Patient position and ports placement

Under general anesthesia, the patient is placed in lithotomy position at a steep Trendelenburg angle with padding of pressure points, similar to an RARP procedure. We use a bean bag for adequate patient positioning to the surgical table ( Fig. 17.1 ).

Patient Position on the Table.

An 18 Fr Foley catheter is inserted into the bladder and six ports are placed across the abdomen similar to RARP: the camera port just above the umbilical scar, three 8-mm arm ports, a 12-mm assistant port in the right flank, and a 5 mm for suction in the right upper quadrant ( Fig. 17.2 ). These surgical steps are similar in all surgical approaches we have adopted.

Port Placement for Robot-Assisted Simple Prostatectomy Procedure.

Transverse bladder neck incision

The prostate adenoma may be accessed in different ways. We initially described a 1 to 2.5 cm transverse incision in the anterior vesicoprostatic junction, ^, similar to the anterior bladder neck dissection performed in a RARP ( Fig. 17.3 ). This approach allows easy identification of ureteral meatus and allows the bladder mucosa to be sectioned in the plane of the adenoma and the prostate capsule. Most robotic surgeons are familiar with this anatomy due to prior experience with RARP. The major disadvantage of this approach is the need of a larger transverse incision for larger adenomas, risking injury of the neurovascular bundle laterally.

Transverse Incision in the Anterior Vesicoprostatic Junction.

In this case, the dorsal venous complex is being preserved.

Due to this limitation, we have evolved our transvesical access to a proximal midline cystotomy after the Retzius dissection, as also described by other authors. ^, This approach allows better access to larger adenomas without the risk of neurovascular bundle injury. The decision on which approach to use depends mainly on the surgeon’s personal experience, but these advantages and disadvantages should be taken into consideration ( Fig. 17.4 ).

Different Approaches to Accessing the Prostate Adenoma.

(A) Transcapsular, (B) horizontal cystostomy, (C) midline incision across the prostatic capsule and bladder neck, and (D) vertical cystostomy in bladder dome (transperitoneal view).

Dissection of prostate adenoma

The plane between the adenoma and the prostatic capsule is identified and incised over the posterior bladder neck; the adenoma is dissected using a combination of cautery, traction, and blunt dissection. This dissection should start posteriorly, preventing blood spillage from the anterior dissection into the posterior plane. The adenoma is then mobilized from the capsule anteriorly and laterally ( Fig. 17.5 ). Occasionally, a 0-polyglactin stay suture can be used for counter traction of the prostate adenoma during the dissection. Finally, the prostatic urethra is carefully sectioned, avoiding injury to the urinary sphincter, and the adenoma finally is removed. Two 2-0 poliglecaprone sutures are placed at 5 and 7 o’clock positions in the vesicoprostatic junction for additional hemostasis; however, this step is not mandatory if the surgeon has found the correct avascular plane. Hemostasis is revised and bleeding vessels are cauterized or ligated with absorbable sutures.

The adenoma is tractioned and its posterior plane is dissected.

Reconstruction: Advancement of the bladder neck mucosa or urethrovesical anastomosis

In the classical “trigonization” technique, the mucosa of the posterior bladder neck is then advanced to the distal urethral mucosa using two figure-of-eight 2-0 polyglactin sutures or using a continuous 3-0 poliglecaprone suture. The idea is to reapproximate the mucosa to reconstruct the anatomy of the prostatic fossa and promote hemostasis. We described a modified reconstruction technique which includes three surgical steps: plication of the posterior prostatic capsule, modified van Velthoven continuous UVA, and suture of the anterior prostatic capsule to the anterior bladder wall. In this approach, after the resection of the adenoma, the posterior capsule was plicated using two 12.5 cm 3-0 poliglecaprone sutures (on RB 1 needles) tied together. The proximal edge of the capsule was approximated to the distal capsule using one arm of the continuous suture. The posterior bladder neck was then sutured to the posterior urethra using the other arm of the suture. A continuous modified van Velthoven UVA was then performed. Two 20-cm 3-0 poliglecaprone sutures of different colors (on RB 1 needles) were tied together with 10 knots to provide a bolster for the anastomosis. The posterior part of the UVA was performed with one arm of the suture ( Fig. 17.6 ), in a clockwise direction, from the 5 to 9 o’clock positions. This step was followed by completion of the anterior anastomosis with the second arm of the suture, in counterclockwise fashion. ( Fig. 17.7 A–C shows needle pathway.) This modified technique of RASP has potential advantages: reduced blood loss, lower blood transfusion rates, shorter length of hospital stay, and no need for postoperative continuous bladder irrigation.

