Mirandolino in 2002 originally described the laparoscopic technique as trans-vesico-capsular prostatectomy. Since then, different descriptions of this technique (such as the Millin technique) that replicate known open surgery techniques have been published. In 2008, Sotelo described a robotic technique with modifications from the original method, including an incision of the capsule and trigonization of the fossa.
The replication of open surgery techniques in laparoscopic/robotic approaches has advantages that include reduced pain and bleeding, shorter hospital stays, and faster recovery times for patients. These advantages come at the expenses of a learning curve for surgeons using the laparoscopy approach and higher institution costs for the robotic approach.
Patient Preparation
Prior to undergoing laparoscopic or robotic simple prostatectomy, the prostate-specific antigen (PSA) levels of the patient should be assessed to rule out the possibility of prostate adenocarcinoma. The International Prostate Symptom Score (IPSS) questionnaire is administered. If necessary, patients should undergo a uroflow or urodynamic study to rule out other causes of obstructive symptoms, especially aspects that may compromise detrusor contractility. Sexual health should be evaluated by means of the sexual function inventory (ie, the Sexual Health Inventory for Men [SHIM]).
Indications
The indications for laparoscopic or robotic simple prostatectomy are the same as those for open surgery. In addition to routine assessments, surgeons should evaluate possible contraindications to laparoscopic or robotic surgery, such as severe chronic obstructive pulmonary disease (COPD) or glaucoma.
Laparoscopic Approach
Endoscope, Instruments, and Surgical Materials
A 0° and a 30° lens are typically used. However, a 0° lens is used for most of the surgery, with the 30° lens usually used only to dissect the urachus or cut the urethra. Laparoscopic ultrasonic and/or bipolar scalpels can be used for dissection. Other instruments include a laparoscopic needle holder, a Maryland grasper, an irrigation-suction system, atraumatic forceps, a laparoscopic blunt adenoma dissector (“prostatotomo”), and an electrocautery loop. Occasionally, a Carter-Thomason needle is used to externalize the traction suture applied to glands with median lobes. Absorbable sutures (usually 3-0 Vicryl type CT-1) are used for hemostasis. Needled 2-0 monocryl UR-6 or V-Loc sutures are used to trigonize the fossa. Nonabsorbable Prolene 2-0 type CT-1 or nylon 2-0 sutures with straight or curved needles are mainly used for traction on adenomas. An extraction bag is normally used. A drainage system, preferably a closed system with negative pressure (Jackson-Pratt type), is used.
Positioning of Equipment and Personnel in the Operating Room
The laparoscopic tower should be located at the foot of the patient, and the surgeon should stand to the patient’s left or right side depending on the surgeon’s dominant hand. Right-handed surgeons are usually positioned on the left side of the patient. The assistant should stand opposite the surgeon to hold the camera. The scrub technician should be located next to the first assistant, and the anesthesiologist should be at the head of the patient ( Fig. 71.1 ). Although not strictly necessary, a second assistant can stand next to the surgeon.
Patient Positioning
The patient should lie in the supine Trendelenburg position to promote the cephalic movement of intestinal contents. The patient’s arms are placed at each side of the body, and the legs can be abducted if perineal compression is required ( Fig. 71.1 ). Pressure points should be padded to avoid muscle and/or neurologic injury. Patients rarely need to be repositioned on the table during surgery. However, chest or shoulder bands can aid repositioning if necessary.
Surgical Technique
The procedure can be performed via either the extraperitoneal or the transperitoneal approach. The transperitoneal approach is described here.
Placement of Trocars
Trocar positioning is described for a right-handed surgeon. A skin incision of 1.5–2 cm is made with a cold scalpel at the umbilical level. The surgeon can enter the abdominal cavity via either the open Hasson or Veres needle technique. The abdominal cavity should be entered using the Hasson technique for patients with a history of previous surgery. The surgeon should slowly enter the abdominal cavity with the needle, taking care to avoid injuring any intraabdominal structures. The pneumoperitoneum pressure should start at 20 mm Hg. Once the surgeon achieves a pressure above 18 mm Hg (to minimize possible injury when introducing the trocar), the first 10-mm trocar should be introduced to provide optical guidance. Because of cosmetic considerations and a risk of hernia, supraumbilical access is not recommended. Next, a horizontal line is drawn 2 cm below the umbilical incision to serve as a marker for subsequent trocars locations, and the surgeon should place two 10-mm trocars on the right side and a 5-mm trocar on the left. These two lateral trocars are positioned 8–10 cm from the umbilical trocar. In addition, a 5-mm trocar is placed posteriorly on the right side, and another 5-mm trocar is similarly placed on the left side. Accordingly, 5 trocars are placed ( Fig. 71.2 ).
Access to the Pre-Bladder Space
The urachus and medial umbilical ligaments serve as anatomic references. With either the 0° or the 30° lens facing upward, the urachus is dissected laterally along the vas deferens on each side as well as horizontally up to the promontory above the pubis. The Retzius space is developed up to the endo-pelvic fascia, enabling the identification of the periprostatic fat, which can be removed ( Fig. 71.3 ).
Technical tip: Care should be taken to not injure the epigastric vessels upon lowering the urachus. During the dissection of periprostatic fat, care should be taken to avoid injuring the iliac vessels when attempting to reach the vas deferens and the dorsal vein complex ( Fig. 71.3 ).
Prostatic Capsule Incision and Dissection of the Adenoma
Initially, the lateral prostatic pedicles and the dorsal venous plexus should be identified and controlled with sutures. Optionally, another point on the dorsal complex can be controlled with a 3-0 Vicryl CT-1 suture to decrease bleeding ( Fig. 71.4 ). Next, the prostate capsule and bladder neck are identified. The prostatic capsule is vertically and horizontally incised (similar to Millin’s technique), or a trans-vesico-capsular ( Fig. 71.5, A–C ) or transverse incision of 4–5 cm is made at the vesico-prostate junction. The latter incision type is the approach of choice ( Fig. 71.5 ). After opening the bladder, the surgeon must identify the presence or absence of a midian lobe. A traction suture on this lobe improves exposure ( Fig. 71.6, A–C ). The trigone and the ureteral meatus should also be identified, and a semicircular incision is made with the electrocautery loop in the groove between the adenoma and the trigone ( Fig. 71.7, A, B ). Next, dissection is carried out from center to side with the ultrasonic scalpel, carefully sealing blood vessels and the lateral complex as the plane between the adenoma and the prostate capsule is developed. The surgeon should subsequently continuously cut the crescent upward to locate the plane between the upper capsule (where the dorsal vein complex is located) and the adenoma ( Fig. 71.8, A, B ). Next, the adenoma should be systematically dissected in synchronized technique using the ultrasonic scalpel and/or blunt dissector, the suction-irrigation cannula, and laparoscopic scissors ( Fig. 71.9, A, B ). A 2-0 Prolene suture in the adenoma provides traction and improves exposure. The suture is used in a “fisherman maneuver” to help define the proper plane for the extraction of a subcapsular adenoma.
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