Robot-assisted Laparoscopic Prostatectomy

Videos

• Anterior approach
  • Anterior approach (Dr. Jim Hu)
  • Anterior approach (Dr. Vipul Patel)
• Posterior approach
  • Posterior approach (Dr. Naveen Kella)
  • Posterior approach (Dr. Naveen Kella #2)
  • Posterior approach (Dr. Ronney Abaza)
  • Posterior approach (Dr. Ronney Abaza #2)
  • Posterior approach (Asian Institute of Nephrology & Urology)

Contraindications

1. Contraindications to laparoscopic surgery
2. History of extensive abdominal or pelvic surgery
3. Morbid obesity
4. Extremely large prostate

Pre-operative Preparation

• Patient preparation
  • Encourage pre-operative Kegel exercises, three times a day
  • Discuss sperm preservation in young patients who might consider fathering children
• Pre-operative imaging
  • Primary tumor
    • Size
    • Location
      • Tumor position on CT will correspond to direction of hilum during surgery i.e. a posterolateral tumor on imaging that is in direct line with the hilum will be a lateral tumor during transperitoneal partial.
    • Endophytic vs. exophytic
      • If endophytic tumor, obtain pre-operative ultrasound.
        • If tumour not visible on pre-operative ultrasound, consider radical nephrectomy as intra-operative ultrasound to identify tumour will unlikely be successful.
    • Proximity to collecting system
    • Vasculature
  • Metastatic staging
• Hold/bridge anticoagulation medications prior to surgery
  • ASA 7 days
  • Clopidogrel 5 days
  • Apixaban 2 days
• Pre-operative testing
  • Urinalysis +/- culture
  • CBC
  • Serum creatinine/GFR

• Venous thromboembolism prophylaxis
  • Compression stockings
  • Heparin[1]
• Antibiotics
  • 2019 AUA Best Practice Guidelines for Open, Laparoscopic or Robotic Surgery involving controlled entry into urinary tract e.g. renal surgery, nephrectomy, partial or otherwise, ureterectomy pyeloplasty, radical prostatectomy; partial cystectomy, etc[2]
    • Prophylaxis Indicated: All cases
      • Antimicrobial(s) of Choice: Cefazolin or TMP-SMX
      • Alternative Antimicrobial(s), if required: Ampicillin/Sulbactam or Aminoglycoside and Metronidazole or Aztreonam and Metronidazole or Aminoglycoside and Clindamycin or Aztreonam and Clindamycin
      • Duration of Therapy: Single dose

