Adjustable tension ligation with anterior suspension (ATLAS) suture of the dorsal venous complex in robotic-assisted radical prostatectomy

Introduction In this study we aim to introduce a novel and simple technique: Adjustable Tension Ligation with Anterior Suspension (ATLAS) Suture, to control the dorsal venous complex (DVC) during robotic-assisted laparoscopic radical prostatectomy (RARP) that allows for excellent hemostasis and visibility during apical prostatic dissection. Methods Between July 2023 and April 2024, 30 consecutive patients who underwent total extra-peritoneal (TEP) RARP with a standardized ATLAS suture of the DVC were included in this study. Inclusion criteria for patient selection include: (1) BMI ≤35 kg/m 2 , and (2) localised prostate cancer. The step-by-step ATLAS suture technique is as follows: (1) apical dissection of the prostate to reveal the “groove” between the DVC and urethra laterally; (2) a 3-O barbed suture with a CT1 needle is passed between the DVC and urethra with a foley catheter in-situ; (3) the barbed suture is looped three times around the DVC and tightened; (4) the suture is anchored onto the periosteum around the symphysis pubis to form a “pulley” mechanism for adjusting the tension of the suture around the DVC. Peri- and post-operative data including DVC ligation times, apical dissection times, estimated blood loss, technical failure rate, and histology of RARP specimen including positive margin rates, and post-operative complications were collected and analyzed. Results The mean dissection and ligation time was: 3.67 minutes (2.83-5.10) and the mean apical dissection time was 3.70 minutes (2.85-4.63). Mean blood loss was 38.3 ml. There was no technical failure in terms of suture breakage, slippage or inadvertent needling of the urethra. Post-operative histology results are as follows: Gleason 3+3 in 2 patients (8%), 3+4 in 10 patients (43%), 3+5 in 1 patient (4%), 4+3 in 8 patients (35%) and 4+5 in 2 patients (8%). All 30 patients had uninvolved apical margins. 3/30 patients had Clavien-Dindo grade I complications including 1 acute retention of urine post catheter removal, 1 superficial wound infection and 1 catheter blockage. Conclusion This study presents a novel, easy to perform and reproducible technique to control the DVC, allowing excellent hemostasis and visibility during apical prostate dissection.