Standard vs Delayed Ligature of the Dorsal Vascular Complex During Robot-Assisted Radical Prostatectomy: Results from a Randomized Controlled Trial

We conceived this randomized trial to investigate potential differences of a standard vs delayed ligature of the Santorini plexus during robot-assisted radical prostatectomy (RARP). Indeed, both advantages and disadvantages of suturing the DVC before or after its transection have been described and how to manage the DVC relies only on surgeon’s preference.

The sample size was based on estimated blood loss (EBL) since previous studies were based on this indicator and in our opinion intraoperative bleeding is the worsen impediment the surgeon has to face to during prostatectomy. We evaluated positive surgical margins, continence rate and potency rate, too.

We found a mean difference of 42 mL between standard (s-DVC) and delayed (d-DVC) ligature, significantly higher in d-DVC group (p=0.003), but not impacting on clinical course. The overall PSM rate was similar, but subgroup analysis showed a significant higher PSM rate for the d-DVC group in case of pT2 disease (15.5% vs 3.6%, p=0.031) and conversely, a lower rate of apical PSM (23.5% vs 66.7%, p=0.02). Continence and potency rate were comparable between both group at each timepoint.

Since the end of this study, our approach to DVC during RARP has changed. At now our preference is a delayed modified approach, suturing the DVC after its section but before apical dissection and urethral detachment. Like this, bleeding is controlled by suturing the DVC, possibly leading to lower PSM rates and the suture is more selective since the risk of binding the fibres of the urethral sphincter is minimized.

Written by: Alessandro Antonelli, MD and Carlotta Palumbo, MD, Department of Urology, Spedali Civili Hospital of Brescia, University of Brescia, Italy

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