EDUCATION > Educational Programs > E-Learning > Urologic Robotic Surgery

Urologic Robotic Surgery Course

After completing this module, the learner should be able to:

  • Describe the surgical steps involved with the safe performance of robotic radical prostatectomy: the transperitoneal approach.
  • State the indications and contraindications for the transperitoneal robotic approach to radical prostatectomy.
  • Identify errors that can occur with the system during robotic surgery.
  • Describe the steps involved with safe operation of the daVinci Surgical System (Intuitive Surgery Inc, Sunnyvale, CA).
  • Describe complications that can occur during transperitoneal robotic prostatectomy and describe methods to avoid and manage the complications.

Authors

David I. Lee, MD
Division of Urology
Pennsylvania Presbyterian Medical Center
Philadelphia, PA
Disclosures: Intuitive Surgical: Meeting Participant or Lecturer;
Ethicon Endosurgery: Meeting Participant or Lecturer; Pfizer: Scientific Study or Trial; Johnson and Johnson Biopharmaceuticals: Scientific Study or Trial; Aureon: Meeting Participant or Lecturer

Mani Menon, MD
Vattikuti Urology Institute
Henry Ford Hospital
Detroit, MI
Disclosures: Nothing to disclose

UROLOGIC ROBOTIC SURGERY COURSE

Robotic Radical Prostatectomy: Transperitoneal Approach

Contents:

  1. Abstract
  2. Indications and Contraindications
  3. Pre-operative Work Up
  4. Patient Positioning
  5. Trocar Placement
  6. Bladder Mobilization
  7. Entering the Endopelvic Fascia
  8. Ligation of the Dorsal Venous Complex
  9. Bladder Neck Dissection
  10. Seminal Vesicle Dissection
  11. Posterior Dissection, Nerve-sparing Technique and Apical Dissection
  12. Outcomes of the Double Layer Urethrovesical Anastomosis
  13. Percutaneous Suprapubic Tube (PST) Drainage
  14. Exiting
  15. Post-operative Care
  16. Management of Intra-operative Complications
  17. Management of Post-operative Complications
  18. Tables
  19. Figures
  20. References

Abstract

The application of robotics has allowed the rapid penetration of minimally invasive prostatectomy into the United States.1 The first robotic Urology program in the world was started in 2001. Since then, robotic surgery, has changed the face of urological oncology, and is now extending to other disciplines. A significant majority of all radical prostatectomy cases in the US are now robot assisted minimally invasive procedures. This chapter will focus on techniques of robot assisted radical prostatectomy, from preoperative workup and preparation to management of complications. The technique is that used by David Lee, with comments and technical modifications by Mani Menon.

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Indications and Contraindications

Nearly any patient that can be considered for an open radical prostatectomy is a candidate for a robotic procedure. There are certain patient factors such as obesity, an enlarged prostate (>70g? >100g?), and previous abdominal surgery that will cause more difficulty. However, these factors are minimized with increasing surgeon experience. We believe in fact that obese patients and enlarged prostates are actually handled more easily robotically.

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Pre-operative Work Up

Following informed consent process, standard pre-operative laboratory work, urinalysis and culture, as well as an electrocardiogram, are ordered. Blood-thinning medication is halted appropriately. On the night before the surgery, the patient takes a dose of magnesium citrate. Pre-operatively, prophylactic antibiotics are administered and compression stockings are placed.

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Patient Positioning

The patient is placed on a bed that has either split leg positioners or Allen stirrups. The legs are split about 30 degrees away from each other and then rotated downward in relation to the bed also about 30 degrees (Figure 1 DL). This allows the patient side cart to be moved sufficiently close to the patient. The legs are very loosely wrapped with blankets and the arms are padded and tucked. The patient is then placed in a thirty degree Trendelenberg position. We do not typically use shoulder rolls, as tucking the arms and lowering the legs sufficiently anchors most patients from sliding.

