(a) Large prostate gland resulting in decreased working space. (b) Lateral Accessory Pudendal Artery (APA) running along the prostate surface but below the endopelvic fascia (*)
In our experience, meticulous, deliberate dissection with good traction and counter-traction is essential to achieving a good outcome. Our port placement has been a five-port robotic approach with the fourth arm on the right side of the patient and the assistant port on the left. Having a grasper available in both the left and right side allows for optimal traction and counter-traction, even with limited working space. Additionally, the assistant port can be used to provide cephalad traction on the bladder.
Large Intravesical Prostatic Lobe (IVPL)
An enlarged median lobe, the most common form of an intravesical prostatic lobe (IVPL), has been found in 8–19 % of RALP patients [10, 11, 15]. Early recognition and meticulous management of a large IVPL can avoid inadvertent complications during RALP. These pitfalls include injury to ureteral orifices, amputation of the lobe, creating a large bladder neck, thinning the bladder wall and potentially causing a detrusorotomy (i.e. “buttonholing” the bladder).
The presence of a large IVPL should be anticipated pre-operatively on the basis of history, digital rectal exam and trans-rectal ultrasound measurement of prostate volume. After the anterior bladder neck is divided, it is imperative to identify a large IVPL by gentle retraction on the bladder neck. Recognition that the Foley catheter is deviated away from midline provides an early clue for the presence of a large IVPL. The use of a 30° down scope optimizes identification of a large IVPL.
Our approach to a large IVPL is the use of a “rescue stitch” for retraction anteriorly out of the bladder lumen . This stitch consists of a 6-inch long 0-polyglactin suture on a CT-1 needle with a Hem-o-lok clip tied to the tail end. It is deployed through the IVPL from distal to proximal, in a parasagittal plane, using a robotic needle driver, with the clip placed and manipulated to sit snugly against the distal aspect of the lobe (Fig. 67.2). The fourth robotic arm can then be used to retract the IVPL towards the pubic symphysis, delivering the IVPL from the bladder lumen and providing an unobstructed view of the posterior bladder neck. The amount of retraction stitches is typically one, however, up to three can be deployed; one for each intravesical lobe. Dynamic retraction of the IVPL (or lobes) facilitated by retraction sutures allows clear definition of the posterior bladder neck to facilitate unobstructed posterior bladder neck incision and ongoing retrovesical dissection until the vas and seminal vesicles are reached. In our experience, this technique allows for meticulous dissection aided by dynamic retraction and avoids trauma to IVLPs caused by direct grasping. Additionally, it maintains a relatively small bladder neck and the need for subsequent reconstruction of the bladder neck is minimized.
Deployment of the Rescue Stitch for the management of intravesical lobes. (a) A single stitch deployed through a median lobe (ML). (b) The stitch retraction provides excellent visualization of the posterior bladder neck (PBN). (c) Two stitches are deployed through lateral lobes (LL). (d) Final view of the dissected intravesical lateral prostate lobes. (e) Stitch deployment through two lateral lobes and a median lobe. (f) Closer visualization: Note that the prostate lobes are lifted up and the posterior bladder neck can be safely approached
Accessory Pudendal Artery
Erectile function preservation not only requires preservation of the neurovascular bundles, but also preservation of anomalous vasculature that supply the cavernosal bodies. This is particularly highlighted by the incidence of vascular insufficiency which can also contribute to post operative erectile dysfunction . Accessory pudendal arteries (APA) arise above the levator ani and head to the penis infra-pubically. The overall incidence of APA is approximately 30 % and can be sub classified into apical and lateral locations. The magnification permitted in robotic surgery and awareness for APAs should be used for identification. Overall, 80–90 % can be preserved [19, 20]. Lateral APAs that run over the endopelvic fascia should be released from surrounding fat and pushed laterally. More care is required, however, for lateral APAs that run along the prostate surface but are below the endopelvic fascia (Fig. 67.1b). The critical maneuver is to incise endopelvic fascia medial to the course of the APA, and push the APA laterally towards the pelvic sidewall and out of harm’s way. Vessel loops can be utilized to provide traction and the extent of dissection is only to free up the APA such that the extirpative part of the operation can be carried out without harm to the artery . Apical APAs must be carefully dissected out since they may appear to be heading into the prostatic apex but are in fact running parallel to the course of the dorsal venous complex (DVC). Directly incising the DVC while aided by the tamponade effect of pneumoperitoneum can facilitate separation of the APA from the DVC, as well as identification of branches of the APA heading towards the prostate that require control.
