Minimally Invasive Therapy. 2014; Early Online, 1–6
ORIGINAL ARTICLE
Minim Invasive Ther Allied Technol Downloaded from informahealthcare.com by University of Washington on 01/04/15 For personal use only.
Impact of barbed suture in controlling the dorsal vein complex during laparoscopic radical prostatectomy
ALI SERDAR GÖZEN, THEODOROS TOKAS, YIGIT AKIN, JAN KLEIN, JENS RASSWEILER Department of Urology, SLK-Kliniken, University of Heidelberg, Heilbronn, Germany
Abstract Objective: To compare applications of unidirectional knotless barbed suture and traditional two single polyglactin sutures for dorsal vein complex (DVC) control during laparoscopic radical prostatectomy (LRP). Material and methods: This was a non-randomized, prospective matched-pair pilot study. Thirty-one LRP cases with barbed suture (V-Loc) were matchpaired with 31 LRP cases in which traditional two single polyglactin stitches according to patient’s prostate volume and body mass index (BMI) were used. Time needed for DVC ligation, DVC control and operation time were recorded. Peri- and postoperative parameters were noted. Statistical analyses were performed. Results: Mean age was 65.4±6.3 years. Mean follow-up was 20.2±3.3 months. Mean BMI and prostate volume were similar in both groups. Mean preoperative clinical stage, Gleason score, and PSA were comparable between both groups. Mean DVC ligature time and mean DVC controlling time in group 1 were statistically shorter than in group 2 (p=0.04, p10 ng/mL and/or a Gleason score >6. TNM classification was used to determine the clinical stage (13).
Cystography was performed in all patients. If no leak was demonstrated, the urethral catheter was removed. For evaluating urinary continence, we used urine loss ratio (ULR), which has been previously described in the literature (14). ULR was defined as the weight of urine loss after removal of the urethral catheter in the pad divided by daily micturition volume. Additionally, the time to continence was classified as early (0–3 months) and late continence (13–24 months). All complications were classified according to a modified Clavien classification (15). Indications for adjuvant therapies were determined by employing the Walz score (16). Dorsal vein complex control The Heilbronn technique with bilateral lymph node dissection was performed as the method of management for all LRP cases (3,6). DVC suturing techniques. The prostate was retracted by a 120 -dissector in order to provide the optimal exposure of the prostatic apex and DVC. The dissector created cephalic tension while gently holding the bladder neck. The endopelvic fascia was excised and the dissection was carried out distally until an optimal exposure of the lateral aspect of the DVC could be achieved. Classical DVC suturing technique. The dorsal vein was controlled at the apex of the prostate with two stitches, each with three knots (2/0 Vicryl, MH needle). During this step the surgeon used a needle driver with the right hand and an endo-dissector with the left hand. The right needle driver was initially used to drive the needle between the DVC and the urethra, just below the DVC at the level of the puboprostatic ligaments. The needle was passed from the right side to the left side, thus the DVC was encircled. In this step, a second stitch was placed with the same technique caudally to the previous one. After knotting the needle was cut and removed. DVC suturing technique using V-Loc. The endopelvic fascia was excised from medial and under the puboprostatic ligaments by endoscopic scissors. The Levator fascia was gently pushed away from the lateral surface of the prostate. The right needle driver was initially used to drive the V-Loc from the right side to the left side between the DVC and the urethra. Thus, it was placed more cranially than for the classical DVC suture, at the level of the insertion of the
3
Barbed suture for DVC control during LRP a
b
c
d
e
Minim Invasive Ther Allied Technol Downloaded from informahealthcare.com by University of Washington on 01/04/15 For personal use only.
Figure 1. Performig V-Loc for dorsal vein complex control. (a,b) The right needle driver was initially used to drive the V-Loc from the right side to the left side between the DVC and the urethra. (c) V-Loc was passed through the loop at the tail of the stitch. (d) V-Loc was pulled until it strangled the DVC, and by using the right needle driver, the needle was passed under the DVC two more times. Each time it was driven a little deeper, and caudally of the previous one according to the prostate apex anatomy. (e) V-Loc stays in its place without loosening.
puboprostatic ligaments to the prostate, on the middle part of the prostate (Figure 1a and b). Afterwards, it was passed through the loop at the tail of the stitch (Figure 1c). The suture was then pulled until it strangled the DVC (Figure 1d). By using the right needle driver, the needle was passed under the DVC two more times. Each time it was driven a little deeper and caudally of the previous one according to the apex anatomy (Figure1d). After the last one, the suture was locked at the left side of the DVC. Then the needle was cut and removed. V-Loc stays in its place without loosening (Figure 1e). There was no need for additional knots. Statistical analyses The Statistical Package for the Social Sciences (SPSS) for Windows 16.0 (SPSS Inc., Chicago, IL) was used for statistical analysis. The independent-samples t test was used to compare measurable values, and the Mann–Whitney U test was used for comparisons between the groups. Statistical significance was accepted at p< 0.05.
Results Mean age was 65.4± 6.3 years. Mean follow-up was 20.2±3.3 months. Demographic data of patients, including tumour characteristics, are summarized in Table I. There was no statistically significant difference regarding mean age, BMI, and prostate volume between the two groups (p=0.58, p=0.59, p=0.71). Additionally, the total Gleason score, clinical stage, and PSA were similar in both groups (p=0.36). The perioperative results are presented in Table II. There was no significant difference in total operation time, and EBL (p=0.27, p>0.35). However, shorter time periods of DVC ligature and DVC control were obtained in group 1 than in group 2 (p=0.04, p
ORIGINAL ARTICLE
Minim Invasive Ther Allied Technol Downloaded from informahealthcare.com by University of Washington on 01/04/15 For personal use only.
