Despite technologic advances in endoscopic techniques for management of benign prostatic hyperplasia (BPH) in the past decade, open simple prostatectomy has traditionally been the treatment of choice for patients with giant symptomatic prostatomegaly. Minimally invasive approaches to simple prostatectomy have gained traction in the urologic community since Mariano and colleagues first described laparoscopic simple prostatectomy (LSP) in 2002. The laparoscopic approach demonstrated reduced pain, quicker recovery, and improved cosmesis compared with the open approach, but blood loss remained a major issue, with a tenth of the patients in the initial series requiring blood transfusions. The technique also presented a steep learning curve and challenges for many surgeons not accustomed to the ergonomics of operating in a narrow pelvis and intracorporeal suturing.
More recently, robotic-assisted simple prostatectomy (RASP) has mitigated these challenges and extended the role of robotic-assisted surgery beyond traditional robotic-assisted radical prostatectomy (RARP) for prostate cancer. In 2008, Sotelo and colleagues initially reported RASP in which they used a transperitoneal suprapubic approach similar to that for RARP, applying the same port placement and positioning. Since then, several groups have reported RASP via the retropubic and extraperitoneal approaches. RASP has been established as a safe and effective modality for adenoma excision and is the main technique described in this chapter.
Indications and Contraindications
The indications for minimally invasive simple prostatectomy (MISP) are similar to those for open simple prostatectomy (OSP)—specifically, high-volume (>80 mL), symptomatic BPH refractory to medical therapy or prior endoscopic management. In addition, surgery is generally indicated for men who have renal insufficiency secondary to chronic outlet obstruction, multiple episodes of retention, recurrent urinary tract infections (UTIs), bladder stones, and significant gross hematuria of prostatic origin. Relative indications include the concomitant presence of bladder stones or large bladder diverticula that also require intervention.
Contraindications to MISP include biopsy-proven prostate cancer, elevated prostate-specific antigen (PSA) level, and concerning digital rectal examination (DRE) findings without prior biopsy. The procedure is also contraindicated in men who are poor surgical candidates in general and in those who cannot tolerate extreme Trendelenburg positions for extended periods (e.g., patients with recent neurosurgical procedures who cannot tolerate increased intracranial pressures; those with pulmonary edema associated with congestive heart failure).
Patient Preoperative Evaluation and Preparation
The diagnostic evaluation of men undergoing MISP consists of a complete physical examination and International Prostate Symptom Score (IPSS) evaluation, PSA level, postvoid residual (PVR) assessment, uroflowmetry, and volumetric imaging of the prostate to determine accurate prostate size. If PSA is elevated or if DRE is concerning, a prostate biopsy should be performed to rule out prostate cancer before proceeding with additional workup of lower urinary tract symptoms (LUTS). Cystoscopy can be helpful to determine the presence of a median lobe, bladder diverticula, and calculi. Formal urodynamic assessment consisting of cystometry and pressure and flow evaluations in patients with more complex conditions and coexisting bladder disease is warranted before prostatectomy.
Urinalysis and urine culture, electrolyte studies, complete blood count (CBC), coagulation studies, and type and screen should all be obtained in patients before proceeding with MISP. Active UTIs should be adequately treated before surgery. Chest x-ray examination and electrocardiography should be part of the presurgical testing for all men older than age 50 and those who have any risk factors for cardiovascular events.
Informed consent should be obtained with the patient having a clear understanding of the surgery and the associated risks, including but not limited to conversion to an open procedure; bleeding; need for transfusions; infections and sepsis; urinary incontinence; and erectile dysfunction or impotence.
Operating Room Configuration and Patient Positioning
After insertion of an endotracheal tube and induction of general anesthesia, the patient is placed either in a supine position with the legs spread apart on a split table or in the dorsal lithotomy position with all pressure points padded ( Fig. 32-1 ). The arms are tucked at the sides. Sequential compression stockings are placed on both legs, and 5000 units of subcutaneous heparin is given for deep venous thrombosis (DVT) prophylaxis. The patient is then placed into the steep Trendelenburg position (>25%) before preparation and draping to test the configuration and confirm that positioning does not affect anesthetic parameters (e.g., loss of tidal volume and difficulty ventilating), because pneumoperitoneum and CO 2 insufflation can induce hypercapnia and oliguria. After standard preparation and draping, an 18-French Foley catheter is inserted into the bladder with 10 mL of sterile water placed in the balloon.
