Editorial Referring to the article published on pp. 235–243 of this issue Dorsal Vein Complex Control After Apical Dissection Results in Low Apical Positive Surgical Margins, But Other Surgical Maneuvers Are Required to Optimize Early Continence Recovery Prasanna Sooriakumaran, Ashutosh Tewari * Lefrak Center of Robotic Surgery and Institute for Prostate Cancer, James Buchanan Brady Foundation Department of Urology, Weill Cornell Medical College – New York Presbyterian Hospital, New York, NY, USA The authors of a study in this month’s Platinum Journal [1] are to be congratulated for their careful demonstration of how the dorsal venous complex (DVC) can be controlled after apical dissection with selective suture ligation (the study group). They compare this technique to the ‘‘standard’’ of DVC suture ligation followed by athermal division. The authors report that the study technique, which avoids controlling the DVC until the apical dissection has been performed, results in fewer instrument changes and thus a shorter operating time; however, this positive result was countered by increased estimated blood loss (EBL) in the study group. We would suggest that neither the 15 min saved nor the 8.7 ml difference in EBL is of clinical importance. The authors [1] also report excellent apical positive margin rates (aPSM) of 1.3% in the study group. Their total positive margin rate was 12.2% for this group and is comparable with most robot-assisted prostatectomy series [2]. Although the authors did not find significant differences in their aPSM between the two groups, this is likely a low power effect because there were only a total of 11 aPSM in the entire series. The trend was in favor of the study group (1.3% vs 2.7%), most likely as a result of better visualization of the prostatourethral junction. Other investigators using a similar technique have also reported improved aPSM rates as a result. For example, Guru et al [3] decreased their aPSM rate from 8% to 2% by changing their technique from suture ligation of the DVC before apical dissection to cold incision of the DVC without prior suture ligation. Menon et al [4] demonstrated aPSM rates that decreased from 12% to 1.5% when suture ligation of the DVC was performed after removal of the prostate instead of suture ligating the DVC before apical dissection. Even open radical prostatectomists have confirmed that cold incision of the DVC without prior suture ligation results in lower aPSM rates [5]. We found in 1874 patients that our aPSM rate using a technique in which we control the DVC after apical dissection is low at 4.1% (3.4% for pT2) and that we can decrease this further to 1.4% by using a retroapical approach to the apical dissection [6]. This technique results in improved circumferential visualization of both the prostatic apex and membranous urethra and their anatomic inter- section so the apex and its surrounding neural scaffold can be dissected more precisely. Not only does this technique approach the prostatic apex from all angles, it often obviates the need for ligation of the DVC and allows the surgeon to cut the venous plexus athermally [6]. A plausible explana- tion for why aPSM rates are lower when ligating the DVC after performing apical dissection is that suturing the DVC tends to bunch up the tissue and can alter apical anatomy so it becomes more difficult to locate the prostatourethral junction precisely. Also, surgeons may fear incising the DVC suture with resulting increased blood loss and thus stray too close to the prostatic apex during dissection [3]. The authors of the current study [1] also found an improvement in their continence outcomes, with the athermal DVC division followed by selective suture ligation patients having a 5-mo continence rate of 61.4% compared with 39.6% in the standard group. The quicker return of continence did not translate into better longer term continence outcomes, however, with 12-mo rates of 69.8% EUROPEAN UROLOGY 59 (2011) 222–223 available at www.sciencedirect.com journal homepage: www.europeanurology.com DOI of original article: 10.1016/j.eururo.2010.08.043 * Corresponding author. James Buchanan Brady Foundation Department of Urology, Weill Medical College of Cornell University, 525 East 68th Street, Starr 900, New York, NY 10065, USA. Tel. +1 212 746 5634; Fax: +1 212 746 9842. E-mail address: ashtewarimd@gmail.com (A. Tewari). 0302-2838/$ – see back matter # 2010 European Association of Urology. Published by Elsevier B.V. All rights reserved. doi:10.1016/j.eururo.2010.09.026