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Procedure Step-by-Step

Trocar Placement

We prefer a Veress needle to obtain pneumoperitoneum however a Hasson approach is a reasonable alternative. Our port placement is shown in Figure 2 DL. It is our practice to precisely measure the distances for each port rather than estimating by hand width. We begin with a mark at the top border of the pubis in the midline and measure 15cm toward the umbilicus and place a second mark. These are the 2 white circles on the diagram. The medial robot ports are then triangulated from these 2 points 15cm away from the suprapubic dot and 8cm away from the umbilical. The lateral ports are then placed 8cm directly lateral to the 2 robot ports. The 5mm assistant port is then placed 8cm superolateral from the 12mm supraumbilical camera port. Difficulty with arm collisions can become greatly magnified if the trocar sites are too close together. Moreover, it is important for the bedside assistant to avoid inserting trocars thru adhesions, where inadvertent bowel injury might occur. If needed, laparoscopic adhesiolysis can be performed prior to trocar placement.

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Bladder Mobilization

In our experience, we perform the anterior approach, e.g. dissection of the seminal vesicles after the dissection of the bladder. Our lens preference is a zero degree lens at the outset. We prefer to use cautery scissors and bipolar graspers. Inspection of the peritoneum reveals the internal inguinal rings and the medial umbilical ligaments. The peritoneum is incised just lateral to the ligaments and carried laterally to a spot immediately anterior to each internal ring. Care must be taken to not injure the epigastric vessels. The two lateral incisions are carried along the ligaments medially and superiorly until they join in the midline.

As the bladder flap is created the whitish fibers of the transversalis fascia come into view. These fibers can be followed caudally; once these thin out the contour of the abdominal wall is followed inferiorly until the pubis is visualized. The pubis is cleaned of connective tissue and the fat medial to the arch of the pubis is bunched medially off the prostate toward the apex, excised and sent for pathologic examination. The superficial dorsal vein is contained within this fat and is divided with bipolar cautery. It is important to approach this step from lateral to medial; starting medially may result in bleeding if the superficial dorsal vein is inadvertently avulsed. Moreover, meticulous dissection is necessary to avoid damage to an accessory pudental vessel. Ligation of an accessory pudental artery may hypothetically affect post-operative sexual function.

MM. Comment: While the entire operation can be done with the 0 degree lens, we use the 30 degree lens looking upwards for this part of the dissection, and switch to the 30 degree down lens, once the bladder is taken down. The anastomosis is done with the straight lens. The depth of perception, particularly for dissecting around the vessels is greater with the 30 degree down lens, and the risk of smudging the lens is lower.

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Entering the Endopelvic Fascia

The fascia is sharply incised with cold scissors laterally to visualize the underlying prostate capsule and levator muscles (Figure 3DL). This incision should be initiated in the mid prostate and carried towards the apex of the prostate. This allows better visualization of the small vessels that may perforate the apex. With the apex clearly in view, the fascia overlying the DVC is thinned and the puboprostatic ligaments incised to define the junction between the vein and the urethra to prepare for division. It is important not to carry the dissection too medially, in order to avoid opening a large sinus. Excessive bleeding from this area could compromise vision for subsequent steps.

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Ligation of the Dorsal Venous Complex

The DVC can be handled by one of several methods. The most common are either suture ligation or stapling. At Penn, we prefer to staple the DVC using a laparoscopic tissue stapler. The stapler is introduced into the field through the lateral 12 mm port. From this angle the anvil portion of the stapler is placed on the contralateral side so that the black lines just pass the edge of the DVC (Figure 4DL). If there is any bleeding or if the staple line separates, a small figure of eight stitch with a 3-0 Vicryl will stop the remaining bleeding. Temporarily increasing the pneumoperitoneum to 20 mmHg can facilitate visualization until the bleeding is controlled.

MM. Comment: We do not incise the endopelvic fascia or ligate the dorsal vein at this stage, but approach the bladder neck first.

