Research Article
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Clipless and Athermal Pedicle Control with Selective Suturing Technique Proceeding with Neurovascular Bundle Preservation during Robot Assisted Radical Prostatectomy

Year 2020, Volume: 12 Issue: 1, 1 - 8, 30.01.2020

Abstract

Aim: During robot assisted radical prostatectomy, pedicle control can be accomplished by surgical clips and/or using

different energy sources. Migration of surgical clips can cause bladder neck contracture and bladder stone formation.

On the other hand;using different energy sources during pedicle division may cause thermal injury of the nerves which are critical for

recovery of potency. In order to obviate this situation; we describe clipless and athermal pedicle control with selective

suturing technique proceeding with neurovascular bundle preservation during robot assisted radical prostatectomy.

Matherials and Methods: Robot assisted radical prostatectomy (RARP) is performed via transperitoneal route in

antegrade fashion. After bladder neck incision, prostatic pedicle is divided. First right prostatic pedicle is selectively

freed and cut. Bleeding is controlled by a running V-Loc suture. Then neurovascular bundle is gently separated from

the prostatic capsule starting at the basis and proceeding towards the apex. The same procedure is performed for

the left prostatic pedicle. Following prostatectomy superficial bleeders are meticulously controlled by separate 5-0

polyfilament sutures. Between March 2018 and May 2019 this technique was performed in 29 patients. Bilateral nerve

sparing procedure was carried out in all cases.

Result: Mean preoperative PSA was 8.1±2.1 ng/ml, mean patient age was 60.8±6.5 and mean follow-up was 13.6±9.9

months. Mean console time, intraoperative blood loss and prostatectomy specimen weight were 201±45 min,

237±97 ml. and 59±29 gr., respectively. Complications were assessed according to the Clavien-Dindo classification.

Clavien Grade 2, 3a and 3b complications were encountered in 1, 2 and 1 patients, respectively. Surgical margins were

positive in 5 patients (17.2%). At post-operative first month 28 of 29 patients were continent. Potency rate was 66%

with PDE5 inhibitors.

Conclusion: Clipless control of pedicles during RARP(Robot assisted radical prostatectomy) seems to be feasible

without compromising intraoperative blood loss.

References

  • 1. Walsh PC and Donker PJ: Impotence following radical prostatectomy: Insight into etiology and prevention. J Urol 128: 492– 497, 1982.
  • 2. Palou J, Alberola JM, Villavicencio H, Vicente J. It’s like a pain in the perineum: a surgical clip protruding into the urethra through the urethrovesical anastomosis after radical prostatectomy. Scand J Urol Nephrol 1997;31:493-5.
  • 3. Long B, Bou S, Bruyere F, Lanson Y. Vesicourethral anastomotic stricture after radical prostatectomy secondary to migration of a metal clip. Prog Urol 2006;16:384-5.
  • 4. Banks EB, Ramani A, Monga M. Intravesical Weck clip migration after laparoscopic radical prostatectomy. Urology 2008;71:351.
  • 5. Kadekawa K, Hossain RZ, Nishijima S, Miyazato M, Hokama S, Oshiro Y, et al. Migration of a metal clip into the urinary bladder. Urol Res 2009;37:117-9.
  • 6. Tunnard GJ, Biyani CS. An unusual complication of a Hem-o-Lok clip following laparoscopic radical prostatectomy. J Laparoendosc Adv Surg Tech A 2009;19:649-51.
  • 7. Mora ER, Gali OB, Garin JA, Arango O. Intravesical migration and spontaneous expulsion of a Hem-o-lok polymer ligating clip after laparoscopic radical prostatectomy. Urology 2010;75:1317.
  • 8. Ong AM, Us LM, Varkarakis I, et al. Nerve sparing radical prostatectomy: Effects of hemostatic energy sources on the recovery of cavernous nerve function in a canine model. J Urol 2004;172:1318– 1322.
  • 9. Menon M, Tewari A, Peabody J; VIP Team. Vattikuti Institute prostatectomy: Technique. J Urol 2003;169:2289– 2292.
  • 10. Mora ER, Gali OB, Garin JA, Arango O. Intravesical migration and spontaneous expulsion of a Hem-o-lok polymer ligating clip after laparoscopic radical prostatectomy. Urology 2010;75:1317.
  • 11. Yi JS, Kwak C, Kim HH, Ku JH: Surgical clip-related complications after radical prostatectomy. Korean J Urol. 2010, 51 (10): 683-687.
  • 12. Banks EB, Ramani A, Monga M. Intravesical Weck clip migration after laparoscopic radical prostatectomy. Urology 2008;71:351.
  • 13. Mora ER, Gali OB, Garin JA, Arango O. Intravesical migration and spontaneous expulsion of a Hem-o-lok polymer ligating clip after laparoscopic radical prostatectomy. Urology 2010;75:1317.
  • 14. Borboroglu PG, Sands JP, Roberts JL, Amling CL. Risk factors for vesicourethral anastomotic stricture after radical prostatectomy. Urology 2000;56:96-100.
  • 15. Blumenthal KB, Sutherland DE, Wagner KR, Frazier HA, Engel JD. Bladder neck contractures related to the use of Hem-o-Lok clips in robot-assisted laparoscopic radical prostatectomy. Urology 2008;72:158-61.
  • 16. Cormio L, Massenio P, Lucarelli G, et al. Hem-o-lok clip: a neglected cause of severe bladder neck contracture and consequent urinary incontinence after robot-assisted laparoscopic radical prostatectomy. BMC Urol 2014;14:21.
  • 17. Ahlering TE, Eichel L, and Skarecky DW: Early potency with cautery free neurovascular bundle preservation study in robotic laparoscopic radical prostatectomy. J Endourol 19: 715-718, 2005.
  • 18. Gill IS, Ukimura O, Rubinstein M, et al: Lateral pedicle control during laparoscopic radical prostatectomy: refined technique. Urology 65: 23-27, 2005.

