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

Ahmed Ghazi, MD
Urology Department
Strong Memorial Hospital
University of Rochester Medical Center
Rochester, NY
Disclosures: Nothing to disclose

Jean Joseph, MD, MBA
Professor, Department of Urology
Professor – Cancer Center
School of Medicine and Dentistry
University of Rochester Medical Center
Rochester, NY
Disclosures: Nothing to disclose

UROLOGIC ROBOTIC SURGERY COURSE

Robotic Radical Prostatectomy: The Retroperitoneal Approach

Contents:

  1. Indications
  2. Contraindications
  3. Preoperative Assessment
  4. Preoperative Care
  5. Instrumentation
  6. Surgical Steps
  7. Complications & Management
  8. Troubleshooting During Extraperitoneal RARP
  9. Results
  10. Conclusions
  11. Figures
  12. References

Indications

The indications of robot-assisted laparoscopic radical prostatectomy are exactly the same as for laparoscopic radical prostatectomy and the open procedure. The extraperitoneal approach is most suitable for patients where avoidance of the abdominal cavity is desirable. Patients with prior abdominal surgeries, with internal scarring are excellent candidates for the extraperitoneal approach. There is no need for lysis of adhesions with the associated risks of bowel or intraabdominal injuries. It is also an excellent approach in patients with conditions that preclude a steep Trendelenburg positioning. With the peritoneum serving as a natural retractor, keeping the bowels out of the operative field, there is no need for any significant Trendelenburg positioning.

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Contraindications

Anesthetic contraindications

There are no specific anesthetic contraindications to the robot-assisted procedures. Contraindications for the extraperitoneal approach are the same as for all laparoscopic procedures. High intracranial pressure remains an absolute contraindication to a laparoscopic approach. Other conditions such as severe emphysema, chronic respiratory disease, glaucoma, history of stroke, or cerebral aneurysm are relative contraindications for the transperitoneal approach. For the extraperitoneal approach, however given the low degree of Trendelenburg position required, these conditions are less prohibitive.

Anatomic contraindications

The extraperitoneal space can be quite difficult to develop in patients with prior laparoscopic extraperitoneal mesh inguinal hernia repair. In this setting the extraperitoneal space is virtually obliterated due to the intense inflammatory reaction from the mesh. Tearing of the peritoneum can result in communication of the two spaces at which case it may be best to perform a transperitoneal procedure.

There are no specific anatomic contraindications to a robot assisted approach, however there are potentially challenging cases. One should always keep in mind that in robot assisted or laparoscopic surgery, conversion to open surgery may be a necessity rather than a failure.

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Preoperative Assessment

The clinical stage, and Gleason score dictate whether a nerve sparing operation is performed. Patients are routinely examined under anesthesia to allow a thorough palpation of the prostate to identify nodules or irregular areas which may require a wide resection. Imaging studies such as pelvic CT or MRI, and bone scan are performed in patients with high volume, high grade cancers, or at risk of metastatic disease.

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Preoperative Care

Patients are admitted to the hospital 90 minutes prior to surgery. A bowel preparation is self administered the day before surgery, which include a clear liquid diet, 8 ounces of magnesium citrate, 1 gm neomycin 3 times daily and 500 mg metronidazole 3 times daily. One hour before surgery intravenous cephalosporin or clindamycin in penicillin allergic patients and enoxaparin subcutaneously are administered. General anesthesia is administered, followed by placement of an orogastric tube.

