Introduction
Prostate cancer is the most common solid malignancy in the United States and most Western countries. , The definitive surgical extirpation for the majority of localized prostate cancer cases in eligible men involves radical prostatectomy, with or without pelvic lymph node dissection (PLND), dependent on clinical risk parameters. , Although open radical prostatectomy and laparoscopic radical prostatectomy are still performed worldwide, the introduction of robotic-assisted radical prostatectomy (RARP), which occurred nearly 20 years ago in Europe and the United States, and its subsequent rapid adoption worldwide, has led to RARP as the current standard of care in most developed countries.
With respect to RARP, there are a multitude of techniques described in the literature. However, based on the method of abdominal/pelvic access to the prostate, RARP can be broadly classified into either the transperitoneal (TP-RARP) or extraperitoneal (EP-RARP) approach. TP-RARP is by far the most commonly performed technique. EP-RARP is performed less frequently, owing to its perceived technical difficulty. However, EP-RARP has its merits, particularly in cases where intraperitoneal access can be problematic. ,
Both TP-RARP and EP-RARP can be performed using either the conventional multi-port (MP) robotic system or the more recent single-port (SP) robotic system. The SP system lends itself particularly well with respect to EP-RARP, with purported advantages in terms of cosmesis, fewer postoperative analgesic and opioid requirements, and shorter duration of hospital stay. ,
Herein, we describe the technical steps relevant to EP-RARP, using either the MP (EP-RARP-MP) system or the SP (EP-RARP-SP) system, and elaborate on the clinically pertinent nuances of both.
Extraperitoneal RARP (see 
)
Multi-port (EP-RARP-MP)
Access
Our experience over 4000 cases since 2003 in a high-volume tertiary cancer referral academic center has been previously reported. EP-RARP-MP is broadly similar and the outcomes are favorably comparable to those of other experienced centers performing EP-RARP-MP. ,
We have developed a reproducible method to access the EP space. The patient is placed in the supine position with arms tucked. A beanbag is used to prevent patient movement when placed in the Trendelenburg position. All pressure points are padded. A Foley catheter is placed, in a sterile manner, after prepping and draping. We use a 3-cm left-sided paraumbilical incision that is carried down to the level of the anterior rectus sheath ( Fig. 33.1 A–B). A 1-cm incision is made in the anterior rectus sheath exposing the left belly of the rectus muscle ( Fig. 33.2 ). The latter is swept exposing the posterior rectus sheath. A balloon dilator (Covidien, Dublin, Ireland) is passed beneath the muscle parallel to the posterior rectus sheath in a caudal direction accessing the space of Retzius ( Figs. 33.3 and 33.4 ). The balloon is manually inflated, gradually expanding the EP space of Retzius. A zero-degree laparoscopic camera placed inside the balloon dilator allows direct visualization of the space creation process. The epigastric vessels can be visualized anteriorly from their connection with the external iliac vessels. Tearing of the tributaries of the epigastric vessels beneath the muscle can occur at times but is generally of no consequence. Once the space is adequately created, the balloon dilator is withdrawn and replaced by a blunt-ended trocar (Ethicon) through which the space is insufflated. With the scope withdrawn into the trocar to avoid soilage, the tip of the trocar is used to further develop the EP space laterally. Additional space creation is obligatory when using a MP robot, given the required distance between the robotic arms. When a SP robot is used, however, no additional space creation is necessary, which is discussed later in this chapter.
During space creation for additional robotic ports or for assistant ports, it is important to not sweep too vigorously when expanding the EP space in the cephalad direction because the peritoneal layer can be inadvertently torn with entry into the intraperitoneal space. However, if this occurs, the procedure can usually be completed as planned. Additional Trendelenburg positioning may be necessary given the compression of the EP space from the billowing peritoneum. For placement of additional ports, the inferior epigastric vessels on the anterior abdominal wall can be easily appreciated and avoided. We often place a long 22-gauge hypodermic needle at the proposed site of trocar insertion to help identify the course of the trocar and thereby avoid a potential injury to the epigastric vasculature. When using the MP Xi da Vinci robot, we routinely place a total of six trocars. Four 8-mm da Vinci ports are used for robot docking (two approximately 10 cm lateral and caudal to the umbilicus on either side, and a third placed 5 cm cephalad to the left anterior superior iliac spine) and two by the assistant (5-mm placed 5 cm to the right of the umbilicus, and a 12-mm port placed 5 cm cephalad to the right anterior superior iliac spine) in the configuration delineated in Figs. 33.5 and 33.6 . Prior to robot docking, the paraumbilical initial access trocar used for additional space creation must be replaced by another da Vinci docking compatible trocar. While a regular 8-mm trocar can be used, we prefer using a 12-mm da Vinci stapler cannula at that site, given the opening in the rectus sheath. The latter is often enlarged with the space creation as the trocar is oriented in multiple directions. We have found it useful to place a purse string suture in the anterior rectus sheath to maintain the required insufflation. With the EP approach, only the lower abdomen is insufflated rather than the whole abdomen in the TP approach ( Fig. 33.7 ).