Nörovasküler Bundle Koruyucu Robot Yardımlı Radikal Prostatektomide Klipsiz ve Atermal Pedikül Kontrolü Sağlayan Selektif Sütürasyon Tekniği

Year 2020, Volume: 12 Issue: 1, 1 - 8, 30.01.2020

Abstract

Amaç: Robot yardımlı radikal prostatektomi operasyonu sırasında pedikül kontrolü; cerrahi klipler ve/veya farklı
enerji kaynakları kullanılarak yapılabilmektedir. Cerrahi kliplerin migrasyonu; mesane boynu kontraktürüne ve
mesane taşı oluşumuna sebep olabilmektedir. Diğer taraftan; pedikülün ayrılması sırasında kullanılan farklı enerji
kaynakları, potensin düzelmesinde kritik role sahip sinirlerde termal hasara yol açabilmektedir. Bu durumun önüne
geçebilmek için; nörovasküler bundle koruyucu robot yardımlı radikal prostatektomide; klipsiz ve atermal pedikül
kontrolü sağlayan selektif bir sütürasyon tekniği tanımladık.
Gereç ve Yöntem: Robot yardımlı radikal prostatektomi(RYRP) transperitoneal olarak antergrad şekilde
gerçekleştirildi. Mesane boynu insizyonunu takiben; prostat pedikülü ayrıldı. Öncelikle prostatın sağ pedikülü
serbestlendi ve kesildi. Kanama kontinü şekilde atılan V-Loc dikişlerle kontrol edildi. Nörovasküler bundle, prostat
kapsülünden basis bölümünde başlanıp apekse doğru ilerleyecek şekildi nazikçe ayrıldı. Aynı işlem prostatın sol
pedikülü için de gerçekleştirildi. Prostatektomi aşamasını takiben, yüzeyel kanamalar titiz bir şekilde , separe 5-0
polifilaman dikişlerle kontrol edildi. Bu teknik; Mart 2018 ve Mayıs 2019 tarihleri arasında 29 hastada uygulandı.
Bilateral sinir koruyucu yaklaşım tüm vakalarda gerçekleştirildi.
Bulgular: Ortalama pre-operatif PSA 8,1±2,1 ng/ml, ortalama hasta yaşı 60,8±6,5 , ortalama takip süresi ise 13,6±9,9
aydı. Ortalama konsol zamanı, intraoperatif kan kaybı ve prostatektomi spesimen ağırlığı sırasıyla 201±45 dakika,
237±97 ml. and 59±29 gr. olarak hesaplandı. Komplikasyonlar Clavien-Dindo sınıflamasına gore değerlendirildi.
Clavien Derece 2, 3a and 3b komplikasyonlara sırasıyla 1,2 ve 1 hastada karşılaşıldı. Cerrahi sınırlar pozitifliği 5 hastada
saptandı(%17,2). Post-operatif birinci ayda 29 hastanın 28’i kontinandı. PDE5 inhibitörü ile potens oranı ise %66’ydı.
Sonuç: RYRP(Robot yardımlı radikal prostatektomi)’de klipsiz pedikül kontrolü; intraoperatif kan kaybını etkilemeksizin
uygulanabilir bir yöntem olarak gözükmektedir.