For both transperitoneal laparoscopic and robotic approaches, the pneumoperitoneum is established with a Veress needle inserted at the base of the umbilicus. If the patient has had prior abdominal surgery with incision in the midline or lower abdomen, the Veress needle can be placed at the upper left or right subcostal area. In patients with prior incisions, an additional Veress needle may be used to ascertain if proposed trocar sites are safe by probing the site of placement for escaping gas. After an intra-abdominal pressure of 15 mm Hg has been established, a 12-mm or 8-mm (if using the da Vinci Xi system [Intuitive Surgical, Sunnyvale, Calif.]) camera trocar is then placed in the midline at the umbilicus. The laparoscopic or robotic camera is then inserted through this port and the abdomen is inspected to assess for adhesions or any injuries sustained from Veress needle or port placement. A 12-mm working trocar is placed approximately 15 cm lateral to the camera port on the left, approximately two fingerbreadths superior to the left anterior superior iliac spine. We prefer to place a 12-mm AirSeal System (SurgiQuest, Milford, Conn.) trocar as the working port for both laparoscopy and robotic-assisted surgery because this system allows us to maintain a more stable pneumocavity and prevent sudden loss of insufflation pressure. The valveless trocar system has been demonstrated to improve visualization by decreasing smudging of laparoscopes and evacuating smoke during cauterization, to maintain pneumoperitoneum while suctioning, and to allow easier extraction of specimens and needles.
For RASP, two 8-mm robotic trocars are inserted 8 cm lateral to the camera port on either side of the rectus muscle. A fourth robotic arm trocar is placed 8 cm to the right of the right lateral port above the right anterior superior iliac spine. A 5-mm assistant screw port is placed between the camera port and left robotic trocar and slightly cephalad to them. Some adjustments are needed to ensure that the 5-mm trocar during assistance does not hamper either the robotic or camera arms. The surgeon operates through the three robotic arms and controls the camera while the assistant uses the 12-mm AirSeal port for insertion and retrieval of needles and instruments and the 5-mm port for suctioning and irrigation. See Figure 32-2 for transperitoneal RASP trocar placements.
Initial access for the extraperitoneal approach requires a 2-cm infraumbilical incision to be made to expose the anterior rectus sheath. A midline vertical incision is made in the sheath itself to expose the rectus muscle, which is then split to delineate the posterior sheath. A balloon dilator PDB or Spacemaker (Covidien, Dublin, Ireland) is inserted over the posterior sheath and advanced toward the space of Retzius. This allows the robotic or laparoscopic camera to pass through the balloon port and assist in creating extrapneumoperitoneum. Care should be taken to preserve the inferior epigastric vessels and not to dissect them off the rectus muscle and also not to inadvertently make a small hole in the peritoneum, which will lead to suboptimal insufflation of the extraperitoneal space.
Once the extraperitoneal space has been developed, the robotic and assistant trocars are placed in similar fashion as for the transperitoneal approach, with emphasis that the ports are not close together to prevent instrument clashing. All trocars are placed slightly below the level of the camera port and under direct endoscopic vision.
The laparoscopic approach also involves establishing pneumoperitoneum with a Veress needle by means of the Hassan technique. A 10-mm camera trocar is placed at the umbilicus. Two 10-mm ports are then placed on each side in the middle of the distance between the anterior iliac spine and the umbilicus. An additional 5-mm port is placed inferior to and lateral to the 10-mm trocar on the surgeon’s side. The 12-mm port (AirSeal) is placed on the contralateral side in the same position. See Figure 32-3 for LSP port configuration.
Procedure (See )
Robotic Simple Prostatectomy: Transperitoneal Approach
After the pneumoperitoneum is established, the anterior peritoneum is incised lateral to the medial umbilical ligaments bilaterally to the level of the vasa deferentia ( Fig. 32-4 ). The bladder is then dropped to develop the space of Retzius.