Knotless Laparoscopic Radical Prostatectomy

Abstract

INTRODUCTION Radical prostatectomy is the standard for the cure of localized prostate cancer. With the development of laparoscopic and robotic techniques, laparoscopic radical prostatectomy (LRP) or robotic-assisted radical prostatectomy (RARP) has been widely accepted with advantages of less invasiveness, shorter recovery, less blood loss, and better visualization of the operative region compared to open techniques.[1234] Laparoscopic suturing and knot-tying are the most difficult steps for most surgeons, especially for novice surgeons. The dorsal venous complex (DVC) ligation and vesicourethral anastomosis (VUA) are the most challenging parts during LRP.[123] We will introduce a unique technique using unidirectional single running self-retaining sutures for DVC ligation and VUA during LRP has been reported in the literature. METHODS Four hundred and forty-six consecutive LRP were carried out at our institution from February 2004 to September 2014. From December 2013 to September 2014, nine knotless LRP were performed by experienced laparoscopist with experience of more than 500 LRP (L. Ma). All the characteristics of patients are shown on Table 1. Demography, perioperative data of patients were collected for further analysis with Statistical Package for the Social Sciences (SPSS) (Version 16.0 for Windows; SPSS Inc., Chicago, IL). Data are shown as the mean ± standard deviation (range). Preoperatively, all patients with localized prostate cancer underwent routine preoperative evaluations including complete history taking, physical examination, laboratory investigations including prostate specific antigen (PSA) level, magnetic resonance imaging (MRI) of the prostate, and transrectal biopsy. Bone scanning or positron emission tomography/computed tomography (PET/CT) is necessary for selected patients suspicious of metastasis.Table 1: Outcomes of patientsThe procedure is described briefly as below. Developing the extra peritoneal space Under general anesthesia, the patient is put in Trendelenburg position. The working space for extraperitoneal approach is created by a cost-effective self-made balloon dilator. Four trocars are placed respectively at the subumbilical area with a 13-mm trocar, at the border of rectus abdominis 3 cm below with a 12-mm trocar right and 5-mm trocar left, and at the incision 2 cm above the right anterior superior iliac spine with a 5-mm trocar. Pelvic lymphadenectomy Dissection is carried out proximally to the iliac bifurcation and distally to the pubis. The precise course of the obturator nerve and vessels can be identified by retracting the lymph node packet medially. The distal extent of the lymph node packet is divided, retracted cranially, and bluntly separated from the obturator vessels and nerve. Control of the dorsal vein complex The deep DVC is sutured using a 15-cm 1-0 1/2 circle barbed self-retaining suture (V-Loc 180, Covidien, Mansfield, MA, USA) with three bites at the same place [Figure 1]. No knot is required for this step.Figure 1: Control of the DVC with 1-0 V-Loc. (a) Suturing of the DVC. (b) Threading into the end. (c) Make the first “Knot”. (d) Second bite to make tightnessBladder neck transection Close identification of the bladder neck between the prostate and bladder is the key for small neck outlet, which helps perform VUA. After the transaction of the anterior wall of the bladder, the tip of Foley catheter can be suspended to the abdominal wall in order to lift the prostate. Dissection of seminal vesicles and vasa deferentia Following the transaction of the bladder neck, the ampullary segments of the vasa deferentia could be found and the vasa deferentia are transected. The seminal vesicles are divided by harmonic scalpel laterally. Posterior dissection between the prostate and rectum Cold dissection is performed distally between Denovilliers’ fascia and the anterior propria fascia of the rectum posterior, avoiding use of electrocoagulation which may lead to delayed thermal in