After plication of the posterior prostatic capsule, the posterior bladder neck is sutured to the posterior urethra.

Anterior Vesicourethral Anastomosis.

(A) Needle going to urethra, (B) needle transfixing anterior wall of urethra, (C) needle transfixing anterior bladder neck.

Closure

Usually, a 18 Fr two-way Foley catheter is placed into the bladder and the balloon is inflated with 20 mL of distilled water. Alternatively, the surgeons who practice the classical “trigonization” technique use a three-way Foley catheter insufflated in the prostatic fossa in order to further promote hemostasis; however, with our technique the prostatic fossa is totally plicated and reconstructed, precluding the need for this maneuver and the use of three-way catheters. After testing the suture with bladder repletion of 120 mL of saline solution and proving no leaking, no drain is required. The midline camera port incision is extended, and the specimen is extracted using an endobag. The aponeurosis is closed using a 0-polyglactin suture, and the skin is closed using a 4-0 poliglecaprone subcuticular suture. We do not use routinely continuous bladder irrigation as the prostatic fossa is “bypassed” by the anastomosis and the patients do not present any grade of hematuria in the early postoperative period.

Our current approach

We have recently changed our approach allowing quicker access to the adenoma without opening the Retzius space. Using the same patient position and port placement, we perform a transperitoneal approach. First, we perform a longitudinal cystotomy on the bladder dome; we then secure each bladder wall to the lateral peritoneum with a Hem-O-Lock ( Fig. 17.8 ), obtaining excellent straight access to the adenoma. After proper identification of the trigonal area, we incise the bladder neck mucosa posteriorly to the adenoma ( Fig. 17.9 ); the plane between adenoma and the prostatic capsule needs to be identified; from this plane, the adenoma is dissected circumferentially and apically using a combination of cautery, traction and blunt dissection ( Fig. 17.10 ). During the apical dissection, we identify and section the urethra, preserving the verumontanum ( Fig. 17.11 ). The adenoma is then removed and we have excellent exposure of the prostatic bed and urethra, allowing us to easily perform the UVA.

The Bladder Wall Being Repaired to the Lateral Peritoneum With Hem-O-Lok.

After incision of the mucosa, we started the posterior dissection of the adenoma.

The Circumferential Prostatic Adenoma Dissection.

Section of the Urethra During the Apex Dissection.

After hemostasis, we perform a continuous modified van Velthoven UVA using the 3-0 poliglecaprone sutures ( Fig. 17.12 ), covering the entire prostatic fossa with mucosa. Finally, a 18 Fr two-way Foley catheter is placed into the bladder; we unclip the Hem-O-Lock previously placed and close the longitudinal bladder incision using a continuous suture with a 3-0 polyglactin ( Fig. 17.13 ). Adenoma removal is performed with an endobag and Foley catheter is inflated with 20 mL of distilled water. We do not routinely leave a drain, nor is continuous bladder irrigation necessary, as the anastomosis promotes excellent hemostasis of the prostatic fossa.

The Urethrovesical Anastomosis Being Performed.

Bladder dome closure (A) and final aspect (B).

Extraperitoneal approach

This approach differs from transperitoneal RASP in the way of accessing the prostate. The surgeon begins with the creation of the preperitoneal space with digital dissection and balloon inflation.

Carefully, all trocars should be inserted without perforating the peritoneum. After that, a vesico-capsular incision is performed from the anterior wall of the bladder to the bladder neck; the adenoma dissection is similar to the transperitoneal approach, using traction and counter traction.