Steps of procedure

• Position: supine (Xi) or dorsal lithotomy (Si), Trendelenburg (head down) to 25-28 degrees
• Venous thromboembolism prophylaxis
  • Compression stockings
  • Heparin
• Antibiotics
  • 2g cefazolin (900 mg clindamycin, if penicillin allergic)
• Surgical plan: anterior approach
  • Words of wisdom: continuous retraction of the prostate is key to safe and speedy progress.
  • Number of ports: 6 (variations possible, depending on institution equipment and surgeon preference)
  • Location of ports:
    • General considerations for robotic port placement
      • Port placement through the rectus muscle risks damage to the epigastric vessels.[3]
        • The epigastric vessels travel near the lateral edge of the rectus muscles in the lower abdomen and travel closer to the midline in the upper abdomen where they join the internal mammary arteries.[4]
        • Generally if trocars are not placed in the midline, they should be placed at least 6cm lateral to the midline to prevent epigastric injury.[5]
      • >8 cm distance is recommended between robotic ports[6]
        • 10-20 cm distance should be maintained between the ports and target anatomy
          • 10 cm distance from TA is good but 20 cm distance is better
      • Xi capable of having ports all in the same transverse line as camera; Si will require ports in an arc, with the lateral ports being more inferior (minimum 3 fingerbreadths medial and 3 fingerbreadths superior to the anterior superior iliac spine).
    • Configuration 1
      • Camera (12 mm): center, above umbilicus
      • Robotic Arm 1 (8 mm): 8 cm right medial of camera
      • Robotic Arm 2 (8 mm): 8 cm left medial of camera
      • Robotic Arm 3 (8 mm): 8 cm left lateral of Robotic Arm 2
      • Assistant 1 (5 mm): cephalad of other ports, in between camera and arm 1
      • Assistant 2: 5 cm right lateral of Robotic Arm 1
    • In tall males (72 inches), port sites should not be more than 18cm from the pubis[7]
  • Step by step:
    • Veress needle access. Make a 12 mm horizontal/transverse incision[8] (cautery on cut or #11 bladed knife) incision in the midline, just superior to the umbilicus. Use hemostat to dissect down to level of fascia.
      • Alternatively, transumbilical insertion can be considered in patients without known or suspected umbilical pathology (e.g. adhesions or herniations) [9]
      • If concerned about injury to aorta or IVC during Veress placement, consider Palmer's point (3 cm below the left costal margin and in the midclavicular line) to obtain access. in midline.
      • Use right hand to steady Veress needle and feel (usually) 2 pops until you are in abdomen.
      • Confirm appropriate placement with saline test. Aspirate first, then inject.
    • Achieve pneumoperitoneum. Connect the needle to high flow CO2 insufflation. There is no need to begin at low flow, because the size of the Veress needle limits flow to 1.5 to 2L/min.[10] Opening pressure (initial pressure) should be <10 mm. If pressure >10 mm, withdraw needle slightly. If pressure decreases <10 mm, this indicates that needle tip was against an intra-abdominal structure such as the intestine or omentum. If the pressure remains ≥10 mm Hg, the needle is not properly placed. As the pressure slowly rises to 20, the remaining port sites are marked.
      • With the Veress needle (before abdominal insertion), low flow should register 1 L/min and at high flow should register 2 to 2.5 L/min.[11]
      • Regardless of the insufflator setting, maximal flow through a Veress needle is only about 2.5 L/min because it is only 14 gauge.[12]
      • A Hasson cannula has a much larger internal diameter and can immediately accommodate the maximum flow rate of most insufflators (Le., >6 L/min)[13]
    • Insert ports. Once at 20mm Hg, remove Veress needle and insert the first port, the camera port, through the initial incision just above the umbilicus. Once inside, remove obturator, connect gas, and insert camera. Check that no injury made to the bowel during Varess or port access. For the remaining ports, inject local anesthetic to identify approximate location inside and then inject a supraperitoneal bleb for local anesthetic purposes. Insert all remaining ports under direct vision. All ports should be inserted perpendicular to the fascia. Port placement may have to be modified due to unexpected anatomy, or adhesions may need to be taken down prior to port insertion. Once all ports are positioned, the gas is transferred to the Assistant port and the pneumoperitoneum is reduced to 12-15 mm Hg for the procedure.
    • Dock robot
      • See https://www.laparoscopyhospital.com/docking-in-robotic-surgery.html for detailed instructions
      • If Xi
