Haemostasis during nerve-sparing Endoscopic Extraperitoneal Radical Prostatectomy
J.-U. Stolzenburg , H.M. Do1, N. Ghulam*2, G. Hellawell*3, T. Häfner1, E. Liatsikos*4
1Universität Leipzig, Klinik und Poliklinik für Urologie, Leipzig, Germany, 2University of Aberdeen, Aberdeen, United Kingdom, 3Northwick Park Hospital, London, United Kingdom, 4University of Patras, Patras, Greece
Laparoscopic transperitoneal and endoscopic extraperitoneal radical prostatectomy are well established surgical procedures for the treatment of localised prostate cancer. Bleeding is one of the potential risk factors and achieving effective haemostasis remains a vital step of all methods of minimal invasive radical prostatectomy including robot-assisted prostatectomy. This video demonstrates various measures of controlling bleeding from commonest sites of haemorrhage such as injury to the epigastric vessels, bleeding from the prostatic pedicle and the Santorini plexus during the dissection of the prostate. In nerve sparing radical prostatectomy, despite a careful dissection, venous as well as arterial bleeding from the neurovascular bundle can occur after the removal of prostate. Any use of energy source at this step of the procedure run the risk of injury to the extremely sensitive neurovascular structures.
In case of arterial bleeding we recommend accurate placement of suture which is shown in the video. In general, we prefer suturing to clip application in this area as vessels retract and clips can not be applied without risk of injury to the bundles. Venous oozing is more often than arterial bleeding and can be carefully controlled using haemostatic agents. Tachosil is a dry equine fibrin adhesivecoated collagen sponge with fixed solid layer of human thrombin and fibrinogen. Tips and tricks are demonstrated how to place Tachosil sponges to achieve adequate haemostasis.
In a series of 300 intrafascial nerve sparing radical prostatectomies, we have used Tachosil in 32 cases. In none of cases of the Tachosil group blood transfusion was required. The transfusion rate in the non-Tachosil group was 0.7%.