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Instrumentation

Non-disposable

  • da Vinci surgical system (Intuitive Surgical Inc.) with: four arms
  • 0 & 30 degree binocular telescope
  • EndoWrist PK dissecting forceps or Maryland bipolar graspers
  • EndoWrist Prograsp forceps
  • EndoWrist monopolar scissors
  • Two EndoWrist needle drivers (1 suture cut device)
  • Three 8 mm robotic trocars

Disposable

  • Two 12 mm, long (150mm), smooth Laparoscopic trocars
  • One standard 5mm Laparoscopic trocar
  • Balloon dilator trocar (OMS-XB2 ExtraviewTM or Spacemaker)
  • Suction/irrigation device
  • Laparoscopic grasper
  • Fan retractor (Karl Storz, Germany)
  • Hem-o-lok clip applier (Weck, Teleflex Medical, Research Triangle Park, NC)

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Surgical Steps

Patient Positioning

Following administration of general anesthesia the patient is secured on the operating table in a supine position using padded chest straps. A split leg table is used, with the buttocks positioned on the edge of the table to allow access to the rectum and perineum (Figure 1). After ensuring adequate functioning of intravenous and other monitoring lines, the patient's arms are adducted and placed in protective foam on his sides. The legs are abducted, with care taken to avoid overextending the hips, to allow subsequent placement of the surgical cart. After the abdomen and genitalia are prepped and draped, an 18 Fr Foley catheter is inserted in the bladder. Once the bladder is fully drained the patient is placed in mild Trendelenburg position (less than 10 degrees).

Accessing the Extraperitoneal Space

A 3 cm paraumbilical incision is made lateral to the umbilicus and dissected down to the anterior rectus sheath with the help of two "S" retractors. A 1-cm incision is made directly over the fascia, the muscle fibers are separated to facilitate visualization of the posterior rectus sheath. Exposure of the sheath is facilitated by repositioning of the "S" retractor into the fascial opening for insertion of a balloon dilator (OMS-XB2 ExtraviewTM or a spacemakerTM) in the extraperitoneal space (Figure 2). Under direct vision via a 0 degree scope through the balloon (Figure 3), the tip of the balloon is guided to the pubic symphysis, and brought across the contralateral side below the arcuate line (Figure 4). Insufflation begins with the assistant slowly squeezing the accompanying pumping device. The rectus muscle is visualized anteriorly. The white posterior rectus sheath, or yellow perivesical fat is seen posteriorly. The epigastric vessels are visualized under the rectus muscles anteriorly (Figure 5). Slow inflation helps minimize tearing of small perforating vessels. Bleeding may occur if the balloon dilator dissects in a plane anterior to the epigastric vessels or pushes them laterally. This can occur if the balloon dilator dissects unevenly. Application of pressure on the balloon dilator can be necessary, to ensure that the balloon dilator distends evenly across the lower abdomen.

Trocar Placement

Once balloon dissection is complete, the balloon is replaced by a 150mm long, smooth trocar (10/12 mm 512 XD, Ethicon Endo-Surgery, Cincinnati, Ohio). Peumo-retroperitoneum is maintained by carbon dioxide insufflation at 12-15mmHg. The beveled tip of the long trocar is used to dissect the extraperitoneal space more lateral and cephalad to allow adequate spacing between the trocars and avoid robotic arms collision, or interference with the assistant ports. We maintain a minimum of 10 cm distance between the trocars and therefore additional space to the balloon dissection is required to accommodate a 5 or 6-port configuration for 4-arm robotic prostatectomy. Tunneling of the trocar should be avoided as it may limit instrument mobility. The trocars are placed under vision, using a laparoscopic scope as opposed to the daVinci scope. The latter is much heavier and can be difficult to manipulate while creating the space. The following trocar configuration is used (Figure 6):

Surgeon Trocars

  • Type: Three 8 mm daVinci trocars
  • Position:
    • 2 primary working trocars; lateral to the epigastric vessels, 10 cm caudal to the umbilicus, forming a triangle with the initial access trocar (Figure 7).
    • 1 for 4th arm; along the umbilical line, about 5 cm medial to the anterior superior iliac spine.
  • Function:
    • The primary working trocars are used for the scissors and bipolar forceps; or needle holders during suturing.
    • The third 4th arm trocar is used for placement of the Prograsp forceps, which is used for retraction.