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Bladder Neck Dissection

The lens is then switched to a 30 degree down lens to provide a more familiar downward view of the prostatovesical junction. The Foley catheter is then slowly pushed in and withdrawn by the bedside assistant. Once the junction is identified, sharp dissection with either cautery or scissors is performed just cranial to the junction (Figure 5 DL). The dissection is carried from medial to lateral; if done carefully the large superficial veins coursing from the prostate to the bladder can be lifted off the underlying structures minimizing bleeding. The lateral junction between the prostate and the bladder is then visualized. The dissection is then carried from lateral to medial to thin out the attachment fibers. The bladder neck is open and the balloon of the Foley is deflated. The catheter is grasped through its eye with the 4th arm equipped and lifted anteriorly. The posterior lip of the bladder neck is left intact while the remaining lateral fibers attaching the bladder to the prostate are divided. This dissection can routinely be carried posterior to the bladder neck thereby preserving the circular fibers of the bladder neck, which may aid in early continence recovery. Careful attention is carried towards not entering the prostate, signs of which include white prostatic secretions and excessive bleeding. Finally the bladder neck is completely divided. At this point, it is essential to identify the ureteral orifices to avoid suturing over these structures during anastomosis.

MM comment: We have recently replaced the monopolar hook with the Harmonic Ace curved shears (Ethicon Endo-Surgery Inc., Cincinnati, OH, USA) at this stage of the procedure. This accounts for a subjective improvement in visibility and better hemostasis.

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Seminal Vesicle Dissection

Posterior to the bladder neck a whitish fibrous layer with longitudinal fibers should be noted. Once this layer is divided, the ampullae of the vas are identified. The plane in between the two vasa is developed. The vesicles can be grasped with the Prograsp robotic instrument and the entire length of the medial edge should be dissected bilaterally. Once this is performed, the vasa and adjacent vasculature can be clipped. Often very little dissection then needs to be performed laterally if the medial edge of the seminal vesicles and vasa have been clipped. Limited use of cautery is preferred for this step to avoid any deleterious effect on sexual function.

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Posterior Dissection, Nerve-sparing Technique and Apical Dissection

The stumps of the vasa are then grasped with the 4th arm and used to pull the prostate upward toward the pubis. Once proper traction is obtained, the posterior contour of the prostate is appreciated and the reflection of Denonvillier's fascia identified. Incising Denonvillier's fascia precisely minimizes any chance of injuring the rectum. The fascia is divided and the perirectal fat is pushed down away from the prostate. This plane should be relatively avascular and carried as distally and laterally as possible.

For a nerve-sparing procedure, we prefer the interfascial space. The lateral prostatic fascia is incised anteriorly around the mid prostate. Large lateral veins of the prostate are visualized and the plane lateral to these veins are dissected (Figure 6 DL). This plane is carried proximally toward the prostate pedicle. The pedicles are clipped with large Hemolok clips. Once the bulk of the pedicle has been divided, the remainderof the posterolateral plane opens up and the remaining bundle can be teased away with very little difficulty. It is important here to avoid excessive manipulation and/or traction, to avoid injuring the neurovascular bundles.

As the dissection is continued to the apex, one must be aware of the proximity of the rectum to the apex. Therefore, it is of great importance to maximize the posterior dissection BEFORE the lateral dissection is performed. Once the apex is reached, the anterior urethra is dissected. The urethra is incised with scissors and the Foley catheter is withdrawn until it is barely visible in the stump of the urethra. The 4th arm is then used to gradually rock the prostate back and forth to provide exposure for division of the posterior urethra and remaining rectourethral attachments. Once freed, the prostate can be examined under magnification to ensure that it has been removed in its entirety and there are no capsular incisions. It is then placed in an entrapment sac and deposited in the upper abdomen until the anastomosis is complete.

