Safe digital isolation of the santorini plexus during radical retropubic prostatectomy

Prostate cancer is the most frequently diagnosed cancer and cause of cancer-related death in men. Since introduction, retropubic radical prostatectomy (RRP) has been considered as gold standard surgical treatment for localised prostatic cancer [1].

Although the use of minimally invasive techniques has increased in recent years, RRP still represents the most frequently employed surgical treatment in most countries [2].

Control of the dorsal vein complex (DVC) or Santorini plexus remains one of the most challenging steps of the procedure to reduce blood loss, avoid damage to the sphincteric muscle and maximize the chance of cure. It is often accomplished by blindly passing a clamp between urethra and DVC before ligation and division [3]. Over the years, several approaches have been developed. In a study by Rainwater and Segura sutured control of the DVC before transection resulted in a significant decrease in the estimated blood loss than unsutured approach [4]. Subsequently, various techniques have been reported including combined infrapubic and retropubic ligation [5], suture passers [6, 7], surgical staplers [8, 9] or Babcock clamp use before ligation and transection [10]. However, management of DVC does not always result easy as well as sometimes difficulties in introducing the clamp exactly in the right plane may be encountered, so that it passes too superficially, inside the Santorini plexus, or too deeply damaging the urethra and the sphincteric muscle. In 2009 Namiki et al. [11] described a novel technique using careful digital dissection to better delineate the apex of the prostate in order to lessen positive surgical margins at the apex and promote continence and erectile function.

Demographics, clinical and pathological characteristics of patients are listed in table (Table 1). The maneuver was successful in 53/56 (95%) patients. In three patients it was not possible to breach the fascia with the finger due to intensive fibrosis and the standard technique of blind passage of a clamp was employed. Mean (range) blood loss and overall operative time for RRP were 620 ml (100–1500) and 130 min. (80–190), respectively. Transfusion rate was 8,9% (5/56). Positive surgical margin rate was 14% (8/56): 1 pT2c, 4 pT3a and 3 pT3b. No complication related to the employed technique was recorded. Continence (no leakage at all) and potency (IIEF-5 > 20) rates were assessed at minimum one year of follow-up (range 12–34 months) and were 88% and 41% respectively.

Management of DVC is an important step of radical prostatectomy. In 1979 Reiner and Walsh described an anatomical approach to control this plexus [3].

Aside from reduction in blood loss, precise understanding of DVC anatomy have also resulted in a better apical dissection and preservation of the neurovascular bundles at this level, allowing improved continence and potency rates [6, 12, 13]. However, intraoperative bleeding still remains an issue in contemporary RRP [14, 15] and any possible measure helpful in reducing should be taken into account. In light of this, pure laparoscopic and then robot-assisted techniques have been also introduced to reduce bleeding mainly exploiting the compressive effect of the pneumoperitoneum. As in LRP and RALP different techniques have been assessed to handle DVC [16‐18], also in RRP there is a need for more effective ways to obtain haemostasis.

Another important aspect to consider is the postprostatectomy incontinence: avoiding damage to the rhabdosphincter is fundamental. Indeed, use of coagulation for hemostasis or not careful ligation before transection may damage the rhabdosphincter and underlying neurovascular components [19, 20]. The blunt digital apical dissection technique described by Namiki et al. represents a clever way to better delineate the apex of the prostate in order to improve results in terms of positive surgical margins, continence and erectile function. Similarly, our technique exploits the digital dissection of the DVC from the urethra, but distally to the prostatic apex, with the main aim to safely and quickly develop a right plane between the two structures. In this way, a safer and easier way to control Santorini plexus while performing RRP is provided. This study suggests its feasibility in order to obtain sufficient haemostasis for a better apical dissection before the prostate had been mobilized and removed. Our results confirms the advantages of the technique described by Namiki et al., and supports its routinary use during RRP.

Limitations of the present study are its retrospective and small cohort analysis without a comparison with our standard technique of blind clamp passage between urethra and DVC.

Finally, since this is only an initial experience, further evaluation is necessary to determine the impact of this technical modification on functional and oncological outcomes. As the follow-up matures, we will be able to report.

The described technique allows for a safe and easily reproducible isolation of the Santorini plexus during radical retropubic prostatectomy. We believe that using the finger, our most clever surgical instrument, we can make this procedure safer and more approachable particularly in the hands of the less experienced surgeon.