Assistant Trocars

  • 2 standard laparoscopic trocars (5 x 100 mm 355 LD, and a 10/12 x 150, 512 XD)
  • Position & Function:
    • The 5 mm trocar is placed about 5 cm lateral to the umbilicus; used for placement of the suction/irrigation device.
    • The 150 mm trocar is placed about 5 cm medial to the anterior superior iliac spine. It is used for clip placement, retraction, and suture/needle passage into the extraperitoneal space. This trocar is long enough, to bridge over the peritoneum, as the latter crosses over the iliac vessels to the inguinal ring (Figure 8).

Once the trocars are in place the robot is docked to complete the procedure.

Endopelvic Fascia

  • Right arm: Endowrist Maryland bipolar graspers
  • Left arm: EndoWrist monopolar scissors
  • Assistant trocar: Suction device

Loose fatty tissues are easily swept off the fascia with all vessels cauterized to ensure hemostasis. The fascia is first opened along the midportion of the prostate. This is generally avascular and can be done without cautery. The incision extends from the puboprostatic ligaments down to the base of the prostate (Figures 9, 10).

Dorsal Vein Ligation

  • Right arm: Endowrist needle driver
  • Left arm: Suture cut or regular EndoWrist needle driver
  • Assistant trocar: Suction device

Delicate dissection of the dorsal vein posterior to the puboprostatic ligament exposes a notch between the prostate apex and dorsal vein. A 2-0 Polygalactin suture on an SH needle is passed from right to left parallel to the urethra into this notch (Figure 11).

Dissection of the Bladder Neck

  • Left arm: Endowrist Maryland bipolar graspers
  • Right arm: EndoWrist monopolar scissors
  • 4th arm: EndoWrist Prograsp forceps (retract the bladder neck in a posterocephalad direction, exposing the plane between the bladder and prostate)

The loose fatty tissue crossing over the bladder neck can be easily removed to facilitate visualization of the bladder neck. The anterior and posterior bladder necks are transected. The funnel of the bladder neck should be followed to maintain the proper plane (Figure 12). In nerve sparing procedures, the dissection should not be carried out too lateral, since it can lead to injury of the neurovascular bundles. The plane between the bladder neck and prostate can be followed posteriorly, with the posterior bladder neck dissection. Care should be taken not to inadvertently place a hole in the posterior bladder, risking injury to the ureteral orifices. The 4th arm can be used to either retract the bladder cephalad, or the Foley catheter anteriorly.

Dissection of the Seminal Vesicle

  • Left arm: Endowrist Maryland bipolar graspers
  • Right arm: EndoWrist monopolar siccors
  • 4th arm: EndoWrist Prograsp forceps (retract the vas deferens)
  • Assistant trocar: suction device, or a grasper to help retract the bladder cephalad

Following transection of the bladder neck, the longitudinal muscle fibers crossing posteriorly can be easily visualized. These are transected in the midline to allow visualization of the underlying seminal vesicles. The vas is grasped and dissected cephalad, until it courses laterally. It is clipped en bloc with the adjacent artery to the vas (Figure 13). The seminal vesicle is retracted upward, with visibly entering vessels clipped. Since there are no attachments to the seminal vesicles posteriorly, the bipolar forceps can be used to push Denonvilliers' fascia posteriorly, leading to complete visualization of the seminal vesicles. Energy avoidance is recommended near the tip of the seminal vesicles in nerve sparing cases, to avoid damage to the neurovascular bundles.