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Posterior Reconstruction and Urethrovesical Anastomosis

For reconstruction, we use a posterior plate reinforcing stitch or "Rocco stitch."3 A running self-anchoring barbed suture (V-Loc®, Covidien, Mansfield, MA) reapproximates the cut edge of Denonvillier's fascia and posterior bladder to the rhabdosphincter. This eases the performance of and reinforces the integrity of the anastomosis, but its benefit for continence is controversial.4 Our preference for the anastomosis is to use the Van Velthoven stitch.5 Two V-Locs are fashioned into a double-armed stitch by passing the needle of each suture through the loop of the second suture to make a single, double-armed suture with roughly 6" of suture on each side of the knot, for a total of 10-11" of barbs. Since the barbs lock into the tissues with each throw, no assistance or "following" is required. The suture is started by placing each arm of the suture outside in at the five and six o'clock position, respectively, of the bladder neck. We then run each arm of the suture counterclockwise and clockwise, respectively, at each point on the clock face until they meet at the 12 o'clock position. The transition suture is then passed at 12 o'clock outside-in on the urethra and passed inside out on the bladder neck. The catheter is passed into the bladder and the single knot of the anastomosis is tied. Irrigation is performed with 240 cc of saline via the Foley catheter. Upon completion of the anastomosis, the needles are cut without the need for tying a knot6 (Figure 1MM and Figure 2MM).

MM Comment: The biggest changes that we have made to our original operation are in the anastomosis and bladder drainage.

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Outcomes of the Double Layer Urethrovesical Anastomosis

We sought to determine the difference in early continence between the single-and double-layer (Rocco stitch) in a randomized trial.4 Patients were randomized to single layer or double layer technique. Early continence was defined as the proportion of patients using 0-1 pads in a 24-hour period and was assessed at one, two, seven and 31 days after catheter removal. At these time points, continence was 20 and 21%, 26 and 26%, 34 and 35%, and 63 and 77% for single layer and double layer, respectively. These differences were not statistically significant.

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Percutaneous Suprapubic Tube (PST) Drainage

Most patients complain about catheter discomfort after radical prostatectomy. If you are beyond your learning curve, and are satisfied with the integrity of the urethrovesical anastomosis, consider placing a percutaneous suprapubic tube (PST) rather than a Foley catheter. After completion of the urethrovesical anastomosis, its integrity is checked with intravesical instillation of 250 mL of sterile saline. Under robotic visualization, a 14F PST is placed through the anterior abdominal wall and held above the bladder. The bedside assistant places a non-absorbable suture on a straight needle through the skin adjacent to the PST, which is grasped by the console surgeon. The suture is passed through the full thickness of the bladder wall with a horizontal mattress suture and then advanced back through the anterior abdominal wall. The ST is then advanced into the bladder wall through the limbs of the horizontal mattress suture, as they are pulled up by the bedside assistant to maintain tension on the anterior bladder wall. Upon extraction of the specimen, the external suture is tied to the skin over a sterile plastic button to cinch the bladder to the anterior abdominal wall. The PST is drained to gravity until post-operative day 5 when it is clamped and patients are encouraged to void per urethra, measuring post-void residuals. After 48 hours of voiding with residuals less than 30 mL, the external suture is cut and the PST is removed (Figure 3MM).

We assessed catheter discomfort in the initial 202 patients undergoing this procedure using a visual analog scale (0 = no discomfort and 10 = agonizing discomfort). When compared with urethral catheter patients, PST patients had significantly decreased catheter-related discomfort on post-operative days 2 and 6 (p<0.001). Anticholinergic medication was required by one PST and four urethral catheter patients (p<0.001). Ten patients required urethral catheterization for PST dislodgement (n=5) or urinary retention (n=5). No patient has developed a urethral stricture at a mean follow-up of seven months.

