Standard vs delayed ligature of the dorsal vascular complex during robot-assisted radical prostatectomy: results from a randomized controlled trial
Prospective randomized trial to compare standard vs delayed approach to dorsal vascular complex (s-DVC vs d-DVC) in robot-assisted radical prostatectomy (RARP).
Patients scheduled for RARP were randomized into a 1:1 ratio to receive either s-DVC or d-DVC by two experienced surgeons. In s-DVC arm an eight-shaped single stitch was given at the beginning of the procedure and the DVC was subsequently cut at time of apical dissection; in d-DVC arm the plexus was transected at the end of prostatectomy, prior to apex dissection and then sutured. Primary endpoint was difference in estimated blood loss (EBL) and a sample size of 226 cases was calculated; ad interim analysis was planned after 2/3 of recruitment.
Endpoint was reached at ad interim analysis after 162 cases (81 s-DVC, 81 d-DVC) and recruitment was, therefore, interrupted. Baseline and tumor characteristics were overlapping. EBL was significantly higher in d-DVC arm (mean EBL 107 vs 65 ml, p = 0.003), but without differences in post-operative hemoglobin, transfusions and complications. Overall PSM rate was higher in d-DVC arm (21.0 vs 14.8%, p = 0.323), with statistical significance relatively to organ-confined disease (15.5 vs 3.6%, p = 0.031). Apical involvement was instead significantly higher in s-DVC arm (prevalence in PSM patients 66.7 vs 23.5%, p = 0.020). Post-operative PSA, continence and potency rates were similar between groups.
Standard and delayed approaches to DVC are safe and lead to similar functional outcomes. A delayed approach exposes to a higher risk of PSM in organ-confined disease but with a lower risk of apical involvement.
KeywordsDorsal vascular complex Robot-assisted radical prostatectomy Prostate cancer Blood loss Positive surgical margins
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Compliance with ethical standards
Conflict of interest
All the authors declare that they have no conflict of interest.
- 1.Walsh PC (1988) Radical retropubic prostatectomy with reduced morbidity: an anatomic approach. NCI Monogr 7:133–137Google Scholar
- 2.Ganzer R, Stolzenburg JU, Neuhaus J, Weber F, Burger M, Bründl J (2014) Is the striated urethral sphincter at risk by standard suture ligation of the dorsal vascular complex in radical prostatectomy? An anatomic study. Urology 84:1453–1458. https://doi.org/10.1016/j.urology.2014.06.092 CrossRefGoogle Scholar
- 3.Leow JJ, Chang SL, Meyer CP, Wang Y, Hanske J, Sammon JD, Cole AP, Preston MA, Dasgupta P, Menon M, Chung BI, Trinh QD (2016) Robot-assisted versus open radical prostatectomy: a contemporary analysis of an all-payer discharge database. Eur Urol 70:837–845. https://doi.org/10.1016/j.eururo.2016.01.044 CrossRefGoogle Scholar
- 5.Antonelli A, Sodano M, Peroni A, Mittino I, Palumbo C, Furlan M, Carobbio F, Tardanico R, Fisogni S, Simeone C (2017) Positive surgical margins and early oncological outcomes of robotic vs open radical prostatectomy at a medium case-load institution. Minerva Urol Nefrol 69:63–68. https://doi.org/10.23736/S0393-2249.16.02518-2 Google Scholar
- 6.Yaxley JW, Coughlin GD, Chambers SK, Occhipinti S, Samaratunga H, Zajdlewicz L, Dunglison N, Carter R, Williams S, Payton DJ, Perry-Keene J, Lavin MF, Gardiner RA (2016) Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet 388:1057–1066. https://doi.org/10.1016/S0140-6736(16)30592-X CrossRefGoogle Scholar
- 7.Nossiter J, Sujenthiran A, Charman SC, Cathcart PJ, Aggarwal A, Payne H, Clarke NW, van der Meulen J (2018) Robot-assisted radical prostatectomy vs laparoscopic and open retropubic radical prostatectomy: functional outcomes 18 months after diagnosis from a national cohort study in England. Br J Cancer 118:489–494. https://doi.org/10.1038/bjc.2017.454 CrossRefGoogle Scholar
- 10.Porpiglia F, Fiori C, Grande S, Morra I, Scarpa RM (2009) Selective versus standard ligature of the deep venous complex during laparoscopic radical prostatectomy: effects on continence, blood loss, and margin status. Eur Urol 55:1377–1383. https://doi.org/10.1016/j.eururo.2009.02.009 CrossRefGoogle Scholar
