Instruments

The important landmarks are the bladder neck, base of the prostate, levator muscles, and apex of the prostate (Fig. 5.3). Once adequate exposure has been obtained, the EPF is opened from the base of the prostate to immediately lateral to the reflection of the puboprostatic ligaments bilaterally using cold scissors. This is the area with the biggest space between the prostate and the levators and the point at which the prostate has most mobility. Proceeding from the base to the apex, the levator fibers are pushed off the prostate until the DVC and urethra are visualized (Fig. 5.4). Extensive dissection of the apex at this time can lead to unnecessary and obtrusive bleeding, so it is important to dissect only that which is necessary to get in a good DVC stitch.

Instruments

Robotic needle drivers are placed via the robotic ports. Patel et al. use a large needle with a non-braided absorbable suture such as Polyglytone™ (e.g., Caprosyn™) on a large CT1 needle. The needle is held about 2/3 back at a slight downward angle and placed in the visible notch between the urethra and DVC (Fig. 5.5). The needle is pushed straight across at 90° and then the wrist is turned to curve around the apex of the prostate. The suture strength needs to be sufficient to allow the needle holders to pull up tight and perform a slip knot, which prevents the suture from loosening as it is tied. A second suture is placed to suspend the urethra to the pubic bone and secondarily ligate the DVC. The DVC is encircled and then stabilized against the pubic bone along with the urethra (Fig. 5.6). The aim of this technique is the stabilization of the urethra avoiding urethral retraction, facilitating the urethral dissection. Patel et al., in a prospective comparative study on 331 patients, found a significant advantage in terms of early recovery of continence at 3 months using a single anterior suspension stitch to the pubic bone (83% vs. 92.9%; p = 0.013) [12].

Instruments

The laparoscope is changed to a 30° down-facing lens, which is optimal to see inferiorly. The bladder neck is identified by a cessation of the fat extending from the bladder at the level of the prostatovesical junction (Fig. 5.7). Another technique is to pull on the urethral catheter and visualize the balloon. However, this can be unreliable and misleading after transurethral resection of prostate (TURP) or with a median lobe or large prostate. The robotic arms also provide a moderate amount of visual and sensory feedback to facilitate localization of the boundaries. The bladder is dissected off the prostate in the midline using a sweeping motion of the monopolar scissor while visualizing the bladder fibers. The key is to stay in the midline to avoid lateral venous sinuses till the anterior bladder neck is opened and then dissect on either side of the bladder neck. Once the anterior urethra is divided, the Foley catheter is retracted out of the bladder using the fourth arm, and upward traction is applied to expose the posterior bladder neck (Fig. 5.8).

Instruments

During the posterior bladder neck dissection, the difficulty is in appreciating the posterior tissue plane between the bladder and prostate and the direction and depth of dissection necessary to locate the seminal vesicles. After incision of the anterior bladder neck, any remaining peripheral bladder attachments should be divided to flatten out the area of the posterior bladder neck and allow precise visualization and dissection of the posterior plane. The full thickness of the posterior bladder neck should be incised at the precise junction between the prostate and the bladder (Fig. 5.9). The lip of the posterior bladder neck is then grasped with the fourth arm and used for gentle traction to visualize the natural plane between the prostate and bladder. The dissection is directed posteriorly and slightly cranially (toward the bladder) to expose the seminal vesicles. It is important to avoid dissecting caudally (toward the prostate) as there is a possibility of entering the prostate and missing the seminal vesicles completely (Fig. 5.10).

Instruments

Once the bladder has been dissected off the prostate, the vasa and seminal vesicles can be identified. The thin fascial layer over the seminal vesicles and vasa should be opened to free the structures for retraction. The fourth arm is used to retract the vasa superiorly. Both vasa are then incised, and the inferior portion of the vas is retracted by the assistant (Fig. 5.11). The vas is then followed posteriorly to expose the tips of the seminal vesicles. Small perforating vessels are cauterized with the bipolar grasper and divided or clipped with a 5 mm clip or Hem-o-lok (Fig. 5.12).

Instruments

The seminal vesicles must be dissected all the way to the base to allow for appropriate elevation of the prostate and identification of the posterior Denonvilliers’ fascia (Fig. 5.13). The incision of Denonvilliers’ fascia is made at the base of the seminal vesicles. The correct plane can be identified by the presence of a clear pearly white plane between the posterior prostatic capsule and the rectum. When entered correctly, the plane is avascular and spreads easily with the Maryland dissector with minimal bleeding. The posterior space is dissected widely to fully release the prostate and facilitate rotation during the nerve sparing (Fig. 5.14).