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Exiting

The specimen retrieval bag string is placed totally into the abdomen under direct vision. The camera is then removed from the port and placed into the lateral 12mm port site. A laparoscopic needle driver is placed into the camera port site and the bag drawstring is removed from the abdomen. The string is clamped with a hemostat. The robot is undocked. The trocars are removed under direct vision to check for any bleeding. The specimen is removed by extending the incision of the camera port site to about 4 cm. The fascia is opened with cautery until the specimen can be retrieved, then closed with 0-Vicryl or 1-PDS . The port sites are closed with a subcuticular stitch of 3-0 or 4-0 Monocryl and the skin is closed with a skin adhesive.

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Post-operative Care

The orogastric tube is removed in the operating suite. Patients are prescribed ketorolac and morphine as needed for pain. Patients are encouraged to ambulate as soon as possible, usually within 6 hours of the returning to their hospital room. A clear liquid diet is instituted that is advanced to a regular diet by their next meal. Discharge is planned for the morning of post-operative day number one. Patients are seen back in one week for catheter removal.

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Management of Intra-operative Complications

Intraoperative complications include bleeding, injury to adjacent organs, and conversion to open surgery. Rectal injury is an ever-present danger especially in patients with a history of preoperative androgen ablation, radiation therapy, and cryotherapy. In cases of small rectal tears, primary closure in 2 layers can be performed. Copious irrigation of the pelvis and broad-spectrum intravenous antibiotics should be instituted. Large injuries might be handled with primary rectal repair and consideration of a diverting ileostomy or colostomy; open conversion may facilitate the repair. Likewise, small bowel injuries can be handled in a similar fashion. Ureteral injuries should be repaired primarily. If the injury is very low, then a ureteral reimplantation can be considered. Conversions for bleeding complications are exceedingly rare.

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Management of Post-operative Complications

Lymphoceles may present in the first few weeks after lymphadenectomy with either leg swelling or fever of unexplained origin. After imaging, this can be managed with a percutaneous drain placement. Bladder neck contractures are also exceedingly rare and can usually be managed with dilation. Deep venous thrombosis should be managed with anticoagulation.

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Tables

Table 1DL Summary of the major published series in a table with a brief description of overall results.

Series

Cases

Margin
Rates

PSA
Recurrence

Continence

Potency

Badani,
et al 7

2766

pT2 = 5%
last 200 cases

8% at 5 years

93% with 0 pad or security pad
at one year

79% successful intercourse for preop
SHIM >17

Ahlering, et al 8

782

7.4% overall,
pT2 = 3.1%

N/A

89% with 0 pads by one year, 100% with cooling

90% by 24 months for preop SHIM >22

Lee 9

1800

11% overall last 500 cases,
pT2 = .5%

N/A

80% with 0 to 1 pad by 3 months

80% by 18 months for preop SHIM > 22

Shikanova,
et al 10

380 analyzed of 1362 patients

17.5% overall

9% at 24 months

98% at 24 mths (80% objective)

93% at 24 months
(69% objective)


Table 2DL

Instrumentation

Non-disposable
Standard laparoscopy tray
Hem-o-lok clips, large (Teleflex Medical, Research Triangle Park, NC)
Bariatric laparoscopic suction tip (45cm shaft length)

Disposable
Robotic instrumentation (Intuitive Surgical, Sunnyvale, CA)
Large needle drivers (2), Prograsp, Permanent spatula cautery, Cautery scissors, Maryland Bipolar Grasper
Laparoscopic entrapment sac (various manufacturers)
Laparoscopic tissue stapler (Ethicon Endo-surgery, Cincinnati, OH and Covidien, Mansfield, MA)
Electrolube (Eagle Medical, Austin, TX)

Optional
EnSeal Bipolar Surgical System (Ethicon Endo-Surgery, Cincinnati, OH)
Scope warmer (OR Solutions, Chantilly, VA)

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Figures

Figure 1DL Patient positioning for robot prostatectomy. Note the Trendelenberg position with a Mayo stand across the patient's face to protect from dislodgement of the endotracheal tube.