Dissection of Prostatic Pedicles and Neurovascular Bundles

  • Left arm: Endowrist Maryland bipolar graspers
  • Right arm: EndoWrist monopolar scissors
  • 4th arm: EndoWrist Prograsp forceps (lifting both ampulla anteriorly, tenting the posteriorly located Denonvilliers' fascia)
  • Assistant trocar: suction device, or a grasper to help retract the bladder cephalad. Also used for clip insertion

A transverse incision of the Denonvilliers' fascia exposes the yellow perirectal fat (Figure 14). The plane between Denonvilliers' fascia ventral to the rectum and the prostatic fascia dorsal to the prostate base is easily developed bluntly using the bipolar forceps, caudally to the level of the prostate apex. We prefer an interfascial dissection in nerve sparing cases to limit the risk of positive surgical margin. The neurovascular bundles are spared between the endopelvic fascia and the periprostatic fascia. In extrafascial dissection, or for procedures requiring wide dissection, Denonvilliers' fascia is left attached to the prostate. In nerve sparing procedures, a combination of antegrade and retrograde dissection of the neurovascular bundles is carried out. The dissection is first started at the prostate base posteriorly, to identify the periprostatic fascia. Using the 4th arm the prostate is pushed medially, opposite to the neurovascular bundles being dissected. The neurovascular bundles coursing posterolateral to the prostate to enter the pelvic diaphragm are identified. The plane between the vessels and the periprostatic fascia is entered, with care taken not to perform a capsulotomy. The vessels are pushed posterolaterally, until entry into the previously dissected plane posterior to the prostate, over the rectum. The vessels and nerves entering the prostate are selectively clipped, while preserving the neurovascular bundles
(Figures 15, 16).

Dissection of the Apex and Urethra

  • Left arm: Endowrist Maryland bipolar graspers
  • Right arm: EndoWrist monopolar scissors
  • 4th arm: EndoWrist Prograsp forceps (retracting the prostate in a posterocephalad direction)
  • Assistant trocar: suction device, or a grasper to help retract the bladder cephalad

The ligated dorsal vein is transected sharply down to the longitudinal urethral fibers. Extreme posterior traction may cause to suture to slip off. Should this occur, the dorsal vein can be oversewn without difficulty. Venous bleeding is diminished by elevating the pressure temporarily to 20 mm Hg. Once the dorsal vein in transected, the urethra is transected sharply, while ensuring a clear margin on the prostate. The posterior prostate often extends more caudally than the anterior aspect. The transection should follow the contour of the apex, to avoid transecting through prostatic tissue. The neurovascular bundles, if spared, should be inspected, or further dissected from the prostate apex to avoid injury. All remaining attachments are transected sharply. The prostate is placed in an entrapment bag, with the string pulled though the assistant's trocar, and retracted out of the operative field. The prostate fossa is then inspected, and hemostasis insured.

Posterior Reconstruction and VesicoUrethral Anastomosis

  • Left arm: Endowrist or suture cut needle driver
  • Right arm: EndoWrist needle driver
  • 4th arm: EndoWrist Prograsp forceps
  • Assistant trocar- Suction Irrigation device

Posterior reconstruction involves connecting the posterior rhabdosphincter to Denonvilliers' fascia using two to three interrupted 2-0 Polygalactin sutures. We include the longitudinal fibers posterior to the bladder (which was previously covering the seminal vesicles) in this suture
(Figure 17). This step helps brings the bladder neck close to the urethra, facilitating the vesicourethral anastomosis. Two separate sutures are used for the anastomosis. The first suture is used to complete the posterior wall of the anastomosis in a clockwise direction from the 5 o'clock to the 11 o'clock position. The second suture is used for the anterior layer which is completed in the opposite direction. A catheter is used to allow urethral visualization (Figure 18). Before tying the anterior anastomotic suture, a 20 Fr catheter is passed under vision into the bladder (Figure 19). Using two separate sutures, relying on a single knot is avoided. To facilitate tying the initial knots the pressure may be lowered to 8-10 mm Hg. This also helps with identification of potential bleeders being compressed by the higher pressure.

Completion of Procedure

Once the procedure is complete, the surgical cart is disconnected from the patient. The working trocars adjacent to the epigastric vessels are removed under vision, inspecting their entry site, ensuring hemostasis. The remaining lateral trocars are also removed. The anterior rectus sheath opening is enlarged to allow removal of the specimen which is later closed with 0 Polygalactin interrupted sutures. The skin incisions are closed using 4-0 monocryl subcuticular sutures.