RALP in Obese and Morbidly Obese Patients
The rate of obesity (body mass index (BMI) ≥ 30 kg/m2) has been increasing, which is troublesome since these men will present with higher grade tumors and are also at higher risk for biochemical recurrence [2, 7]. Obesity can pose further challenges intraoperatively, including ventilation difficulty in Trendelenburg position, risk of positioning injury and compartment syndrome . Careful positioning is critical including adequate padding of pressure points and use of large size lithotomy-stirrups (Fig. 67.3). We utilize extra long bariatric trocars, including camera and robotic ports in obese patients. While Veress needle entry is safe, we typically make an adequate incision to expose the fascia clearly and to provide counter-traction. Port placement should be carefully planned noting that there will be a longer distance form skin to operative field and that the deeper and narrowed true pelvis seen in the obese can co-exist with exostosis of the symphysis pubis [3, 13, 25]. One should anticipate decrease working space related to increased peri-prostatic and perivesical fat as well as larger prostate glands in obese men . Deployment of an extra assistant lateral port (5 mm) can be useful to provide cephalad traction on the bladder and to assist with lymph node dissection. In addition, the pelvic floor is often pushed caudally in obese men by the intra-abdominal weight, leading to increased distance between the bladder neck and membranous urethra, and this combined with decreased space in the pelvis due to large amounts of pre-vesical fat makes the vesico-urethral anastomosis challenging. We usually excise the prevesical fat to create more room in the pelvis, and employ directed perineal pressure to facilitate the anastomosis.
Morbidly obese patient undergoing RALP. Patient habitus poses unique positioning, laparoscopic access and robotic technical challenges
Challenging Post-surgical Scenarios
Although a past history of trans-peritoneal surgery is predictive of intra-abdominal adhesions, the extent of adhesions encountered is not directly correlated or predictable based on the timing, extent and amount of past surgeries (Fig. 67.4a). Thus, while Veress needle entry is certainly feasible, a lower threshold to converting to open laparoscopic access should be maintained. Open laparoscopic access should be established with the selection of the entry point being the furthest away from the area of prior surgery. A pitfall of open entry is that there is a persistent leak around the port site. This can be circumvented by using a balloon port to establish an air-tight seal (Fig. 67.4b). If extensive lysis of adhesions is to be performed to allow precise robotic port placement, this is best done laparoscopically to begin with. Once enough room has been created to place robotic ports, the remaining lysis of adhesions can be completed robotically, if necessary.
(a) Extensive intra-abdominal adhesions. (b) Balloon port device use to establish an air-tight seal after open entry. (c, d) Sagittal T2-weighted Pelvic MRI demonstrating full penile prosthesis reservoir (arrow) in close anatomic relation to the bladder
Prior Transurethral Resection of the Prostate
RALP following prior transurethral resection of the prostate (TURP) poses unique challenges with overall increased risk of incontinence and erectile dysfunction . One may anticipate the presence of peri-prostatic adhesions that make the procedure more difficult. Difficulty may be encountered in identifying the posterior bladder neck, while paying close attention to also identifying potentially close ureteric orifices.
It has been our approach to perform pre-operative cystoscopy to identify the anatomy of the bladder neck and proximity of the ureteric orifices. Consideration should be given to the placement of bilateral ureteric stents to aid in transvesical identification of ureteric orifices. Additionally, intra-operative identification can be facilitated by IV Indigo Carmine to ensure the bladder neck incision is appropriately spaced away from the ureteric orifices. Care must be taken during the urethro-vesical anastomosis as well to avoid inadvertent incorporation into the anastomosis or obstruction of the ureteric orifices.
Prior Artificial Urinary Sphincter or Inflatable Penile Prosthesis
The presence of a reservoir supplying an artificial urinary sphincter (AUS) or inflatable penile prosthesis (IPP) may obscure visualization and dissection of the bladder anteriorly. While the reservoir is typically placed in the space of retzius, it may also be located in the pre-peritoneal space. The most conservative approach is to deactivate the device, remove the reservoir, complete the RALP then subsequently replace the reservoir after re-prepping the patient. Return of the reservoir could be delayed for a longer period post-operatively as well. This conservative approach has been advocated as inadvertent injury or contamination to the reservoir or connecting tubing may render the device inactive, obviate subsequent surgery, or risk device infection that requires eventual explanation. Moreover, this view has also found support since the reservoir may directly be obstructive to an open radical retropubic prostatectomy .