        • Attach camera port to robot. Insert and attach camera. Target camera in pelvis. Hold camera port steady and allow robot to adjust. Attach remaining ports to robot.
      • Insert instruments into arms (Robotic Arm 1 - monopolar scissors, Robotic Arm 2 - bipolar Maryland graspers, Robotic Arm 3 - Prograsp fenestrated graspers). Connect cords. Advance arms under vision.
    • Take down any adhesions that may inferfere with surgery.
    • Divide urachas. Cauterize the urachas high above the bladder then transect it.
    • Drop the bladder. Incise the peritoneum lateral to the medial umbilical ligament, from the urachas down to the vas deferens, medial to the inguinal canal. If doing lymph node dissection, continue peritoneal incision to the ureter. Develop the avascular space of Retzius down towards the pubic bone. Superiorly, do not get to close to the aterior abdominal wall musculature. Inferiorly, stay close to pubic bone anteriorly. Use the Prograsp fenestrated graspers in Robotic Arm 3 to retract the urachas posteriorly and superiorly. Expose endopelvic fascia bilaterally.
      • Always stay lateral to medial umbilical ligament
        • The ureter travels over the iliac vessels to run medial and deep to the medial umbilical ligament. Therefore, as long as dissection is lateral to the medial umbilical ligament, the ureter will not be at risk.
        • Do not be too lateral or you will encounter external iliac vessels.
      • Accessory pudendal arteries traveling longitudinally along the anteromedial aspect of the prostate are easily recognized during RALP. Attempt at preservation of these arteries is important for erectile function because in some men these arteries may be the dominant source of arterial blood supply to the corpora cavernosa
    • Defat anterior prostate. Use heat to dissect the anterior prostatic fat from the anterior prostatic capsule from the apex to the bladder neck to help visualize the border between the prostate and bladder neck.. Skeletonize the puboprostatic ligaments for optimal visualization of the apex.
      • Anterior prostatic fat is sent for a pathologic examination in case the pathologist reports a positive surgical margin. If a positive surgical margin is seen anteriorly, the fat can be evaluated for residual cancer.
      • About 15% of men will have lymph nodes in the anterior prostatic fat and that in 2% to 3% of men, this will be the only site of metastasis.
    • Coagulate superficial branches of DVC, if present
    • At this point, visible landmarks include:
      • Anterior aspect of the bladder and prostate
      • Puboprostatic ligaments
      • Endopelvic fascia
      • Pubis/superior pubic ramus
    • Incise endopelvic fascia. Retract the prostate medially and use scissors to make an incision in the endopelvic fascia, laterally closer to muscle than the nerve. This location fully exposes the neurovascular bundles (NVBs), which facilitates visualization and reduce traction injury. At the apex, release Myer’s muscle completely to visualize and protect the apex, neurovascular bundles, and urethra when transecting the dorsal venous complex (DVC) and remaining apical structures.
    • Incise anterior bladder neck. Retract the foley catheter to visualize the distal end of the balloon to identify the approximate location of the bladder neck. Once location identified, advance foley completely, use bipolar to coagulate in midline then use scissors to make a transverse incision in this area. Transection of the bladder from the prostate is facilitated with retraction of the left hand with continuous sufficient force to maximize visualization. Continue dissecting in midline towards the catheter. The anterior bladder neck incision should not be carried too far laterally because branches of the bladder pedicle are often encountered, resulting in unwanted bleeding. Once the catheter has been identified, deflate the balloon and suspend the prostate with Prograsp focep grapers. Complete lateral dissection of the anterior bladder neck.
    • Inspect interior of the bladder. Evaluate for median lobe of prostate. Identify locations of ureteric orifices, to avoid injury during repair. In patients with prior TURP, the ureteric orifice may be much closer to the bladder neck.
    • Incise posterior bladder neck. Continue dissection to enter the muscular/ vascular space behind the detrusor (or the posterior bladder neck). Immediately behind the posterior bladder are the longitudinal muscle and multiple vessels that need cauterization. This muscular/ vascular layer is later incorporated into the Rocco stitch. The bladder neck incision is completed and the prostate is now free at the base. The Foley catheter is withdrawn so only the tip is visible.
