Robotically Assisted Laparoscopic Radical Prostatectomy

SANDIP M. PRASAD

DAVID GILLATT

MAGNUS ANNERSTEDT

Until the past two decades, radical prostatectomy for clinically localized prostate cancer was traditionally performed through a retropubic or perineal approach. Since the first reported laparoscopic radical prostatectomy (LRP) performed by Schuessler and colleagues (1) in 1997, the use of this minimally invasive approach gained favor in certain centers for the reported improvements in perioperative outcomes including blood loss and length of stay with similar functional and oncologic outcomes in high-volume centers (2). However, the technical challenges associated with this approach, including intracorporeal suturing of the vesicourethral anastomosis, limited range of motion, and two-dimensional optics, limited its widespread adoption to skilled laparoscopists.

One decade following the first LRP, Abbou and colleagues (3) first reported the use of a robotic system to perform the critical steps of radical prostatectomy in 2001. They used the da Vinci surgical system, which remains to this day the only commercially available surgical robot used for radical prostatectomy. Since that time, robotically assisted laparoscopic radical prostatectomy (RALP) has become the standard of care for radical prostate cancer surgery in most western countries accounting for the majority of all such procedures.

The aim of this chapter is to describe the use of the da Vinci surgical system to deliver RALP and to outline some of its potential advantages and pitfalls.

BENEFITS OF ROBOTIC-ASSISTED SURGERY

The da Vinci system is a precise master-slave surgical assistance device with high-quality, three-dimensional, magnified optics. It offers the surgeon the opportunity to operate in narrow spaces with difficult access through the use of three (in earlier generations) and four multijointed robotic arms. In addition, the robotic platform offers the surgeon the additional benefits of motion scaling to allow precise dissection and tremor filtration to facilitate delicate movements (4). The instrumentation articulates about a “wrist” allowing 7 degrees of movement exceeding that of the human wrist. It is particularly effective for difficult dissection and for suturing in tight spaces.

INDICATIONS FOR SURGERY

The indications for RALP are the same as those for open or laparoscopic approaches. Patients should have clinically localized prostate cancer and a life expectancy exceeding 10 years. As experience with RALP has grown, previously stated contraindications such as prior abdominal surgery and obesity are rarely an obstacle to performing RALP with reasonable
short- and long-term outcomes in the hands of experienced surgeons (5,6).

PREPARATION

Standard preoperative assessment is appropriate, including a type and screen. Blood products are uncommonly administered given the low rate of blood transfusion with RALP (7). We use a clear liquid diet the day before surgery and a mild mechanical bowel prep the evening prior to surgery. Some surgeons use a preoperative enema to cleanse the rectum; however, in our practices, this is only employed in those undergoing salvage surgery postradiation given the increased rate of rectal laceration in these patients (8).

On the morning of surgery, patients receive perioperative antibiotic prophylaxis with a cephalosporin and deep venous thrombosis prophylaxis with subcutaneous heparin and sequential pneumatic compression devices prior to induction per AUA recommendations (9,10).

ANESTHETIC CONSIDERATIONS

General anesthesia is essential for this operation. The patient requires relaxation and will be positioned in extreme Trendelenburg for a prolonged period. This position, coupled with pneumoperitoneum, may produce cardiopulmonary derangements in certain patients. In addition, a history of glaucoma or intracranial pathology such as arteriovenous malformation or cerebral aneurysm should be reviewed, as this position results in increased intraocular pressure and cerebral blood volume (11,12). Typically, an arterial line or central venous access is not routinely needed except in selected patients at higher risk of complication. In addition, to avoid periorbital and laryngeal edema, judicious fluid administration should be delivered while the patient is in Trendelenburg position (13).

SURGICAL TEAM

The surgical team is composed of one surgeon at the robotic console and one bedside assistant. To facilitate efficiencies in preparation for and performance during robotic surgery, we endorse the use of a dedicated “robot team” for nursing and surgical assistants.

POSITIONING

The patient is positioned in a lithotomy position with the arms tucked. The operating table needs to allow the legs to be separated and the hips to be flexed/extended. It should allow Trendelenburg positioning. The hips should be slightly flexed and the thighs supported to reduce stress on the anterior thigh muscles. The legs should be bandaged to the leg supports in order to fix their position. Once the ports are in place, the patient will be tilted into Trendelenburg to an angle of approximately 30 degrees. The legs may then be brought downward by extension at the hip to allow access for the da Vinci robot between the legs. At all times, care must be taken to avoid tension on the thigh muscles and any excess pressure on calves and thighs. Positioning injuries, although uncommon, can lead both to nerve impairment and rhabdomyolysis (14,15). Once the patient is prepped and draped, an 18Fr Foley catheter is placed sterilely on the field.

PORT PLACEMENT AND DOCKING

Pneumoperitoneum is obtained by surgeon preference; we employ the Veress needle through the anticipated camera port immediately cranially or inferiorly to the umbilicus. Pneumoperitoneum is established to 15 mm Hg with CO₂. The 12-mm camera port is then introduced directly through this incision and then the 0-degree camera (used for the entire case) is passed into the peritoneum and accessibility including the presence of adhesions is assessed. In the setting of prior upper abdominal surgery or umbilical hernia repair, we use an optical trocar or the open Hasson technique to gain access into the peritoneum.