Patient Preoperative Preparation.

Figure 2DL Port positioning. Meticulous attention must be paid to ensure proper spacing and precise trocar placement.

Trocar Placement.

Figure 3DL Endopelvic fascia dissection. Avoidance of cautery in the area is likely prudent. In the proper plane there are very few significant vessel and the neurovascular bundle is very close by.

Entering the Endopelvic Fascia.

Figure 4DL Stapler on dorsal venous complex. The stapler provides excellent hemostasis and is rapid and reliable.

Ligation of the Dorsal Venous Complex.

Figure 5DL Bladder neck dissection. Note the catheter coming into view. Careful dissection in the area can define an avascular plane that leads to the bladder neck.

Bladder Neck Dissection.

Figure 6DL Lateral prostate vein. This is a useful landmark for safe nerve sparing where an interfascial plane is desired.

Posterior Dissection, Nerve-Sparing Technique and Apical Dissection.

Figure 1MM Barbed wound closure device (Suture). Close up view showing the unidirectional barbs.

Barbed wound closure device (Suture). Close up view showing the unidirectional barbs.

Figure 2MM Double armed anastomotic suture created by passing the needle of each suture through the loop of the other suture.

Double armed anastomotic suture created by passing the needle of each suture through the loop of the other suture.

Figure 3MM Percutaneous Suprapubic Tube placement. Left - showing placement of PST after placement of 2-0 polypropylene holding stitch in bladder. Right – Fixation of the PST on the skin using a polypropylene button.

Percutaneous Suprapubic Tube placement. Left - showing placement of PST after placement of 2-0 polypropylene holding stitch in bladder. Right – Fixation of the PST on the skin using a polypropylene button.

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References

  1. Abbou, C. C., Hoznek, A., Salomon, L. et al.: Laparoscopic radical prostatectomy with a remote controlled robot. J Urol, 165: 1964, 2001.
  2. Menon, M., Shrivastava, A., Bhandari, M. et al.: Vattikuti Institute prostatectomy: technical modifications in 2009. Eur Urol, 56: 89, 2009.
  3. Rocco, B., Gregori, A., Stener, S. et al.: Posterior reconstruction of the rhabdosphincter allows a rapid recovery of continence after transperitoneal videolaparoscopic radical prostatectomy. Eur Urol, 51: 996, 2007.
  4. Menon, M., Muhletaler, F., Campos, M. et al.: Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (robotic) prostatectomy: results of a 2 group parallel randomized controlled trial. J Urol, 180: 1018, 2008.
  5. Van Velthoven, R. F., Ahlering, T. E., Peltier, A. et al.: Technique for laparoscopic running urethrovesical anastomosis:the single knot method. Urology, 61: 699, 2003.
  6. Kaul, S., Sammon, J., Bhandari, A. et al.: A Novel Method of Urethrovesical Anastomosis during Robot Assisted Radical Prostatectomy using a Unidirectional Barbed Wound Closure Device: Feasibility Study and Early Outcomes in 51 Patients. J Endourol, in print, 2010.
  7. Badani, K. K., Kaul, S., Menon, M.: Evolution of robotic radical prostatectomy: assessment after 2766 procedures. Cancer, 110: 1951, 2007.
  8. Finley, D. S., Osann, K., Chang, A. et al.: Hypothermic robotic radical prostatectomy: impact on continence. J Endourol, 23: 1443, 2009.
  9. Lee, D.: Robotic prostatectomy: what we have learned and where we are going. Yonsei Med J., 50: 177, 2009.
  10. Shikanov, S. A., Zorn, K. C., Zagaja, G. P. et al.: Trifecta outcomes after robotic-assisted laparoscopic prostatectomy. Urology, 74: 619, 2009.

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Status
Module 2 Prostate: Transperitoneal Posttest Available 1.50 credits/hours

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