Although a pure laparoscopic approach to radical prostatectomy is feasible, the operation is formidable for a surgeon without advanced laparoscopic skills. The surgical robot is a computerized system of mechanical arms controlled remotely by the surgeon who is seated at a console. Currently, there is only a single robotic system available for surgical use, the da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA). The da Vinci system, with the new Xi version, provides three-dimensional magnification of the operative field and permits precise tissue handling and easy suturing. It can greatly facilitate performance of radical prostatectomy.
Candidates for robotic-assisted laparoscopic prostatectomy (RALP) in general are the same as those eligible for open surgery. Wide surgical resection margins can be achieved with robotic prostatectomy and an extended pelvic lymph node dissection can be performed when desirable. There may be particular advantages to RALP for obese men and those with prior laparoscopic hernia repair with mesh. A large prostate volume can create some exposure difficulties as the prostate may fill the pelvis but prostate size alone or the presence of a large median lobe do not preclude successful performance of RALP. Salvage RALP after previous radiotherapy or HIFU can also be safely performed on occasion.
Surgical Technique
Patient Positioning
With all operations, proper patient positioning is key but this is particularly important with robotic prostatectomy. A steep Trendelenburg position helps provide easy access to the pelvis for instruments but also helps displace the bowel cephalad. The patient’s legs must be carefully placed in a lithotomy position although a side docking position with the patient’s legs flat is feasible with the da Vinci Xi. With the steep Trendelenburg, it is important to use a patient support or strapping mechanism such as an egg crate or other nonslipping surface to prevent the patient from sliding to the head of the table. After positioning, the table should be placed temporarily in steep Trendelenburg to make certain the patient does not slide and then repositioned without tilt for placement of the laparoscopic ports.
Port Placement
Comparable results have been achieved for both extraperitoneal and transperitoneal laparoscopic access. The transperitoneal approach is used most commonly and is described in this chapter.
A 12-mm vertical incision is made superior to the umbilicus and an open Hasson approach used or a Veress needle is carefully introduced through the abdominal wall. The Veress needle is aspirated and a drop test is performed to confirm the transperitoneal location of the needle. The insufflation tubing is connected and careful attention is paid to the opening pressure, which should be less than 7–8 mm Hg. The abdomen is insufflated to 12–15 mm Hg and a 12-mm trocar is introduced through the previously fashioned 12-mm incision. The robotic camera is inserted, and the abdomen is inspected to show the absence of vascular or bowel injury. The patient is then placed in a steep Trendelenburg position.
The patient is marked approximately 15 cm superior to the pubic symphysis ( Fig. 79.1 ). There is some variability in the distance from the symphysis to the umbilicus; however, this mark will generally fall just below the level of the umbilicus. This reference mark will guide the placement of the robotic trocars. Attention is initially paid to the left side of the patient’s abdomen, which will accommodate two 8-mm robotic trocars (arm 2 and arm 3). The patient is marked approximately 7 to 8 cm lateral to the reference mark, and an 8-mm robotic trocar is introduced under direct vision avoiding the inferior epigastric artery. A second 8-mm robotic trocar is placed 7 to 8 cm lateral to the first robotic trocar. These trocars will accommodate robotic arms 2 and 3, respectively. Attention is then turned to the right side of the patient’s abdomen. The table-side assistant is on the right side, so two assistant ports and one robotic trocar will be placed. An 8-mm robotic trocar is placed under direct vision approximately 7–8 cm lateral to the reference mark. This trocar will accommodate robotic arm 1. Once the final robotic trocar has been placed, the 12-mm lateral assistant port is placed. The anterior superior iliac spine is palpated and serves as a landmark for placement of the lateral-most right-sided trocar. A 12-mm trocar is placed approximately 3–4 cm superomedial to the iliac crest in a line drawn directly between the iliac crest and the camera port. Lastly, a 5-mm assistant port is placed directly between the two previously placed right-sided ports approximately 3 cm superior to a line drawn between the two trocars.
Points of Technique: Initial Access to the Abdominal Cavity
Bowel injury is most common when gaining access to the abdominal cavity. There are a number of techniques that can mitigate the risk of bowel injury. First, as previously described, the camera port can be created using an open Hassan technique. Second, the patient can be placed in steep Trendelenburg position prior to inserting all additional robotic and assistant ports as the Trendelenburg position causes all mobile bowel to move out of the operative field, and third, the intraabdominal pressure can be raised to 20 mm Hg for the initial port placement, being reduced to 12 mm Hg once port placement is established.
Exposure of the Prostate
Key anatomic landmarks to note are the median umbilical ligament with the urachus and the two medial umbilical ligaments and the internal inguinal ring. Using either the straight or the 30-degree up lens, an incision is made in the peritoneum above the level of the pubic symphysis. The medial umbilical ligaments and the urachus are divided ( Fig. 79.2 ). This reveals the pubic symphysis and helps develop the space of Retzius ( Fig. 79.3 ). The peritoneal incision is carried along the lateral pelvis all the way up to the level of the vas deferens at the internal inguinal ring. A dissection that is too far lateral could injure the epigastric vessels and when too posterior puts the ureter at risk. The lateral attachments of the bladder are bluntly and sharply developed. This allows the bladder to fall posteriorly and expose the prostate in the space of Retzius. The fourth arm can be used to place cephalad traction on the bladder to allow good exposure. Caution must be used to identify an accessory pudendal artery, which may course through the tissues just lateral to the prostate and enter the genitourinary diaphragm at the dorsal vein complex ( Fig. 79.4 ).