Impact of barbed suture in controlling the dorsal vein complex during laparoscopic radical prostatectomy
ALI SERDAR GÖZEN, THEODOROS TOKAS, YIGIT AKIN, JAN KLEIN, JENS RASSWEILER Department of Urology, SLK-Kliniken, University of Heidelberg, Heilbronn, Germany
Abstract Objective: To compare applications of unidirectional knotless barbed suture and traditional two single polyglactin sutures for dorsal vein complex (DVC) control during laparoscopic radical prostatectomy (LRP). Material and methods: This was a non-randomized, prospective matched-pair pilot study. Thirty-one LRP cases with barbed suture (V-Loc) were matchpaired with 31 LRP cases in which traditional two single polyglactin stitches according to patient’s prostate volume and body mass index (BMI) were used. Time needed for DVC ligation, DVC control and operation time were recorded. Peri- and postoperative parameters were noted. Statistical analyses were performed. Results: Mean age was 65.4±6.3 years. Mean follow-up was 20.2±3.3 months. Mean BMI and prostate volume were similar in both groups. Mean preoperative clinical stage, Gleason score, and PSA were comparable between both groups. Mean DVC ligature time and mean DVC controlling time in group 1 were statistically shorter than in group 2 (p=0.04, p10 ng/mL and/or a Gleason score >6. TNM classification was used to determine the clinical stage (13).
Cystography was performed in all patients. If no leak was demonstrated, the urethral catheter was removed. For evaluating urinary continence, we used urine loss ratio (ULR), which has been previously described in the literature (14). ULR was defined as the weight of urine loss after removal of the urethral catheter in the pad divided by daily micturition volume. Additionally, the time to continence was classified as early (0–3 months) and late continence (13–24 months). All complications were classified according to a modified Clavien classification (15). Indications for adjuvant therapies were determined by employing the Walz score (16). Dorsal vein complex control The Heilbronn technique with bilateral lymph node dissection was performed as the method of management for all LRP cases (3,6). DVC suturing techniques. The prostate was retracted by a 120 -dissector in order to provide the optimal exposure of the prostatic apex and DVC. The dissector created cephalic tension while gently holding the bladder neck. The endopelvic fascia was excised and the dissection was carried out distally until an optimal exposure of the lateral aspect of the DVC could be achieved. Classical DVC suturing technique. The dorsal vein was controlled at the apex of the prostate with two stitches, each with three knots (2/0 Vicryl, MH needle). During this step the surgeon used a needle driver with the right hand and an endo-dissector with the left hand. The right needle driver was initially used to drive the needle between the DVC and the urethra, just below the DVC at the level of the puboprostatic ligaments. The needle was passed from the right side to the left side, thus the DVC was encircled. In this step, a second stitch was placed with the same technique caudally to the previous one. After knotting the needle was cut and removed. DVC suturing technique using V-Loc. The endopelvic fascia was excised from medial and under the puboprostatic ligaments by endoscopic scissors. The Levator fascia was gently pushed away from the lateral surface of the prostate. The right needle driver was initially used to drive the V-Loc from the right side to the left side between the DVC and the urethra. Thus, it was placed more cranially than for the classical DVC suture, at the level of the insertion of the
3
Barbed suture for DVC control during LRP a
b
c
d
e
Minim Invasive Ther Allied Technol Downloaded from informahealthcare.com by University of Washington on 01/04/15 For personal use only.
Figure 1. Performig V-Loc for dorsal vein complex control. (a,b) The right needle driver was initially used to drive the V-Loc from the right side to the left side between the DVC and the urethra. (c) V-Loc was passed through the loop at the tail of the stitch. (d) V-Loc was pulled until it strangled the DVC, and by using the right needle driver, the needle was passed under the DVC two more times. Each time it was driven a little deeper, and caudally of the previous one according to the prostate apex anatomy. (e) V-Loc stays in its place without loosening.
puboprostatic ligaments to the prostate, on the middle part of the prostate (Figure 1a and b). Afterwards, it was passed through the loop at the tail of the stitch (Figure 1c). The suture was then pulled until it strangled the DVC (Figure 1d). By using the right needle driver, the needle was passed under the DVC two more times. Each time it was driven a little deeper and caudally of the previous one according to the apex anatomy (Figure1d). After the last one, the suture was locked at the left side of the DVC. Then the needle was cut and removed. V-Loc stays in its place without loosening (Figure 1e). There was no need for additional knots. Statistical analyses The Statistical Package for the Social Sciences (SPSS) for Windows 16.0 (SPSS Inc., Chicago, IL) was used for statistical analysis. The independent-samples t test was used to compare measurable values, and the Mann–Whitney U test was used for comparisons between the groups. Statistical significance was accepted at p< 0.05.
Results Mean age was 65.4± 6.3 years. Mean follow-up was 20.2±3.3 months. Demographic data of patients, including tumour characteristics, are summarized in Table I. There was no statistically significant difference regarding mean age, BMI, and prostate volume between the two groups (p=0.58, p=0.59, p=0.71). Additionally, the total Gleason score, clinical stage, and PSA were similar in both groups (p=0.36). The perioperative results are presented in Table II. There was no significant difference in total operation time, and EBL (p=0.27, p>0.35). However, shorter time periods of DVC ligature and DVC control were obtained in group 1 than in group 2 (p=0.04, p
