Oncology Bladder Neck Contractures Related to the Use of Hem-O-Lok Clips in Robot-Assisted Laparoscopic Radical Prostatectomy Kevin B. Blumenthal, Douglas E. Sutherland, Kristofer R. Wagner, Harold A. Frazier, and Jason D. Engel OBJECTIVE Recently, several large series of robot-assisted laparoscopic radical prostatectomy (RALP) have described a low incidence of bladder neck contractures (BNC). We have had a similar experience at our institution. Our objective is to describe our experience with BNC after RALP and a novel relationship to the use of Hem-o-lok Clips (HOLC). METHODS We reviewed a database of patients who underwent RALP at our institution from January 2004 to September 2007 and identified patients with BNC or complications related to the use of HOLC. We performed a retrospective chart review to attempt to determine the cause of each BNC. We also performed a PubMed search and review of the Food and Drug Administration Manufacturer and User Facility Device Experience (MAUDE) database. RESULTS Of 524 patients undergoing RALP, 4 had a BNC develop, 2 of the BNCs were associated with HOLC migration and erosion into the vesicourethral anastomosis, and 1 was found to have HOLC migration within the bladder. A fifth patient had an anastomotic leak develop secondary to a HOLC that migrated into the bladder neck. Two similar cases of HOLC-related migration have been reported to MAUDE. CONCLUSIONS When early BNC or unexplained urinary retention occurs after RALP, one should have a high index of suspicion for migration of HOLC. Clip use should be minimized on tissue immediately adjacent to the anastomosis, and every effort should be made to retrieve loose clips after the procedure. UROLOGY 72: 158 –161, 2008. © 2008 Elsevier Inc. B ladder neck contracture (BNC) is a complication of prostate surgery that can be a devastating prob- lem leading to urinary retention, incontinence, and multiple repeated invasive procedures. The esti- mated incidence after open radical prostatectomy ranges from 3% to 26%. 1–9 Risk factors may include previous surgery, radiation, postoperative bleeding, or anastomotic leakage. Robot-assisted laparoscopic radical prostatec- tomy (RALP) is becoming a more prevalent procedure with clear differences in postoperative complications when compared with open retropubic radical prostatec- tomy (RRP). Several RALP series have suggested that the incidence of BNC after RALP may be lower than in patients undergoing RRP, ranging from 0.6% to 3% after RALP. 10 –15 The cause of this lower incidence is unclear. The purpose of this study was to evaluate our own expe- rience with post-RALP BNC, and document the rela- tionship of BNC formation with the use of Hem-o-lok clips (HOLC; Teleflex Medical, Research Triangle Park, NC). MATERIAL AND METHODS The robotic program at our institution was initiated in January 2004. We have since maintained a prospective database of clinical, surgical, and pathologic parameters. For this study, we retrospectively reviewed our database of complications to iden- tify all patients who had a BNC develop. We also performed a search of the United States Food and Drug Administration Manufacturer and User Facility Device Experience Database (MAUDE) to identify reported failures of HOLC between July 2005 and June 2007. We perform the vesicourethral anastomosis after RALP by using the double-arm technique described by Van Velthoven et al. 16 Two monocryl sutures, tied together at their ends, are used to perform a running closure. One arm is started at the 5:30 position and is run counter clockwise to the 12:00-o’clock position, and the second arm is started at the 6:30 position and run clockwise to the 12:00-o’clock position. The 2 arms are tied together at the 12:00-o’clock position with the knot in an extravesical location. Originally, we ligated the vasa and seminal vesicle arteries along with the prostatic pedicles after placing large HOLC to From the Department of Urology, the George Washington University Hospital, Wash- ington District of Columbia; the Division of Urology, Scott and White Health System, the Texas A&M Health Science Center College of Medicine, Temple Texas. Reprint requests: Douglas E. Sutherland, M.D., George Washington University Hospital, Department of Urology, 2150 Pennsylvania Avenue, NW 3rd Floor, Wash- ington, DC 20037. E-mail: desutherland@gmail.com Submitted: September 7, 2007, accepted (with revisions): November 19, 2007. 158 © 2008 Elsevier Inc. 0090-4295/08/$34.00 All Rights Reserved doi:10.1016/j.urology.2007.11.105