Robotic Simple Prostatectomy

Fig. 21.1

Operating room setup for robotic simple prostatectomy. Schematic demonstrating the typical operating room setup for robotic simple prostatectomy utilized at our institution

Patient Positioning

Under general endotracheal anesthesia, the patient is placed in a modified lithotomy position (Fig. 21.2) over a nonskid foam pad. The patient is secured using the Yellofin^® stirrups and an upper-body warming blanket is applied. Care is taken to adequately pad all pressure points to avoid positioning injuries. The abdominal skin is shaved with clippers, and the patient is prepped and draped in standard sterile fashion for a transperitoneal pelvic robot-assisted surgery. An 18-French urethral catheter is inserted and an orogastric tube is placed. A standard time-out is called prior to incision.

Fig. 21.2

Patient positioning. For robotic simple prostatectomy, the patients are positioned in lithotomy and modified Trendelenburg

Instrumentation and Equipment List

Equipment

Si or Xi da Vinci^®
0° robotic scope (Intuitive Surgical, Inc., Sunnyvale, CA)
Monopolar Scissors (Intuitive Surgical, Inc., Sunnyvale, CA) × 1
ProGrasp™ Forceps (Intuitive Surgical, Inc., Sunnyvale, CA) × 2
Needle Drivers (Intuitive Surgical, Inc., Sunnyvale, CA) × 2
Clip Appliers (Intuitive Surgical, Inc., Sunnyvale, CA) × 2
Tenaculum Forceps (Intuitive Surgical, Inc., Sunnyvale, CA) × 1

Trocars

12 mm trocars × 2 (1 for the Xi)
8 mm trocars × 3 (4 for Xi)

Assistant Instruments

Suction irrigator device (Bariatric length)
Laparoscopic spoon forceps
Hem-o-lok applier (Teleflex Medical, Research Triangle Park, NC)
Medium (purple) Hem-o-lok clips (Teleflex Medical, Research Triangle Park, NC)
Laparoscopic needle driver
Laparoscopic scissor
10 mm specimen entrapment bag

Step-by-Step Technique (Videos 21.1, 21.2, 21.3, 21.4, 21.5, 21.6, 21.7, 21.8, and 21.9)

Step 1: Pneumoperitoneum and Trocar Placement

The first incision is made approximately 1–2 fingerbreadths above the umbilicus. Through this incision we establish pneumoperitoneum to 15 mmHg with a Veress needle. A 12-mm port (8 mm for the Xi) is inserted through this incision into the peritoneal cavity. The peritoneal cavity is then inspected using the 0° scope to ensure absence of any intra-abdominal injury from the Veress needle or the trocar. Four additional trocars are then inserted under direct vision. The 8-mm da Vinci^® working trocars are all placed at the horizontal level of the umbilicus with a separation of 8–10 cm between trocars. We prefer to keep the fourth robotic arm on the right side of the patient. A 12-mm assistant trocar is placed in the left upper quadrant in the midclavicular line taking care to avoid being too close to the camera trocar or the left robotic arm. Thus, a 4-arm, 5-trocar transperitoneal approach is employed (Fig. 21.3).

Fig. 21.3

Trocar placement . For transperitoneal robotic simple prostatectomy, a five-trocar placement is utilized. This placement is identical to that for robotic radical prostatectomy

At this point, the patient is placed in Trendelenburg position , and the da Vinci^® is docked (Fig. 21.4) between the legs for the Si or from the right side of the patient for the Xi. The instruments are inserted into the peritoneal cavity under direct vision. We initially start with a ProGrasp™ in the left and fourth arm and a monopolar scissor in the right arm.

Fig. 21.4

Robot docking . With the patient placed in lithotomy position and modified Trendelenburg, the da Vinci^® Si is docked in between the patient’s legs

Step 2: Cystotomy (Table 21.1)

Table 21.1

Instrumentation required for step 2: cystotomy

Surgeon instrumentation			Assistant instrumentation
Left arm	Right arm	Fourth arm	• Laparoscopic suction irrigator
• ProGrasp™ forceps	• Monopolar scissors	• ProGrasp™ forceps	• Laparoscopic suction irrigator
• Endoscope lens: 0°

The sigmoid colon is initially mobilized out of the pelvic cavity for better exposure of the target anatomy (Fig. 21.5a–d). The bladder is filled with approximately 200 mL of saline through the urethral catheter and a vertical midline cystotomy is created with monopolar scissors gaining access to the bladder lumen (Fig. 21.6a, b).

Fig. 21.5

(a–d) Mobilization of the sigmoid colon. The sigmoid colon (SC) is mobilized to allow for better exposure of the bladder (BL)

Fig. 21.6

(a, b) Midline vertical cystostomy . A midline vertical cystostomy is created to gain access to the anterior portion of the bladder

Step 3: Deploying Stay Sutures (Table 21.2)

Table 21.2

Instrumentation required for deploying stay sutures

Surgeon instrumentation			Assistant instrumentation
Left arm	Right arm	Fourth arm	• Hem-o-lok applier
• Needle driver	• Needle driver	• ProGrasp™ forceps	• Laparoscopic scissors
• Endoscope lens: 0°

All the fluid is suctioned out and 2–4 stay sutures are deployed to keep the edges of the cystotomy widely retracted. These stay sutures are 2-0 Polyglactin sutures , 6-in. long, on a CT-1 needle with a medium Hem-o-lok clip tied into the end of the suture. The stay suture is passed outside-in through the bladder wall at the edge of the cystotomy, anchored laterally to the abdominal wall, then pulled taut and secured with an additional Hem-o-lok clip (Fig. 21.7a, b).

Fig. 21.7

(a, b) Exposing the operative space of the bladder. A 2-0 Polyglactin suture on a CT-1 needle stitch with a Hem-o-lok at the end is passed through the bladder, anchored laterally to the abdominal wall, then pulled and secured with a Hem-o-lok to expose the bladder and keep open the operative space

Typically, a large prostatic adenoma that bulges into the bladder is immediately apparent. A 2-0 Polyglactin suture on a CT-1 needle stay suture is placed in the median lobe to provide traction and countertraction during the procedure using the ProGrasp forceps in the fourth robotic arm (Fig. 21.8). Bilateral ureteral orifices are then carefully identified and care is taken to keep them safe throughout the procedure.

Fig. 21.8

Prostatic median lobe control . A large prostatic adenoma is identified from within the bladder and a 2-0 Vicryl on a CT-1 needle stay suture is placed within the median lobe (ML) to provide traction and countertraction during the procedure

If simultaneous bladder diverticulectomy is to be performed, or if the intravesical adenoma is extremely large and very close to the ureteral orifices, ureteral double J stents can be placed using a 2 mm mini-port deployed in the suprapubic area. A 0.035-in. guide wire is inserted through the mini-port , floppy end first, and then a 4.8–6 French ureteral stent is advanced over the wire (Fig. 21.9a–d).