Contents
10.1 Installation and Robot Connection . . . .144 10.2 Robotic Radical Extraperitoneal
Prostatectomy . . . 147 References . . . 159
Extraperitoneal Robotic Radical
Prostatectomy: – Operative Technique – Step by Step
Hubert John ∙ Matthew T. Gettman
10
10
delenburg position and is more comparable to the standard open retropubic radical prostatectomy. This chapter demonstrates step by step the extraperitoneal technique that has been used since 2002 by the first author and performed now in over 400 cases [7]. The transperitoneal access is chosen only after laparo- scopic hernia repair with preperitoneal mesh implant, after kidney transplantation or further extensive ret- roperitoneal surgery.
The access is similar to the technique described in Chap. 7. A short oblique subumbilical incision of 3–
peritoneal space (Tyco®). The balloon is filled 10–15 times until the extraperitoneal space is appropriately created. Balloon dilation must be performed carefully to avoid bladder rupture, which has been known to occur in cases of overdilation. The camera trocar (Ethicon, 12 mm) is then inserted via the subumbili- cal incision. An inspection of the extraperitoneal space is performed. Under direct vision, the camera can be used to increase the size of the extraperitoneal space by gently sweeping the peritoneal borders to the side and upwards.
10.1 Installation and Robot Connection
The 8-mm bilateral robot trocars are placed pararectally and two 10-mm standard trocars (Versaport®, Ethi- con) just anteromedial of the iliac spine (left). In procedures with only one assistant, the left-sided standard 10-mm trocar may be replaced by a 5-mm multiuse trocar, which is positioned between the right- sided robot trocar and the camera (right).
Chapter 10 145 Extraperitoneal Robotic Radical Prostatectomy
The 0° 3D endocamera is introduced (left). The abdominal wall is slightly lifted by the camera arm trocar (“laparo-lift”).
The left arm is brought to the left robot trocar and attached (right).
The right arm is also connected and the instruments (bipolar forceps on the left side and round-tip scissors on the right) are inserted under visual control (left). The bipolar cable is attached onto the forceps.
Before starting with the operation, always ensure the lower extremities are not compressed by the robotic arms (right).
10
The instruments allow wrist-like instrument movement (Endo-wrist®-technology). We use the bipolar hemostatic forceps (a), a round-tip scissors (b) and two needle holders (c).
The table-side assistants are comfortably installed (left). They assist with an aspirator (right 10-mm trocar), laparoscopic grasper, laparoscopic scissors and clip appliers.
The console surgeon leaves the operating table after port placement and is not sterile scrubbed during radical prostatectomy (right).
Chapter 10 147 Extraperitoneal Robotic Radical Prostatectomy
The entire radical prostatectomy is performed by the operating urologist from the remote console (left).
He controls the robotic arms at the console (camera, working channels, additional fourth arm if installed).
The console surgeon controls the interchangeable instruments attached to the two working robotic arms (right). They are felt as direct extensions of his arms and fingers.
10.2 Robotic Radical Extraperitoneal Prostatectomy
If the preperitoneal space is completely developed, the anterior prostatic surface and the endopelvic fascia are exposed and the fatty tissue overlying these structures is gently swept away.
10
If the endopelvic fascia is freed from the fatty tissue, it is incised from the prostatovesical junction to the apex of the prostate. Fibers of the levator ani muscle are swept off laterally until the entire lateral aspect of the pros- tate is visible.
The puboprostatic ligaments are incised to expose the prostatic apex and the urethra.
Chapter 10 149 Extraperitoneal Robotic Radical Prostatectomy
Fibers of the rhabdosphincter are swept distally to the pelvic floor.
Control of the dorsal vein plexus is achieved by a simple or a figure-of-eight ligation. For this we use a 0 Vicryl suture with a slightly straightened MH+ needle.
Radical prostatectomy is performed in a descending fashion starting with the incision of the ventral bladder neck. If necessary, the bladder neck can easily be identified by gentle traction on the catheter. The anterior bladder neck is separated from the prostate by blunt and sharp dissection.
10
As soon as the urethra is opened, the Foley catheter is grasped by the assistant. Upward traction on the cath- eter permits the prostate to likewise be rotated upwards and ventrally, thereby optimizing exposure of the dorsal structures.
The dorsal bladder neck is incised and the dissection continues in strictly posterior direction until the vas deferens become visible.
Chapter 10 151 Extraperitoneal Robotic Radical Prostatectomy
The vasa deferentia are dissected and the seminal vesicles exposed.
