Feasibility study for robotic radical prostatectomy cautery-free neurovascular bundle preservation

Efforts continue to develop techniques that maintain the neurovascular bundles and minimize trauma for robotic laparoscopic radical prostatectomy. We evaluated the feasibility of preserving the nerve bundles without cautery or surgical clips.

The seminal vesicles were dissected using scissors and bipolar cautery. After the rectum was mobilized, the vascular pedicles (VPs) were delineated. Laparoscopic bulldog clamps (30 mm) were placed at least 1 cm from the prostate. Using scissors, the VPs were divided right at the prostate. The neurovascular bundle was gently dissected off the prostatic capsule. After mobilizing the bundle, FloSeal was applied along its entire length. The FloSeal was then covered with a dry 1 x 4-cm sheet of Gelfoam. Once the prostate was removed, the bulldog clamps were sequentially withdrawn. The VPs were observed, and, if pulsatile bleeding was encountered, a 3-0 figure-of-eight suture was precisely placed for hemostasis. When hemostasis was complete, the anastomosis was performed.

In 17 men, temporary vascular occlusion was applied to 27 VPs and FloSeal and Gelfoam was applied each time. In 4 cases (15%), hemostasis was inadequate because of continued arterial bleeding that was easily controlled with a superficial figure-of-eight ligature of 3.0 absorbable suture. The average estimated blood loss was 91 mL (range 75 to 150).

Cautery-free, clip-free, nerve-sparing robotic laparoscopic radical prostatectomy is feasible using a combination of temporary occlusion of the thick posterior prostatic pedicles with bulldog clamps followed by application of FloSeal. The effect on potency needs further follow-up.