Points of Technique: Bladder Retraction Suture
In patients with a large body mass index (BMI) or alternatively those patients with large-capacity bladders as a result of chronic retention, the bladder itself can often obstruct vision, dropping down into the operative field. One maneuver to overcome this problem is to insert a bladder retraction suture. A full-length suture can be brought in, passed through the apex of the dissected urachus and then brought out through the 5-mm assistant port. A clip is then applied to the bladder retraction suture, with greater tension applied to the bladder retraction suture throughout the procedure as the bladder becomes more mobile.
Points of Technique: Opening of Endopelvic Fascia
The endopelvic fascia can be opened to expose the prostate at various times during the operation. This step is often performed after removal of the anterior prostatic fat; however, the endopelvic fascia can be left intact with the prostate dissected from below the fascia, leaving what some referred to as the “Veil of Aphrodite.” Evidence for the efficacy of this approach regarding return of potency is debatable, but there is mounting evidence that preservation of the puboprostatic ligaments and the arcus tendineus may improve continence outcomes
Control of the Dorsal Vein Complex
The fatty tissue overlying the prostate should be carefully excised, further defining not only the anatomic boundaries of the prostate but also the superficial dorsal vein and the puboprostatic ligaments. The superficial dorsal vein can be divided with electrocautery.
Two basic techniques have been described for control of the dorsal vein complex, one that involves sutures or staples and the other that cuts it without energy after mobilization of the rest of the prostate. As with open surgery, suture rather than staple control of the dorsal vein complex is used more commonly if control is required early. After the endopelvic fascia is incised ( Fig. 79.5 ), a no. 0 polydioxanone suture (PDS) or Vicryl suture is placed around the dorsal vein complex using a CT-1 needle. Careful identification of an anatomic notch between the venous complex and the anterior urethra facilitates placement of the suture ( Fig. 79.6 ). A slip-knot tie can help ensure that the knot is secure. A second more proximal suture may be placed. Suspension of the urethra is accomplished by passing the suture through the pubic symphysis and securing it with a laparoscopic clip ( Figs. 79.7 and 79.8 ). Once the sutures are secured, it is not necessary to divide the dorsal vein complex at this point. The vascular venous control achieved by the suture placement helps avoid blood loss during the remainder of the operation while division of the dorsal vein complex and urethra is reserved for later in the procedure.
The alternative technique is to “cold-cut” the dorsal vein complex without prior suture ligation after full mobilization of the prostate just prior to division of the urethra. The intraabdominal pneumoperitoneum is increased to 20 mm Hg for a brief period and the dorsal vein is incised with scissors whilst the prostate is retracted cranially. This may decrease positive margin rates and improve early continence but can lead to increased blood loss. After incision the dorsal venous complex is sutured with a 3-0 Vicryl or barbed suture.
Dissection of the Bladder Neck
Proper identification of the anatomic plane between the bladder neck and the prostate is essential to avoid entry into the prostate base or result in an overly large bladder neck. Several visual cues are used. Grasping the more proximal bladder with the fourth arm and a ProGrasp instrument can place some tension on the bladder and help with exposure. Typically, the perivesical fat ends at an anatomically defined point at the prostatovesical junction. Some surgeons pull on the Foley catheter gently and use the balloon to help define the bladder neck. If the Foley appears to move laterally a middle lobe may be present. An important technique is to use the right and left arms of the robot to indent or “pinch” the bladder at the prostatovesical junction ( Fig. 79.9 ). This helps define the contour of the lateral prostate and allows the surgeon to visualize the point of division anteriorly.
Monopolar electrocautery scissors are used to begin the dissection of the prostatovesical tissue ( Fig. 79.10 ). Typically, there are some veins that require cautery control coursing from the dorsal vein complex and into the perivesical tissue. Most surgeons either use a Maryland bipolar forceps in the left arm or a bipolar grasper. The prostate tissue has quite a characteristic appearance to alert the surgeon when the dissection is too close to the prostate. It is more vascular, thicker in quality, and often exudes a bubbly white secretion when the incision is into the prostate tissue. The entry into the bladder should be proximal to the prostatovesical junction. The technique of bladder neck sparing with precise dissection of the bladder/prostate junction can be employed in an attempt to improve early continence, but this risks a positive margin in this area. The Foley catheter is deflated and withdrawn into the urethra to expose the bladder trigone. The trigone should be readily visible. Switching to a 30-degree down lens is advised at this point. Careful inspection should be performed to make certain that there is not a median lobe and identify the ureteric orifices. If so, the median lobe is grasped with the fourth arm, or a Vicryl suture placed through it, and lifted anteriorly to expose the trigone ( Fig. 79.11 ). Exposure is facilitated either by using the fourth arm or an assistant to elevate the Foley catheter or by directly grasping and elevating the prostate itself.