We cut the seminal vesicles leaving their tips in place if PSA is <10 ng/ml and Gleason score <7, in order not to injure the neurovascular bundles, which pass in very close proximity to the seminal vesicle tips and are more likely to be damaged by the added tension that has to be exerted during full dissection of the seminal vesicles [8, 9].
10
The fascia of Denonvilliers is then opened.
The posterior prostate surface is lifted from the perirectal fat.
Chapter 10 153 Extraperitoneal Robotic Radical Prostatectomy
No cautery is used in the further dissection of the prostate along the neurovascular bundles. Hemostasis is achieved by clips if this is necessary.
In a nerve-sparing prostatectomy we allow slight bleeding at this stage since it does not interfere with precise preparation and the danger of nerve injury is further reduced. The dissection of the prostate continues in the plane on the periprostatic fascia on both sides towards the apex.
10
Dissection is continued towards the anterior surface of the prostate. Next, the dorsal vein complex is tran- sected.
The apex of the prostate is meticulously dissected.
Chapter 10 155 Extraperitoneal Robotic Radical Prostatectomy
The urethra is exposed and apical prostate tissue retracted to minimize the risk of positive margins.
The urethra is opened anteriorly and the catheter becomes visible. The catheter is pulled back into the urethra to facilitate posterior urethral dissection. The rest of the urethra is then transected just distally to the prostatic apex.
10
The anastomosis is performed in dorsal to ventral direction, using 2-0 Vicryl sutures with a UR-6 needle.
The first stitch is placed at the posterior bladder neck. An adequate distance from the bladder neck is warranted to create a stable posterior plate. Care must also be taken, however, to avoid injury to the ureteral orifices.
Chapter 10 157 Extraperitoneal Robotic Radical Prostatectomy
We usually place six to eight interrupted sutures to complete the anastomosis. Before the anastomosis is fin- ished, a 20-F Foley catheter is introduced across the anastomosis and into the bladder. Alternatively, the anastomosis can be performed in similar running fashion using 2-0 Vicryl or Monocryl suture.
If the bladder neck is widely patent, the bladder neck can be plicated anteriorly with 2-0 Vicryl suture in run- ning fashion.
10
Through the new Foley catheter, 200 ml of saline is filled into the bladder to check the anastomosis for watertightness.
The specimen is placed in a specimen-retrieval bag and extracted through the subumbilical incision.
A suction drain is placed through one of the lateral trocars.
Chapter 10 159 Extraperitoneal Robotic Radical Prostatectomy
The instruments and the robot are removed. The incisions are closed in two layers. The drainage is removed within 24 h, as is the intravenous access.
References
1. Raboy A, Ferzli G and Albert P (1997) Initial experience with extraperitoneal endoscopic radical retropubic pros- tatectomy. Urology. 50: 849–53
2. Bollens R, Vanden Bossche M and Roumeguere T (2001) Extraperitoneal laparoscopic radical prostatectomy. Re- sults after 50 cases. Eur Urol. 40: 65–9
3. Hoznek A, Antiphon P, Borkowski T, Gettman MT, Katz R and Salomon L (2003) Assessment of surgical technique and perioperative morbidity associated with extraperito- neal versus transperitoneal laparoscopic radical prostatec- tomy. Urology. 61: 617–622
4. Dubernard P, Benchetrit S and Chaffange P (2003) Pros- tatectomie extra-péritoneale rétrograde laparoscopique (P.E.R.L) avec dissection première des bandelettes vascu- lo-nerveuses érectiles. Technique simplififée - à propos de 100 cas. Prog Urol. 13: 163–74
5. Stolzenburg JU, Truss MC, Do M, Bekos A, Stief C and Jonas U (2003) Evolution of endoscopic extraperitoneal radical prostatectomy (EERPE)--technical improvements and develpment of a nerve-sparing, potency-preserving approach. World J Urol. 21: 147–152
6. Gettman MT, Hoznek A, Salomon L, Katz R, Borkowski T, Antiphon P, Lobontiu A and Abbou CC (2003) Laparo- scopic radical prostatectomy: description of the extraperi- toneal approach using the da Vinci robotic system. J Urol.
170: 416–9
7. John H, Engel N, Brugnolaro C, Muentener M, Strebel R, Schmid DM, Hauri D, Jaeger P (2006) From standard lapa- roscopic to robotic extraperitoneal prostatectomy: evolu- tion in 350 cases. Eur Urol 5:52
8. John H, Hauri D, Maake C (2003) Impact of seminal vesi- cle-sparing radical prostatectomy on postoperative serum PSA. BJU Int 92:920–923
9. John H, Hauri D (2000) Seminal vesicle-sparing radical prostatectomy: a novel concept to improve early urinary continence. Urology 55:820–824
