Robotic Laparoendoscopic Single‐site Lower Tract Surgery

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Robotic Laparoendoscopic Single‐site Lower Tract Surgery

Daniel Ramirez¹, Matthew J. Maurice,² & Jihad H. Kaouk²

¹ Urology Associates of Nashville, Nashville, TN, USA

² Cleveland Clinic, Glickman Urological and Kidney Institute, Cleveland, OH, USA

Introduction

The use of robotic platforms in urologic surgery has become widely prevalent secondary to the benefits it provides over conventional laparoscopy, including enhanced three‐dimensional optics, improved instrument control and dexterity, and superior ergonomics. These technological advancements have resulted in the adoption of robotics in laparoendoscopic single‐site (LESS) surgery to surmount difficulties associated with intra‐abdominal triangulation and intracorporeal suturing. The first robotic laparoendoscopic single‐site surgery (RLESS) series was published in 2008 [1], and since that time, various studies have demonstrated its application in lower tract urologic procedures [2–8]. Although the benefits afforded by the application of the robotic platform are tremendous, major limitations inherent to single‐site surgery still exist, including bulky external mechanics, instrument clashing, and limited space for the bedside assistant surgeon. Although many technical improvements have been described to tackle these challenges, pelvic RLESS is still evolving and has not been widely embraced [9, 10].

Several aspects of conventional robotics cross over to RLESS, including operating suite layout, instrumentation, and surgical draping. The main difference between the two approaches is port‐site access and docking. RLESS typically utilizes ports that are more obliquely placed to one another in order to limit external clashing. The specific steps of each procedure are similar, though some creativity must be used when employing RLESS to address the aforementioned challenges. This chapter discusses the tools, techniques, published outcomes, and up‐and‐coming technology associated with specific urologic RLESS procedures of the lower urinary tract. In addition, a video has been included to demonstrate our technique for performing RLESS perineal radical prostatectomy utilizing a novel single‐port robotic platform (see Video 122.1).

Robotic docking for RLESS technique

In terms of docking, a few noteworthy differences exist between traditional multisite robotic surgery and RLESS. The authors typically prefer the da Vinci Si or Xi models versus the S model due to the improved optics and ergonomics. The Xi model offers a more compact, sleeker external profile of the patient cart, which may allow for decreased external clashing. In addition, only three robotic arms are using during pelvic RLESS surgery as there is limited space to accommodate the additional robotic instrument arm.

Other techniques which may limit external clashing include the “chopstick” technique popularized by Joseph et al., in which the robotic instruments are crossed at the fascial level in order to create more working space between the robotic arms outside of the surgical field [11]. This technique was previously utilized in the traditional LESS approach but proved to be very challenging due to the “reverse‐handedness” associated with crossing of the instruments. A major benefit of applying the robotic platform to LESS is the ability to control each instrument electronically, permitting the interchange of instruments and master controllers, effectively removing the limitation of “reverse‐handedness.” The main limitation of the chopstick technique is the trade‐off of external clashing for internal clashing. Crossing of the instruments at the fascial level results in the deflection of the instruments where their shafts cross. The surgeon must always be aware of the position of each instrument to avoid any counter‐springing associated with exaggerated movements.

Pelvic surgery

Radical retropubic prostatectomy

For radical retropubic prostatectomy we favor obtaining single‐site access using a multichannel SILS port (Medtronic, Minneapolis, MN, USA). For this technique, all of the robotic ports occupy the same skin incision but enter the intra‐abdominal space through separate fascial incisions. The robotic camera port, bedside assistant port, and insufflation tubing are placed through the SILS port at the lower aspect of the umbilicus. Arrangement of the operative suite, patient positioning and docking are the same as conventional robotic radical prostatectomy, with the patient positioned in dorsal lithotomy and steep Trendelenburg with the robotic cart docked between the patient’s legs. The multichannel port is inserted at the inferior aspect of the umbilicus through the linea alba of the rectus fascia. The 8 mm lateral robotic ports are placed at the lateral‐most inferior edge of the skin incision and are skived through the subcutaneous fat as far laterally as possible to approximate the positioning used for the traditional approach. The fourth instrument arm is not used for the RLESS technique. Using this port arrangement, the “chopsticks” method is not needed.

The major steps of performing RLESS retropubic radical prostatectomy are the same as those used for the conventional robotic approach. Initially the bladder is mobilized to develop the space of Retzius using an 8 mm curved monopolar scissor in the right arm and an 8 mm ProGrasp forceps or a 5 mm Schertel grasper in the left arm. Use of a 30° up scope initially may be beneficial for controlling and ligating the urachus. The bladder is dropped from the anterior abdominal wall, and the anterior surface of the prostate is defatted to expose the endopelvic fascia and dorsal venous complex (DVC). The endopelvic fascia is opened, and the DVC is identified and controlled with 2‐0 braided polyglactin suture using an 8 mm robotic needle driver in the right arm. The junction between the bladder and prostate is then identified, and the bladder neck is opened in order to expose the urethral catheter. Identification and dissection of the bladder neck is facilitated by having the catheter balloon deflated and the catheter advanced all the way into the bladder. Once the bladder neck is open, the catheter is pulled up into the field. A “marionette” suture is used to secure the catheter to the anterior abdominal wall, as was explained in our initial RLESS series [1]. This allows for anterior retraction of the prostate during posterior dissection. Once the prostate is completely freed from the bladder neck, the anterior Denonvilliers’ fascial layer is identified and opened to reveal bilateral vas deferens and seminal vesicles. When nerve sparing is not performed, energy may be used during this dissection. If nerve sparing is planned, energy should be avoided. The posterior dissection is performed from the base of the prostate to the apex, carefully releasing the rectum. Once the posterior plane is complete, bilateral nerve sparing is performed (when appropriate), along with bilateral control of the prostatic vascular pedicles. Once this is done, attention is turned to the prostatic apex. We typically perform a meticulous apical dissection to ensure the longest urethral length possible while avoiding positive margins. The urethra is sharply transected. Once the prostate is removed from the pelvis, bilateral pelvic lymph node dissection is performed. Once the lymph nodes are removed, the vescicourethral anastomosis is performed using two 8 mm robotic needle drivers in the left and right arms. We typically perform our anastomosis in a running fashion with two 2‐0 poliglecaprone 25 sutures on RB‐1 needles. At the end of the procedure, the anastomosis is tested by instilling 200 ml of sterile saline into the bladder, and a 10 mm Jackson–Pratt drain is routinely left. A separate facial stab incision is made for placement of the drain, but the drain is externalized via the same skin incision used for the multichannel port, thereby limiting the number of skin incisions.