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Complications & Management

COMPLICATIONS

TREATMENT

INTRAOPERATIVE

 

Rectal injury

Pelvic wash
Double layer suture (not overlapping)
Perioperative antibiotics

Ureter injury

Intraoperative repair
Stent placement

EARLY PO (<1mth)

 

Urinary retention

Catheterization for 7 days

Anastomosis leak

Prolong catheter for 7 days

Hematoma

Conservative or Evacuation

Urinoma/ pelvic abscess

Conservative
Percutaneous (PC) drainage

Lymhocele

PC drainage +/- sclerotherapy

Obturator nerve injury

Conservative

LATE PO (>1mth)

 

Urethral stricture

Dilatation
Visual internal urethrotomy

Bladder neck contracture

Dilatation
Resection of the bladder neck

Inguinal hernia

Surgical repair


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Troubleshooting During Extraperitoneal RARP

Problem

Points to consider

Technical tips for solution

Loss of the extraperitoneal space

The peritoneal tear may either be apparent or peritoneal thinning may transmit gas with no obvious breech

Intraperitoneal decompression by a transperitoneal 5mm trocar or a Veress needle for intermittent or continuous venting of the peritoneum.

Injury of the Epigastric vessels

Usually due to excessive balloon dissection

Avoid overstretch of the vessels during balloon dilatation. If injured control with clips, electrocautery or fascial closure device from the anterior abdominal wall.

Prior intraabdominal surgery

 

Begin dissection away from old scars and delay scarred areas to the last to avoid peritoneal violation.

Subcutaneous emphysema

The fascial layers are not as air tight as the peritoneum

Avoid by placing a purse string suture around the port site or the use of a balloon occlusion trocar.

Difficult approximation of the bladder neck and urethral stump

 

The following maneuvers may help:
- perineal pressure
- posterior reinforcing suture
- lowering the pressure to 8-10mmHg

Lymphocele

Due to loss of contact with the absorptive peritoneal surface

Meticulous clipping during lymph node dissection minimizes the risk

Balloon rupture

May cause peritoneal laceration

- Careful inspection of balloon for missing fragments
- Inspection of both extra and intraperitoneal space, if necessary for missing fragments


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Results

Robot assistance was first utilized during an extraperitoneal laparoscopic prostatectomy in 2003, with 4 cases performed in Creteil, France 1. In 2003, after prior experience with laparoscopic extraperitoneal prostatectomy, we converted from a pure laparoscopic to a robot assisted approach. To date, we have performed nearly 2000 robot assisted radical prostatectomies extraperitoneally. We have previously reported on our initial 325 patients using this minimally invasive approach 2, showing cancer control, maintenance of continence and potency similar to other experienced centers, while avoiding the abdominal cavity.

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Conclusions

The extraperitoneal space is generally perceived as being more difficult, which has limited its adoption. Several centers however are increasingly performing this approach on a routine basis, once they have overcome the associated learning curve. While the initial creation of the extraperitoneal space may be seen as time consuming, procedural steps such as taking down the bladder, during a transperitoneal approach are eliminated. The removal of the prostate or completion of the procedure is also a much expeditious step with the extraperitoneal approach. Only the anterior rectus sheath is closed, while the remaining trocar sites are left intact, with no increased risk of herniation, given their extraperitoneal location.

There has not been any instrument developed to facilitate this approach. The current instruments utilized were generally developed for general surgery use during hernia repair. The balloon dilator was not designed to expand the extraperitoneal space beyond the retropubic area. When using a four-arm robot, the space needs to be further developed laterally to facilitate port placement. A long smooth trocar however can help enlarge the space atraumatically, facilitating the procedure.

With the quest of minimal invasiveness, the extraperitoneal approach remains an excellent route to perform a radical prostatectomy. It is a useful approach not only for the patient with prior intraabdominal surgeries, but also leave the abdominal cavity free of related adhesions, facilitating potential future intraabdominal interventions.

