Introduction
The first report of robotic-assisted radical prostatectomy (RARP) was performed by Binder and Kramer in 2000, describing 10 patients who underwent surgical treatment for prostate cancer using robotic technology. In this study, the authors combined the Walsh retrograde technique with Campbell’s anterograde approach. Since then, several groups worldwide have described the robotic surgery approach to radical prostatectomy. However, the unpredictable functional and oncological outcomes following RARP still challenge patients and surgeons. According to contemporary studies performed in referral centers, incontinence rates range from 14% to 31%, while erectile dysfunction affects up to 81% (32% to 81%). ,
Recent studies have described that potency outcomes depend mainly on the patient’s age, preoperative sexual status, and degree of nerve-sparing technique. Furthermore, some authors have described improvements in early potency and continence rates after modifying the surgical technique in order to minimize the apical dissection and preserve the lateral prostatic fascia. In this scenario, after performing 15,000 cases, our surgical technique has evolved. Therefore, after recent refinements, our chapter describes the anatomical and technical considerations of our current RARP technique.
Robotic console and CO 2 insufflation
We routinely perform all robotic-assisted radical prostatectomies with the da Vinci Xi or with the da Vinci SP. In addition, we use the AirSeal Intelligent Flow System (CONMED, New York, USA) in all cases, which is a three-lumen insufflation method with a valveless trocar for maintaining constant intra-abdominal pressure and removing the surgical smoke periodically. Several authors have described the outcomes of the AirSeal insufflation system in the literature compared to the standard CO 2 insufflation (12 to 15 mm Hg) in laparoscopic procedures. ,
Patient positioning and trocar placement
All patients are positioned in dorsal decubitus with pad protection in all articulations and points of contact with the operative table. Then, after general anesthesia and antibiotic prophylaxis, a bilateral TAP (transversus abdominis plane) block is performed by the anesthesia team.
After the sterile draping and time-out, we perform a supraumbilical incision to insufflate CO 2 with a Veress needle. Then, the first robotic trocar is placed at the midline, followed by the other five trocars (three robotic and two assistant), as illustrated in Fig. 13.1 . After placing the trocar, the table is angled to 26 degrees Trendelenburg, and the robot is docked on the left side of the patient (side docking). Then, the AirSeal provides a constant pneumoperitoneum of 10 mm Hg during the procedure.
Dropping the bladder and retzius space access
Instruments used: Scissors (right arm), Maryland bipolar (left arm), ProGrasp (4th arm), scope (30 degrees up or down).
After docking the robot and inserting the instruments under visualization, we identify the umbilical ligaments to incise the peritoneum with the bipolar and scissors. In this step, the pubic bone (medial) and the deferens (lateral) are used as landmarks to guide the Retzius space dissection for accessing the anterior aspect of the prostate. In sequence, we remove the excessive periprostatic and perivesical fat to approach the anterior bladder neck.
Anterior bladder neck
Instruments used: Scissors (right arm), Maryland bipolar (left arm), ProGrasp (4th arm).
We identify the precise location of the bladder neck (BN) by using the double pinch maneuver while pulling on the catheter repeatedly. In some cases, it is possible to identify a median lobe if the catheter deviates toward one side. Once we identify the transition between the prostate and bladder, we incise the BN horizontally with scissors and bipolar (applying traction) in a downward direction until reaching the Foley catheter ( Fig. 13.2 ). The Foley catheter is then used as upward traction for delineating and approaching the posterior bladder neck.
Posterior bladder neck and seminal vesicles dissection
Instruments used: Scissors (right arm), Maryland bipolar (left arm), ProGrasp (4th arm).
In this step, the ProGrasp (4th arm) holds the Foley catheter toward the pubic bone, applying upward traction on the prostate. In sequence, the posterior BN is accessed through a transverse incision, while the Maryland is used to provide countertraction. Special care is taken during this step to flatten the lateral aspects of the bladder before entering the posterior dissection to ensure ample exposure and adequate bladder neck width circumferentially. It is crucial to check the ureteral orifices’ (UOs’) location and anatomy before proceeding to the posterior dissection ( Fig. 13.3 ).
During the dissection, it is necessary to identify the musculofascial plate correctly, avoiding the wrong dissection into prostatic tissue. Vertical muscle fibers (retrotrigonal fibromuscular layer) are key landmarks in posterior bladder dissection because the incision of this tissue will expose fatty tissue until the seminal vesicle space. Then, after an appropriate dissection, the deferens and seminal vesicles are ligated at the tip using Hem-o-lok clips. Upon their release, the seminal vesicles are used as upward traction to enter the posterior plane through Denonvilliers’ fascia. It is crucial to minimize cautery energy in this step, especially during the seminal vesicle tip, to avoid damaging the posterior neural fibers.
Nerve sparing
Posterior dissection
Instruments used: Scissors (right arm), Maryland bipolar (left arm), ProGrasp (4th arm), scope (30 up).
The posterior dissection between the Denonvilliers’ fascia (DF) layers is a key step of our nerve-sparing (NS) technique. The DF comprises multiple layers of connective tissue created by the fusion between the posterior prostatic fascia and the seminal vesical fascia presenting an enormous interpatient variability in terms of tension and thickness. Laterally, it ends in the neurovascular bundles at the prostatic pedicles.
After incising the posterior fascia, we toggle the camera from 30 degrees down to 30 degrees up. The dissection of this plane encompasses dissecting between ( Fig. 13.4 A) the DF layers, which are visualized as a pearly white plane. Once we have dissected this avascular plane, we start preserving the neurovascular bundle (NVB) by accessing the prostatic fascia from 5 to 1 o’clock on the right side and 7 to 11 o’clock on the left side (see Fig. 13.4 B). During this step, as we previously described, we use the prostatic vasculature (prostatic artery) as landmarks to guide the nerve-sparing degrees of preservation. , The degrees of NS vary according to the tumor grade, tumor location, and neural bundle anatomy.