The anticipated location of each port is infiltrated with local anesthetic without epinephrine. All ports are then placed under direct vision, with laparoscopic adhesiolysis performed as needed to facilitate port placement. Three 8-mm da Vinci reusable ports are then placed. Two are positioned laterally 8 to 10 cm from either side of the midline just below the camera port and the third laterally approximately 8 cm from the medial robotic port at least two fingerbreadths above the anterior superior iliac spine (ASIS). The right-handed robotic port will house the scissors/shears; the left-handed robotic port uses the bipolar forceps (fenestrated or Maryland); and the third robotic port exclusively uses the ProGrasp forceps. This third arm is placed on the right or left side of the patient per surgeon preference. It is critical that the ports are separated by a minimum of 8 cm so that the da Vinci arms do not clash outside the patient during the procedure.

In addition, two conventional laparoscopic assistant ports are placed on the opposite side to the third arm. A 12-mm port is placed laterally, at least 2 cm anterior and superior to the ASIS, and a 5-mm port is placed above and just medial to the medial robotic port below the costal margin. These ports are used for retraction, suction, introduction of sutures, and other laparoscopic assistance by the bedside assistant.

Prior to docking, the patient is placed in extreme Trendelenburg at an angle of approximately 30 degrees and the legs are dropped by extending the stirrups at the hip joints. Once the ports are in position, the da Vinci system should be guided over the patient’s abdomen by being driven in a straight line between the patient’s legs. When the central arm is over the camera port in the “sweet spot,” the four da Vinci arms can be positioned and locked on to their respective ports. The camera and its port are positioned to view the lower abdomen and pelvis. The instruments are inserted under vision and locked into their respective ports.

With experience, the steps from Veress insertion to docking the robot can be achieved in less than 15 minutes.

THE OPERATION

There are two traditional surgical approaches to RALP—the “anterior” and “posterior” approach. This specifically refers to the approach for dissection of the vasa and seminal vesicles (SV). If the posterior approach is employed, this is the first
step in the procedure and is described in the following text. In the anterior approach, dissection of the seminal vesicles is performed following division of the posterior bladder neck. If indicated, we also advocate performing pelvic lymph node dissection (PLND) prior to beginning radical prostatectomy, as the therapeutic benefit of prostatectomy is unknown in the setting of positive regional lymph nodes.

Dissection of the Vasa and Seminal Vesicles (Posterior Approach Only)

Adhesions of the large and small bowel to the lateral pelvic side walls are common and adhesiolysis is performed to allow for exposure of the planned PLND and for allowing mobilization of the sigmoid colon out of the pelvis. The peritoneum overlying the vas deferens is divided in the pouch of Douglas 3 to 4 mm above the insertion of the sigmoid colon into the posterior peritoneum. Once the vas is identified, it is dissected to the base of the prostate and laterally to an anatomic “bend” that can be visualized at the lateral edges of the posterior peritoneum overlying the pouch of Douglas and then divided laterally. Once the vas is freed, it is retracted anteriorly and the SV can be identified posteriorly. Dissection of the SV occurs in a medial to lateral direction posteriorly, with a combination of sharp and blunt cold dissection to free the SV from surrounding tissues. Hem-O-Lok clips can be used to isolate and divide perforating arteries that are present posteriorly and at the tip of the SV. This process is repeated on the other side and once the vasa and SVs are divided, they are retracted anteriorly. Denonvilliers fascia is then visible under these structures and can be sharply incised just below the SVs and a plane can be developed using sharp and blunt dissection posterior to the prostate up to the apex. Some surgeons will choose to start this plane and then complete the posterior dissection following bladder neck division, but the entire posterior dissection to the prostatic apex can be performed at this time.

Bilateral Pelvic Lymph Node Dissection (If Indicated)

The standard PLND boundaries are the bifurcation of the common iliac artery proximally, the node of Cloquet posteriorly, the bladder medially, the obturator nerve posteriorly, and the pelvic side wall laterally. The fourth arm is used to mobilize the sigmoid colon to the contralateral side of PLND to visualize the bifurcation of the common iliac artery. The peritoneum is divided along the visualized path of the external iliac artery from the bifurcation of the common iliac artery to the internal inguinal ring. The lateral aspect of the lymph node package is developed by opening the fibroadipose tissue from the anterior and medial surface of external iliac vein until the pelvic side wall is identified. We find this easiest at the level of the pubis where the obturator nerve can be identified and then carried out proximally.

The medial aspect of the PLND is then performed by grasping the obliterated umbilical artery and retracting it medially. There is a fibroalveolar plane lateral to the bladder that can be carried bluntly to the obturator nerve. Once the obturator nerve is identified, the closed scissors is used to bluntly and gently strip nodal tissue off the nerve along the entire length of the nodal packet. The lymph node packet is then divided distally beyond the node of Cloquet. Clips or bipolar energy are recommended for larger lymphatic vessels to avoid postoperative lymphatic leak. Anterior retraction of the packet facilitates proximal dissection to the iliac artery bifurcation. Lymph nodes are placed into a 10-mm laparoscopic specimen retrieval bag and removed through the assistant 12-mm port. We do not routinely send frozen sections unless there is high clinical suspicion intraoperatively or by preoperative imaging.

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