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Figures

Figure 1. Patient positioned.

Patient positioned.

Figure 2. The 1cm S shaped retractor is used to lift the anterior rectus sheath and muscle to identify the posterior sheath.

The 1cm S shaped retractor is used to lift the anterior rectus sheath and muscle to identify the posterior sheath.

Figure 3 View through the balloon of extraperitoneal space being created.

View through the balloon of extraperitoneal space being created.

Figure 4. Identification of the pubic symphsis.

Identification of the pubic symphsis.

Figure 5. Identification of the epigastric vessels.

Identification of the epigastric vessels.

Figure 6. Final 6-port trocar arrangement for 4 arm robot assisted extraperitoneal radical prostatectomy. Left insert endoscopic view, right insert external view.

Trocar arrangement; internal and external view.

Figure 7. Close proximity of the epigastric vessels to the site of introduction of the robotic working trocars (View of the left side).

Close proximity of the epigastric vessels to the site of introduction of the robotic working trocars (View of the left side).

Figure 8. Advantage of using a long right lateral trocar to bridge over the peritoneal reflection, avoiding inadvertent injury during passage of instruments by the assistant.

Advantage of using a long right lateral  trocar to bridge over the peritoneal reflection, avoiding inadvertent injury during passage of instruments by the assistant.

Figure 9. Dissection of the right surface of the prostate following incision of the endopelvic fascia.

Dissection of the right surface of the prostate following incision of the endopelvic fascia.

Figure 10. The neurovascular bundles can be visualized early in the prostatic dissection.

The neurovascular bundles can be visualized early in the prostatic dissection.

Figure 11. Ligation of the dorsal vein complex, identification of the notch allows proper passage of the needle to avoid including the Foley catheter.

11 Ligation of the dorsal vein complex, identification of the notch allows proper passage of the needle to avoid including the Foley catheter.

Figure 12. Dissection of the vesicoprostatic junction. Lateral dissection allows identification of the longitudinal bladder neck fibers.

Dissection of the vesicoprostatic junction. Lateral dissection allows identification of the longitudinal bladder neck fibers.

Figure 13. Clipping of the Vas deferens and its artery.

Clipping of the Vas deferens and its artery.

Figure 14. Incision of the Denonvililers' fascia at the prostate base exposing the yellow pararectal fat.

Incision of the Denonvililers' fascia  at the prostate base exposing the  yellow pararectal fat.

Figure 15. Combined antegrade and retrograde dissection of the neuro-vascular bundle before control of the delineated pedicle.

Combined antegrade and retrograde dissection of the neuro-vascular bundle before control of the delineated pedicle.

Figure 16. Dissected neurovascular bundle.

Dissected neurovascular bundle.

Figure 17. Posterior reconstruction which approximates the posterior Rhabdospincter (RS), Denonvilliers' fascia (DF) and posterior bladder (PB).

17 Posterior reconstruction which approximates the posterior Rhabdospincter (RS), Denonvilliers' fascia (DF) and posterior bladder (PB).

Figure 18. The tip of the Foley catheter is used as a guide for passage of the needle through the urethral stump.

The tip of the Foley catheter is used as a guide for passage of the needle through the urethral stump.

Figure 19. Passing a long standing catheter into the bladder before thighting of the anterior anastomotic sutures.

Passing a  long standing catheter into the bladder before thighting of the anterior anastomotic sutures.

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References

  1. Gettman MT, Hoznek A, Salomon L, Katz R, Borkowski T, and Antiphon P et al., Laparoscopic radical prostatectomy: description of the extraperitoneal approach using the da Vinci robotic system, J Urol 2003; 170:416.
  2. Joseph JV, Rosenbaum R, Madeb R, Erturk E, Patel HR, Robotic Extraperitoneal Radical Prostatectomy: An Alternative Approach, J Urol 2006; 175:945-951.

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Status
Module 7 Prostate: Extraperitoneal Posttest Available 1.50 credits/hours

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