Instruments

The approach to the nerve sparing is retrograde, mirroring the open approach. The periprostatic fascia is incised at the level of the apex and midportion of the prostate (Fig. 5.15). Gentle spreading of the tissue on the lateral aspect of the prostate will allow the prostatic capsule and the neurovascular bundle (NVB) to be identified. No thermal energy is used during dissection of the NVB or ligation of the pedicle. At the apex of the prostate, a plane between the NVB and prostate capsule can be identified and separated (Fig. 5.16). The NVB is then released in a retrograde manner toward the prostatic pedicle. The NVB is stabilized with the Maryland dissector and the prostate is gently stroked away using the scissors. The plane between the NVB sheath and the prostate capsule is relatively avascular, consisting of only small tributary vessels; therefore, no energy or clipping is required close to the path of the NVB. As the dissection proceeds in a retrograde fashion, the NVB can clearly be seen being released off the prostate. The prostate pedicle can then be thinned out with sharp dissection and the path of the NVB clearly delineated at this level. The clear definition of the anatomy allows the placement of two clips on the pedicle away from the NVB and sharp incision to release the prostate completely (Fig. 5.17). It is important to release the NVB to the apex of the prostate in order to prevent injury during the apical dissection.

Instruments

The landmarks are the ligated DVC, urethra, apex of the prostate, and NVB. Ligation of the DVC prevents bleeding which may interfere with the apical dissection and division of the urethra under direct vision (Fig. 5.18). Cold scissors are used to divide the DVC and a long urethral stump is developed, as a longer urethral stump facilitates the anastomosis and may improve continence. Complete dissection of the apex and urethra is facilitated by the robotic magnification. The urethra is then incised at the apex of the prostate under direct vision to completely liberate the prostate (Fig. 5.19).

Instruments

Bladder neck preservation is usually attempted during RARP, but, in case of large prostate volume or large median lobe or in patients with previous TURP, a bladder neck reconstruction can be necessary. Before starting the bladder neck reconstruction, it is essential to check the position of the ureteric orifices and their distance from the edge of the bladder neck. Bilateral plication over the lateral aspect of the bladder is then performed using sutures of 3-0 poliglecaprone, 13 cm long, in a RB-1 needle (Ethicon Inc. Somerville, NJ, USA). The suture begins laterally and runs medially until the bladder neck size matches that of the membranous urethra. The same suture then runs laterally, back to the beginning of the suture, and is tied (Fig. 5.20). Occasionally, additional stitches need to be placed, if indicated, until the bladder neck size matches that of membranous urethra [13].

Instruments

In 2006, Rocco F et al. proposed a technique for restoration of the posterior aspect of the rhabdosphincter (RS) which demonstrated to shorten time to continence in patients undergoing RRP [14]. In 2007, Rocco B et al. described the application of the posterior reconstruction technique to transperitoneal laparoscopic radical prostatectomy (LRP) [15], while, in 2008, Coughlin et al. applied the posterior reconstruction of the rhabdosphincter to RARP with some minor technical modifications [16]. The technique has been further modified in 2011 [17].

The reconstruction is performed using two 3-0 poliglecaprone sutures (on RB-1 needles) tied together, with each individual length being 12 cm. Ten knots are placed when tying the sutures to provide a bolster. The free edge of the remaining Denonvilliers’ fascia is identified after the prostatectomy and approximated to the posterior aspect of the RS and the posterior median raphe using one arm of the continuous suture. As a rule, four passes are taken from the right to the left and the suture is tied (Fig. 5.21a, b). The second layer of the reconstruction is then performed with the other arm of the suture approximating the posterior lip of the bladder neck (full thickness) and the vesicoprostatic muscle, as described by Walz et al. [18], to the posterior urethral edge and to the already reconstructed median raphe (Fig. 5.22a, b). This suture is then tied to the end of the first suture arm.

One of the key steps for an appropriate reconstruction is the preservation of the Denonvilliers’ fascia when dissecting the posterior plane between the prostate and the rectal wall. If this dissection is performed at the perirectal fat tissue, the Denonvilliers’ fascia is not adequately spared, precluding posterior reconstruction.

An updated systematic review and meta-analysis showed that reconstruction of the posterior musculofascial plate improves early return of continence (relative risk 1.77, 95% CI 1.43–2.20; P < 0.001) within the first 30 days after RP (Fig. 5.23); furthermore, a trend toward lower leakage rates (relative risk 0.43, 95% CI 0.25–0.75; P = 0.006) has been found in patients who received the posterior reconstruction (Fig. 5.24) [19].

Instruments

The urethra and bladder are re-approximated using a continuous suture as per the technique described by Van Velthoven [11]. Two 20 cm 3-0 Monocryl sutures on RB-1 needles of different colors are tied together with ten knots to provide a bolster. The posterior urethral anastomosis is performed first with one arm of the suture. Three passes are made through the bladder and two passes through the urethra and the suture is pulled straight up in order to bring the bladder down. The posterior anastomosis is continued in a clockwise direction from the 5 to 9 o’clock position obtaining adequate bites of tissue (Fig. 5.25). This is followed by completion of the anterior anastomosis with the second arm of the suture in a counterclockwise fashion (Fig. 5.26). The key to performing quick watertight anastomosis is to have an adequate urethral length, normal-sized bladder neck, clear operative field, and perineal pressure. A Foley catheter is placed and saline is irrigated to confirm watertight anastomosis. A Jackson–Pratt drain is placed around the anastomosis, and all the trocars are removed under direct vision.