References

  • 1. Walsh PC and Donker PJ: Impotence following radical prostatectomy: Insight into etiology and prevention. J Urol 128: 492– 497, 1982.
  • 2. Palou J, Alberola JM, Villavicencio H, Vicente J. It’s like a pain in the perineum: a surgical clip protruding into the urethra through the urethrovesical anastomosis after radical prostatectomy. Scand J Urol Nephrol 1997;31:493-5.
  • 3. Long B, Bou S, Bruyere F, Lanson Y. Vesicourethral anastomotic stricture after radical prostatectomy secondary to migration of a metal clip. Prog Urol 2006;16:384-5.
  • 4. Banks EB, Ramani A, Monga M. Intravesical Weck clip migration after laparoscopic radical prostatectomy. Urology 2008;71:351.
  • 5. Kadekawa K, Hossain RZ, Nishijima S, Miyazato M, Hokama S, Oshiro Y, et al. Migration of a metal clip into the urinary bladder. Urol Res 2009;37:117-9.
  • 6. Tunnard GJ, Biyani CS. An unusual complication of a Hem-o-Lok clip following laparoscopic radical prostatectomy. J Laparoendosc Adv Surg Tech A 2009;19:649-51.
  • 7. Mora ER, Gali OB, Garin JA, Arango O. Intravesical migration and spontaneous expulsion of a Hem-o-lok polymer ligating clip after laparoscopic radical prostatectomy. Urology 2010;75:1317.
  • 8. Ong AM, Us LM, Varkarakis I, et al. Nerve sparing radical prostatectomy: Effects of hemostatic energy sources on the recovery of cavernous nerve function in a canine model. J Urol 2004;172:1318– 1322.
  • 9. Menon M, Tewari A, Peabody J; VIP Team. Vattikuti Institute prostatectomy: Technique. J Urol 2003;169:2289– 2292.
  • 10. Mora ER, Gali OB, Garin JA, Arango O. Intravesical migration and spontaneous expulsion of a Hem-o-lok polymer ligating clip after laparoscopic radical prostatectomy. Urology 2010;75:1317.
  • 11. Yi JS, Kwak C, Kim HH, Ku JH: Surgical clip-related complications after radical prostatectomy. Korean J Urol. 2010, 51 (10): 683-687.
  • 12. Banks EB, Ramani A, Monga M. Intravesical Weck clip migration after laparoscopic radical prostatectomy. Urology 2008;71:351.
  • 13. Mora ER, Gali OB, Garin JA, Arango O. Intravesical migration and spontaneous expulsion of a Hem-o-lok polymer ligating clip after laparoscopic radical prostatectomy. Urology 2010;75:1317.
  • 14. Borboroglu PG, Sands JP, Roberts JL, Amling CL. Risk factors for vesicourethral anastomotic stricture after radical prostatectomy. Urology 2000;56:96-100.
  • 15. Blumenthal KB, Sutherland DE, Wagner KR, Frazier HA, Engel JD. Bladder neck contractures related to the use of Hem-o-Lok clips in robot-assisted laparoscopic radical prostatectomy. Urology 2008;72:158-61.
  • 16. Cormio L, Massenio P, Lucarelli G, et al. Hem-o-lok clip: a neglected cause of severe bladder neck contracture and consequent urinary incontinence after robot-assisted laparoscopic radical prostatectomy. BMC Urol 2014;14:21.
  • 17. Ahlering TE, Eichel L, and Skarecky DW: Early potency with cautery free neurovascular bundle preservation study in robotic laparoscopic radical prostatectomy. J Endourol 19: 715-718, 2005.
  • 18. Gill IS, Ukimura O, Rubinstein M, et al: Lateral pedicle control during laparoscopic radical prostatectomy: refined technique. Urology 65: 23-27, 2005.
There are 18 citations in total.

Details

Primary Language English
Subjects Urology
Journal Section Research Articles
Authors

Mustafa Bilal Tuna 0000-0003-2845-9801

Tünkut Doğanca This is me

İlter Tüfek This is me 0000-0003-4758-4069

Can Öbek This is me

Ali Rıza Kural This is me

Publication Date January 30, 2020
Published in Issue Year 2020 Volume: 12 Issue: 1

Cite

Vancouver Tuna MB, Doğanca T, Tüfek İ, Öbek C, Kural AR. Clipless and Athermal Pedicle Control with Selective Suturing Technique Proceeding with Neurovascular Bundle Preservation during Robot Assisted Radical Prostatectomy. Endourol Bull. 2020;12(1):1-8.