ligation.

Materials and Methods:

A recording was taken during two separate cases of a robot-assisted radical prostatectomy performed by different surgeons and summarized in this video.

Results:

The first method demonstrated involves ligating the DVC before the anterior bladder neck dissection. This is done by passing a figure-of-eight suture just above the urethra, distal to the apex, but proximal to the rhabdosphincter. The second method demonstrated is an alternative to the early ligation, and involves clipping the lateral branches of Santorini's plexus at the level of the bladder neck at the time of the anterior bladder neck dissection. Once the posterior dissection is complete, the vascular pedicles have been taken and the prostatic apex has been well exposed, the DVC is pinched with the robotic grasper and divided with electrocautery before ligation. The pneumoperitoneum is increased to 20 mm Hg to maintain hemostasis during this portion of the procedure. Once the DVC has been completely divided, it is oversewn with a running suture. We believe this alternative method may offer several unique advantages. Pinching the DVC allows one to obtain a good apical margin because of the excellent exposure of the prostatic apex without bunching the tissue, as can be encountered with the conventional technique. Additionally, the running stitch anecdotally is more secure and helps to avoid postoperative bleeding from this site. Finally, this method also allows a seamless anterior urethropexy to provide support to the DVC and urethra.

Conclusions:

Both methods of suture ligation of the DVC demonstrated in this video offer excellent hemostasis. The late ligation method may offer several anecdotal benefits.

Videos recorded during live patient surgery.

Each author has contributed significantly to this work and there are no commercial associations or any conflicts of interest in connection with this video.

Runtime of video: 6 mins 5 secs