Dissection of the Bladder Neck

Dissection of the bladder neck represents one of the most challenging steps of RARP, particularly in the presence of difficult anatomic conditions, which can be natural, such as the presence of a median lobe, or due to previous surgery, as in case of TURP.

The line of dissection of the anterior bladder neck can be identified by pulling the catheter, operating a traction with the fourth arm, or by means of a symmetric pressure of the right and left arm (Fig. 5.27). The use of a low monopolar energy helps in maintaining the features of the tissue and so in distinguishing the muscular tissue of the detrusor from the glandular tissue of the prostate.

The approach to the posterior bladder neck is based on two opposite tractions: that on the catheter superiorly and that on the bladder neck cranially. The incision begins on the lateral aspects of the detrusor (Fig. 5.28). After releasing the lateral muscular fibers, and so transferring the traction on the midline, the bladder neck is dissected. A constant traction is made by means of the left arm; the scissors, with separate blades, develop the surgical plane, until the seminal vesicles are visible (Fig. 5.29).

In the presence of a median lobe, traction on the catheter can help identify an eventual asymmetry of the lobes. The dissection of the anterior bladder neck begins again on the midline, until the catheter is identified and suspended. The lateral aspects of the detrusor are separated, while a traction is exerted with the left arm. When the median lobe becomes evident, the point of traction is changed to improve exposition (Fig. 5.30). Special attention should be given to the thickness of the posterior aspect of the bladder neck. In 2012, Coelho et al. reviewed postoperative outcomes of 1693 patients who underwent RARP performed by a single surgeon. Three hundred and twenty-three (19%) presented a median lobe (ML). The authors did not find significant differences between patients with or without ML in terms of estimated blood loss, length of hospital stay, pathologic stage, complication rates, anastomotic leakage rates, overall PSM rates, and PSM rate at the bladder neck. The median overall operative time was slightly greater in patients with ML (80 vs. 75 min, P < 0.001); however, there was no difference in the operative time when stratifying this result by prostate weight. Continence rates were also similar between patients with and without ML at 1 week (27.8% vs. 27%, P = 0.870), 4 weeks (42.3% vs. 48%, P = 0.136), 12 weeks (82.5% vs. 86.8%, P = 0.107), and 24 weeks (91.5% vs. 94.1%, P = 0.183) after catheter removal [27].

The bladder neck defect after TURP can create many difficulties in the dissection (Fig. 5.31). The catheter is pulled cranially and superiorly, exposing the large defect of the bladder neck. Here it is even more important to separate the lateral aspect before dissection on the midline. The presence of scar tissue can make it more difficult to distinguish the muscular from the glandular tissue. Tugcu et al. compared 25 patients with previous history of prostatic surgery for benign prostatic hyperplasia (TURP in 20 patients and open prostatectomy in 5 patients) and 36 patients who were naïve to prostatic surgery, demonstrating significant increase in the operative time, estimated blood loss, and complication rates (40% vs. 19%) in patients with past history of prostatic surgery. However, there were no significant differences between the groups as regards the functional outcomes [28].

RARP in Obese Patients

RARP in obese patients can sometimes be a technically challenging procedure as a result of the deeper and narrower pelvis and the excess periprostatic and abdominal fat that obscure vision and reduce the robotic working space. In such patients, some precautions are required in order to overcome obesity’s associated difficulties: increasing the Trendelenburg position of the table from 25° to 30° (use bean bags and gel pads to avoid sliding of the patient). Moreover, the trocar position should be modified according to the patients’ habitus; thus in obese patients it should be placed more laterally and proximally to allow deeper access in the pelvis. Furthermore, changing the telescope form 30° to 0° may improve vision during the apical dissection and vesicourethral anastomosis if the pubic bone interferes in the working field, obscuring vision [29].

RARP in Patients with Small BMI and Narrow Pelvis

On the other hand, surgeons may encounter two main problems in patients with small BMI and narrow pelvis undergoing RARP: external clashing of robotic arms and narrow working space internally. These can be avoided by adjusting the distance to a minimum of 8 cm externally or using a three-arm robot with additional port for the assistants [29].

The Role of the Prostatic Vasculature as a Landmark for Nerve Sparing During Robot-Assisted Radical Prostatectomy

In 2011, Patel VR et al. performed a retrospective video analysis of 133 consecutive patients who underwent RARP with nerve sparing performed using a retrograde, antegrade, or combined approach [30].

After opening sharply the levator fascia over the prostate, they observed the presence of a distinctive prostatic artery (PA) that could be found between the midprostate and base. The artery entered the prostate on the anterolateral aspect, and it was easily recognized by its large size and tortuosity (Fig. 5.32a). Delicately developing a plane of dissection between the PA and the prostate resulted in a natural detachment of the NVB from the prostate. For a complete NS, the correct plane of dissection was recognized by the presence of pearly areolar tissue and was gently developed posteriorly following the prostatic contour until the previously created posterior plane was reached. After detaching the prostate, it was evident that the PA was located at the most medial aspect of the NVB and followed its course down into the perineum (Fig. 5.32b).