    • Posterior dissection (seminal vesicle and rectum). Identify and dissect out the vas deferens. Use Prograsp forcep grapsers to retract the vas superiorly and continue dissect distally towards the ejaculatory ducts. The seminal vesicles are found immediately lateral to the distal portion of the vasa. The seminal vesicles are dissected from the surrounding vas medially and laterally from the neurovascular bundle. The seminal vesicles should be mobilized with minimal traction to the surrounding hypogastric nerves, which are important for the sensation of orgasm. Minimize use of monopolar given proximity to neurovascular bundle. After one side complete, dissect out contralateral vas and seminal vesicles.
    • Dissect prostate from rectum. Suspend the seminal vesicles with Prograsp forcep grapsers. Denonvilliers is grasped and lifted and incised sharply. The incision is above the fascia for aggressive nerve-sparing, and below the fascia until perirectal fat is seen for aggressive cancer. Dissection of the plane between the prostate and rectum is facilitated by the surgeon’s left hand elevating the prostate as the assistant retracts gently but firmly on the rectum with the sucker as needed. The dissection is carried distally to the apex.
    • Nerve sparing. The periprostatic vasculature within the interfascial space has been used as a macroscopic landmark and visual surrogate for identifying and preserving the cavernous nerves. the interfascial plane is between capsular artery and fascia. Critical to nerve preservation is holding the prostate with Prograsp forcep grapsers, sharply releasing the nerve from the prostate without traction.
    • Pedicles. Create windows in the pedicles, apply clips, and gradually divide posterolateral pedicles
    • Divide DVC. Consider using 30 degree lens. Increase pneumoperitoneum to 20 mm Hg. Use left hand to retract prostate superiorly and cut straight through DVC with cold scissors. When DVC gives, change angle of scissors and follow curve of prostate.
    • Urethral transection. Cut through urethra, will eventually identify catheter. Remove catheter so only the tip is visible and continue to transect urethra and down to rectourethralis muscle with scissors perpendicular to the urethra.
    • Deliver specimen. A laparoscopic entrapment sac is introduced by the assistant through the 12 mm assistant trocar; the specimen is placed in the sac and the string brought out through the midline incision.
    • Oversew DVC. Exchange for robotic needle drivers. Use a 1-0 Vicryl or 4-0 V-lock running suture to oversew the DVC in all cases to prevent late or delayed venous bleeding. After DVC has been overswen, decrease pneumoperitoneum to 15 mm Hg.
    • Obtain hemostasis. Arterial bleeding along the nerves sutured with 4-0 vicryl. The prostatic pedicles are oversewn with a 3-0 V-lock suture for arterial but more importantly venous hemostatic security.
    • Lymph node dissection, if applicable. Identify appropriate landmarks (external iliac artery and vein, ureter, obturator nerve, node of cloquet) and dissect out lymph nodes.
    • Rocco stitch (optional). A 3-0 V-lock begins at the bladder incorporating the cut edge of Denonvilliers and then the posterior bladder detrusor. The next suture is intended to incorporate as much of the muscular structural support behind the urethra as possible. We stress that only the bladder is pulled toward the urethra to avoid pulling and tearing out from the urethral side.
    • Vesicourethral anastomosis. Reduce bladder neck, if needed with 1-0 vicryl. Use 3-0 V lock stitch for running vesicourethral anastamosis. Take an outside-in bite at the 6 o’clock position on the bladder neck. Run the needle through hole of V-lock stitch. Then take an inside-out bite at same position on urethra. Repeat another outside-in bite on the bladder to the right of this and a corresponding inside-out bite on the urethra. Bring in another 3-0 V-lock stitch. Take an outside-in bite on the bladder to left of the pervious 6 o’clock bite. Run the needle through hole of V-lock stitch. Then take a corresponding inside-out bite on the urethra. Repeat another bite to the left of this. Catheter is advanced into bladder. Cinch down both V-locks that are on the bladder neck. Continue running sutures around the clock. As anastomosis completed, insert final catheter. Sutures are cinched.
      • Video (Dr. Ketan Bedani)
      • Video (Dr. Edward Shaeffer)
      • Video (Dr. Kevin Zorn)
      • Video (Dr. Alexandre Mottrie)
      • Video (Dr. Jim Hu)
      • Guided written instructions with video (USC Robotic vesicourethral anastomosis tutorial - see Supplemental Data)
    • Closure. Catheter is irrigated. If satisfied with irrigation, inflate balloon is inflated with 20cc NS. All needles are removed from the patient. Ensure hemostasis.

