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

Yıl 2020, Cilt: 12 Sayı: 1, 1 - 8, 30.01.2020

Mustafa Bilal Tuna , Tünkut Doğanca İlter Tüfek Can Öbek Ali Rıza Kural

Öz

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.

Anahtar Kelimeler

Robotic surgery, prostate cancer, clipless

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

Öz

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.

Anahtar Kelimeler

Prostat Kanseri, Robotik Cerrahi, Klipsiz

Kaynakça

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