Because of the EP nature of the resulting surgical field, mild Trendelenburg (around 10–15 degrees) is usually more than sufficient ( Fig. 33.8 ). The peritoneum serves as a natural barrier keeping the bowels out of the operative field. Pneumoinsufflation of the EP space with carbon dioxide (CO 2 ) is adequately maintained at around 12–15 mm of Hg. Access-associated injuries to the bowel are avoided with the EP approach. All trocars and instruments are placed under direct vision at every step. We have not experienced access-related viscus injury with our described extraperitoneal approach.
The access method described above is set up for a left-sided bedside assistant. Suction, the most commonly used port, is placed in the 5-mm port and operated with the left hand. The other assistant port (12 mm) is used by the assistant for passage of sutures, clips, fat retrieval, specimen bag, etc. For a right-handed assistant, the assistant port can be placed in the left lower quadrant, allowing appropriate handling of the necessary instrumentation based on the assistant’s dexterity. Extraperitoneal access can also be obtained in the midline. We, however, prefer paraumbilical access with visualization of the consistent rectus anatomy. Entering the linea alba in the midline near the umbilicus may lead to inadvertent entry into the peritoneal cavity.
Radical prostatectomy with or without pelvic lymph node dissection
As described previously, once adequate EP access is obtained, the prostate is approached anteriorly for a radical prostatectomy, with or without PLND, as indicated clinically. , 18 With a few modifications, this approach is similar to the TP access procedure at this point. The bladder takedown step necessary with the TP approach is not necessary when using the EP technique. The bladder is dissected from the anterior abdominal wall with the initial balloon dilation step. In most patients, the endopelvic fascia is visualized through the balloon dilator. Upon docking, there is quick access to the prostate or lymph node fossa. The prostatectomy begins promptly by incising the endopelvic fascia, freeing the prostate from its lateral attachments ( Fig. 33.9 ). The apical dissection leads to visualization of the dorsal venous complex (DVC), which is ligated by a barbed-wire suture. The author’s preference is to anchor this suture anteriorly to the pubic symphysis ( Fig. 33.10 ). Provided there are no issues with high-grade/stage lesions in the vicinity of the prostatic base, bladder neck dissection is then performed as anatomically as possible to optimally preserve the bladder neck detrusor muscle ( Fig. 33.11 ). Next, release of the vasa and seminal vesicles posteriorly is performed as athermally as possible, depending on the level of neurovascular bundle (NVB) preservation required ( Fig. 33.12 ).
Posterior dissection, anterior to Denonvillier’s fascial space, is continued in the apical direction followed by control of the lateral vascular pedicles. Again, the degree of NVB preservation is customized, on either side, as per the index patient’s clinical risk and desire for preservation of erectile function if not contraindicated from a cancer control standpoint. Apical dissection is then completed carefully and athermally, not only to preserve pelvic floor muscle but also to avoid inadvertent damage to any preserved NVB distally near the apex ( Figs. 33.13 and 33.14 ). After completing the prostatectomy, bilateral PLND is performed, as dictated by clinical indication. The author’s preference is to perform a posterior reconstruction, with a double-ended barbed-wire suture, so as to approximate the posterior urethra to the bladder neck in the posterior plane. We routinely use these sutures to perform an anterior suspension by hitching the two ends of the barbed-wire suture with Weck clips (Weck Closure Systems Research, Triangle Park, NC) onto Poupart’s ligaments approximately 5 cm on either side of the midline ( Fig. 33.15 ). The urethrovesical anastomosis is carried out using two 3-0 Vicryl sutures on an RB-1 needle in a semicontinuous fashion. Our practice is to routinely leave a 16-French Jackson-Pratt drain in the pelvis with the aim of removing it prior to the patient’s discharge from hospital the following day. The anterior rectus sheath defect from the initial incision for access is closed. No additional port or peritoneal closure is necessary. Skin incisions are closed in a subcuticular fashion ( Fig. 33.16 ). No routine lab/blood tests are ordered postoperatively, unless clinically indicated.