Post-operative care

• Catheter removed after 7 days
• Sexual function recovery may occur over 1-2 years

Complications

• Intra-operative
  • Bleeding
  • Obturator nerve injury
  • Conversion to open surgery
  • Rectal injury (0.3%)[14]
• Early post-operative
  • Lymphocele/lymphorrhea (3.1%)
  • Urine leak (1.8%)
  • Infection
  • Re-operation (1.6%) due to
    • Bleeding
    • Wound dehiscence
    • Urinary retention
• Late post-operative
  • Incisional hernia
    • A retrospective cohort study of 900 consecutive robot-assisted radical prostatectomies found that the rate of incisional hernias was significantly higher with vertical (5.3%) compared to transverse (0.6%) midline camera port incision[15]
  • Erectile dysfunction
  • Urinary incontinence
  • Vesicourethral anastomotic stenosis
  • Failure to cure

Factors affecting continence after robot-assisted radical prostatectomy

• Pre-operative factors[16]
  • Age
  • Cancer characteristics
  • Prostate size
  • Preoperative lower urinary tract symptoms
  • Preoperative erectile dysfunction
  • Preoperative membranous urethra length, measured by T2-weighted magnetic resonance images
  • Presence of a median lobe
  • Previous transurethral resection of the prostate
  • Prostate cancer treatment
  • Bony pelvic dimensions
  • Cigarette smoking at the time of surgery
  • Type 2 diabetes mellitus
• Operative[17]
  • Surgeon experience
  • Surgical technique
    • Nerve-sparing
      • Meta-analysis published in 2014 of 27 studies found that patients who underwent nerve-sparing had improved urinary continence in the first 6 months after surgery. After this time, there was no difference in continence.[18]
    • Bladder neck-sparing
    • Retzius-sparing
    • High nerve release technique
    • Preserving maximal urethral length
    • Dorsal venous complex ligation technique
    • Posterior reconstruction
      • Posterior reconstruction is the approximation and suturing of the posterior layer of the rhabdosphincter to the Denonvilliers’ fascia and to the posterior surface of the bladder before the vesico-urethral anastomosis is completed
      • Often known as the "Rocco" stitch since Rocco et al. presented for the first time a modification of the Walsh technique to maintain the early recovery of incontinence after open radical prostatectomy. Rocco et a. later adapted the technique to laparoscopy-assisted prostatectomy.
      • Aims (2):
        • Approximation of the urethral sphincter cranially by approximation of the Denonvilliers’ fascia to the posterior aspect of the rhabdosphincter and posterior median raphe
        • Reduces tension in the anastomosis and provides pelvic support to the bladder neck by fixation of the Denonvilliers’ fascia to the posterior wall of the bladder
        • Meta-analysis published in 2016 of 21 studies found that posterior reconstruction improved early continence recovery at 3-7, 30, and 90 days after catheter removal, while the continence rate at 180 days was statistically but not clinically affected. Statistically significantly lower anastomotic leakage rates were described after posterior reconstruction.[19]

Previous TURP

• Normal anatomy of the bladder neck may frequently be quite distorted.
• Distortion makes it more of a problem to assess where the prostate ends. In addition, the bladder neck opening is significantly bigger and will usually need surgical reconstruction. We recommend plication of the bladder neck at the 3 and 9 o’clock positions. We recommend against a 6 o’clock position as this posterior position has the greatest amount of tension and the crossing of two suture lines increases the risk of distraction and urinary leakage.

Hernia repair

• Inguinal hernias should be fixed at the time of RALP

References

• Huynh, Linda M., and Thomas E. Ahlering. "Robot-assisted radical prostatectomy: a step-by-step guide." Journal of endourology 32.S1 (2018): S-28.
• Valdivieso, Roger F., Pierre-Alain Hueber, and Kevin C. Zorn. "Robot assisted radical prostatectomy: how I do it. Part I: Patient preparation and positioning." Can J Urol 20.5 (2013): 6957-6961.
• Urkmez, Ahmet, Weranja Ranasinghe, and John W. Davis. "Surgical techniques to improve continence recovery after robot-assisted radical prostatectomy." Translational Andrology and Urology 9.6 (2020): 3036.
• https://abdominalkey.com/robotic-assisted-laparoscopic-prostatectomy/
• Djokovic, Dusan, et al. "Principles of safe laparoscopic entry." European Journal of Obstetrics and Gynecology and Reproductive Biology 201 (2016): 179-188.
• Thepsuwan J, Huang KG, Wilamarta M, Adlan AS, Manvelyan V, Lee CL. Principles of safe abdominal entry in laparoscopic gynecologic surgery. GMIT. 2013;4:105–9.