- 11.Lei Y, Alemozaffar M, Williams SB, Hevelone N, Lipsitz SR, Plaster BA, Amarasekera CA, Ulmer WD, Huang AC, Kowalczyk KJ, Hu JC (2010) Athermal division and selective suture ligation of the dorsal vein complex during robot-assisted laparoscopic radical prostatectomy: description of technique and outcomes. Eur Urol 59:235–243. https://doi.org/10.1016/j.eururo.2010.08.043 CrossRefGoogle Scholar
- 12.Woldu SL, Patel T, Shapiro EY, Bergman AM, Badani KK (2013) Outcomes with delayed dorsal vein complex ligation during robotic assisted laparoscopic prostatectomy. Can J Urol 20:7079–7083Google Scholar
- 13.Otsuki H, Nakamura K, Kuwahara Y, Tsukamoto T (2015) Modifications for controlling the dorsal vein complex in robotic-assisted laparoscopic radical prostatectomy. Nihon Hinyokika Gakkai Zasshi 106:7–11Google Scholar
- 16.Daley J, Khuri SF, Henderson W, Hur K, Gibbs JO, Barbour G, Demakis J, Irvin G, Stremple JF, Grover F, McDonald G, Passaro E, Fabri PJ, Spencer J, Hammermeister K, Aust JB, Oprian C (1997) Risk adjustment of the postoperative mortality rate for the comparative assessment of the quality of surgical care: results of the National Veterans Affairs Surgical Risk Study. J Am Coll Surg 185:315–327Google Scholar
- 17.Gandaglia G, Fossati N, Zaffuto E, Bandini M, Dell’Oglio P, Bravi CA, Fallara G, Pellegrino F, Nocera L, Karakiewicz PI, Tian Z, Freschi M, Montironi R, Montorsi F, Briganti A (2017) Development and internal validation of a novel model to identify the candidates for extended pelvic lymph node dissection in prostate cancer. Eur Urol 72:632–640. https://doi.org/10.1016/j.eururo.2017.03.049 CrossRefGoogle Scholar
- 18.D’Amico A, Altschuler M, Whittington R, Kao G, Malkowicz SB, Wein A (1993) The use of clinical parameters in an interactive statistical package to predict pathological features associated with local failure after radical prostatectomy for prostate cancer. Clin Perform Qual Health Care 1:219–222Google Scholar
- 20.Mitropoulos D, Artibani W, Biyani CS, Bjerggaard Jensen J, Rouprêt M, Truss M (2017) Validation of the Clavien-Dindo grading system in urology by the European Association of Urology guidelines ad hoc panel. Eur Urol Focus. https://doi.org/10.1016/j.euf.2017.02.014. (Epub ahead of print)Google Scholar
- 21.Epstein JI, Egevad L, Amin MB, Delahunt B, Srigley JR, Humphrey PA, Grading C (2016) The 2014 international society of urological pathology (ISUP) consensus conference on gleason grading of prostatic carcinoma: definition of grading patterns and proposal for a new grading system. Am J Surg Pathol 40:244–252. https://doi.org/10.1097/PAS.0000000000000530 Google Scholar
- 23.Rocco B, Coelho RF, Albo G, Patel VR (2010) Robot-assisted laparoscopic prostatectomy: surgical technique. Minerva Urol Nefrol 62:295–304Google Scholar
- 24.Walz J, Epstein JI, Ganzer R, Graefen M, Guazzoni G, Kaouk J, Menon M, Mottrie A, Myers RP, Patel V, Tewari A, Villers A, Artibani W (2016) A critical analysis of the current knowledge of surgical anatomy of the prostate related to optimisation of cancer control and preservation of continence and erection in candidates for radical prostatectomy: an update. Eur Urol 70:301–311. https://doi.org/10.1016/j.eururo.2016.01.026 CrossRefGoogle Scholar
- 25.Hoshi A, Usui Y, Shimizu Y, Tomonaga T, Kawakami M, Nakajima N, Hanai K, Nomoto T, Terachi T (2013) Dorsal vein complex preserving technique for intrafascial nerve-sparing laparoscopic radical prostatectomy. Int J Urol 20:493–500. https://doi.org/10.1111/j.1442-2042.2012.03181.x CrossRefGoogle Scholar
- 26.Xu P, Xu A, Chen B, Zheng S, Xu Y, Li H, Li B, Huang P, Zhang Y, Ge Y, Liu C (2017) Ligation-free technique for dorsal vascular complex control during laparoscopic radical prostatectomy: a single-center experience from China. World J Urol 35:395–402. https://doi.org/10.1007/s00345-016-1889-0 CrossRefGoogle Scholar