Disadvantages of this approach include mandatory drainage of the Retzius space and higher risk of injuring the epigastric vessels, compared to the transperitoneal approach. Also, the surgical field is narrower, and to optimize the Retzius dissection a balloon dilator device is usually employed, thereby increasing procedural costs. ^,

On the other hand, from the experience of comparative studies between different approaches of RARP, the extraperitoneal approach may prevent inadvertent bowel injuries, reduce postoperative pain and ileus, avoid the need of intraperitoneal adhesiolysis, and, in combination with a single port platform, may reduce the urethral catheter removal to the postoperative day one. ^{, ,}

Intrafascial simple prostatectomy

In 2013, Clavijo et al. reported the intrafascial simple prostatectomy. Similar to a radical prostatectomy, neurovascular bundles are preserved early in the intrafascial layer, and the prostate pedicle and deep DVC are divided and secured. In sequence, the urethra is sectioned, the seminal vesicle and vas deferens are cut at the prostate base and then sutured, and finally UVA is performed.

The authors defend that this technique offers some advantages such as: it eliminates the need for irrigation due to the absence of bleeding, facilitates the detection of prostate cancer and high-grade prostatic intraepithelial neoplasia, and prevents the development of prostate cancer or new prostate enlargement because it completely removes all prostatic tissue.

Although innovative, we believe this technique requires greater expertise from the surgeon and increases the unnecessary risk of erectile dysfunction during the treatment of a benign condition.

Single-port approach

The da Vinci Single Port (da Vinci SP) surgical system is an evolution in the miniaturization process of the robotic surgery platform.

Steinberg et al. were the first to report a series using this platform. In this series, a surgeon with extensive experience in RASP performed 10 extraperitoneal and transvesical procedures through the robotic cannula of the da Vinci SP system placed in a median vertical incision of 2.5 cm positioned two fingers below the navel. The results were encouraging, with an average estimated blood loss (EBL) of 141 ± 98 mL; the operative time (OT) was 172 ± 19 minutes, and the mean catheter time was 1.9 ± 1.8 days.

They have demonstrated that this method was safe, feasible, and effective. However, as an initial series, the OT was still longer than conventional multiport RASP (median 95 minutes reported by Autorino et al. ), probably due to the learning curve inherent to the novelty. Maybe, the greatest achievement brought by da Vinci Single Port in RASP is a smaller incision over the bladder resulting in a shorter period of catheter, allowing removal on the first postoperative day for most patients.

Robotic-total prostatectomy for low-risk prostate cancer patients with enlarged glands

Recently Pathak et al. reported 12 consecutive patients submitted to this novel technique developed by them, with similar trocars placement and patient positioning for RASP. They described the procedure through the transperitoneal approach, following bladder drop and with a complete circumferential bladder neck sparing.

Once the posterior bladder neck is identified, an incision is made two-thirds down or one-third above the traditional bladder neck ( Fig. 17.14 ), with the main premise of dissecting above Denonvilliers’ fascia sparing musculofascial plate, seminal vesicle, and ampulla of the vas deferens.

Anatomic Delineation of Robot-Assisted Laparoscopic Total Prostatectomy With 3D Reconstruction.

Then the prostate is dissected following the plane at the level of the pseudocapsule, the outer stromal edge of the prostate parenchyma. Thereafter, a complete circumferential anatomic UVA is performed. No continuous bladder irrigation is required. Hospital discharge occurs at the first postoperative day and Foley catheter removal at 1 week.

They included mainly patients with inconclusive but suspicious prostate biopsies (e.g., ASAP, HGPIN, negative biopsy with suspicious resonance). Final pathology demonstrated only one patient with HGPIN and all others had prostate cancer (ISUP 1 in seven patients; ISUP 2 in two and ISUP 3 in two), all with negative surgical margins. The mean postoperative PSA levels at 3 and 15 months (9/12 patients) were .03 (.006 to .07) and .04. No patients required additional treatment for LUTS. Only one patient developed stress urinary incontinence with no pad needed after 6 weeks postoperatively. Urinary continence and pad free status were achieved in all patients at the 3-month postoperative period. The SHIM score reduced, on average, 5.5 points compared to preoperative.