Santorini Plexus Control and Transection

First, the bladder is retracted cranially with a forceps grasping at the urachus (VI trocar 5-mm, caudally to the right). The fatty tissue overlying the endopelvic fascia has to be resected or swept cephalad and lateral. An endo-peanut-sponge holder is used to push the prostate medially, exposing the endopelvic fascia. The point of incision is where the fascia is transparent, revealing the underlying levator ani musculature, lateral to the arcus tendineus fascia pelvis because the lateral branches of the dorsal venous complex are directly beneath it. The incision in the endopelvic fascia is then carefully extended in an anteromedial direction toward the puboprostatic (or pubovesical) ligaments (17). This incision, allowing access to the levator ani muscles arching lateral, is carried distally up to lateral most puboprostatic ligament. If necessary, the small veins around the pubo-prostatic ligaments may be safely cauterized with bipolar forceps. With the pubopro-static ligaments transected, the superficial branch of the dorsal vein is readily apparent in the midline over the bladder neck. The adherent levator ani muscle is gently detached from the prostate, followed by transection of the puboprostatic ligaments (pubovesical ligament). The Santorini plexus is adequately controlled by two stitches caudally and one at the base of prostate for the back flow, using endoscopic suturing technique (17mm Vicryl MH 2/0). The needle is passed from the right to the left side and should be situated so that the curve of the needle follows the curves of the symphysis pubis. The dorsal vein complex is first coagulated with bipolar forceps then divided cranial to the two distal stitches due to the coagulation-induced shrinkage of the tissue. With slight cranial traction on the prostate, the coagulated veins and the surrounding fibromuscu-lar fatty tissue retract on both sides.

Tips and Tricks

The angle between the needle and the needle holder should be 100 degrees. The dorsal vein complex is transected proximal to the caudal stitches. The optimal retraction of the prostatic apex is accomplished by the use of 120-degree endodissector (10 -mm), with the blunt tips up to avoid injuries in the bladder. Minor bleeding (i.e., back bleeding from the prostate, lateral branches of deep dorsal vein complex) can be controlled by bipolar coagulations.

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