With rapid changes in medical technologies, there has been significant growth in surgical approaches for the management of benign prostatic enlargement (BPE) and bladder outlet obstruction. Despite more surgical approaches, there remain few options for large prostates (≥80 g). Previously, open simple prostatectomy was the gold standard for the management of large prostates. Minimally invasive approaches have recently gained popularity by maintaining clinical benefit and reducing patient morbidity.
This chapter reviews laparoscopic and robotic simple prostatectomy. With the advent of laparoscopy, this approach was initially undertaken and embraced because of decreased perioperative complications. While laparoscopy gained traction, its diffusion into practice was limited to experienced laparoscopic surgeons. This changed with the use of robotics initially described by Sotelo et al in 2008. Laparoscopic simple prostatectomy is discussed, but the primary focus of this chapter is the various approaches to robotic-assisted simple prostatectomy (RASP).
Indications and contraindications
Ideal candidates for laparoscopic or robotic simple prostatectomies are those with bothersome lower urinary tract symptoms or upper tract deterioration secondary to large prostates (≥80 g). Additional surgical indications in patients with large prostates include recurrent urinary tract infections, recurrent gross hematuria with or without bladder stones due to BPE, and lower urinary tract symptoms refractory to medications (American Urological Association Benign Prostatic Hyperplasia [AUA BPH] guidelines). The robotic simple prostatectomy approach is particularly well suited for patients who have additional pathologies such as bladder diverticula or bladder stones, as these conditions can be managed concomitantly without significant additional operative time or risk of morbidity.
Contraindications to the minimally invasive simple prostatectomy include patients whose cardiopulmonary status cannot tolerate prolonged steep Trendelenburg position, those who cannot be medically optimized for abdominal surgery, and patients who are unable to discontinue use of anticoagulants. Relative contraindications to RASP include patients with clinically significant prostate cancer who are candidates for extirpative therapy, as well as those who have had pelvic radiation or multiple transabdominal procedures, as this significantly increases the morbidity of the operation.
Patient preoperative evaluation and preparation
As with any minimally invasive procedure, careful preoperative evaluation is crucial for appropriate patient selection and operative success. Generally, a complete blood count, coagulation profile, type and screen, and comprehensive metabolic panel in conjunction with a urinalysis and culture are ordered as part of the presurgical work-up. Preoperative antibiotics are not routinely administered unless there is evidence of an infection on urine tests. Depending on the patient’s age and comorbidities, medical and/or cardiac clearance and optimization are essential. Additionally, a digital rectal exam should be performed and a prostate-specific antigen (PSA) level should be obtained to screen for prostate cancer in men less than 70 years old. If the PSA level is elevated, calculating a PSA density can help differentiate benign causes versus possible adverse pathology that would warrant a preoperative prostate biopsy. Imaging (ultrasound, magnetic resonance imaging) or direct visualization (cystoscopy) of the prostate is recommended to ensure the prostate is of the appropriate size (≥80 g) to warrant such a procedure and to evaluate for additional pathology such as bladder stones or diverticula. While other screening tools such as the International Prostate Symptom Score (IPSS) questionnaire, uroflowmetry, urodynamics, and a postvoid residual (PVR) can be used to aide in decision making, the utilization of such tests is surgeon-dependent.
Patients should be informed regarding the possible operative complications, such as the need for a blood transfusion, bowel injury, or urine leak. Furthermore, patients should be counseled as to the expected postoperative course, which involves having an indwelling urethral catheter and self-suction drain, as well as potential issues including hematuria requiring continuous bladder irrigation. Finally, patients should be aware of the possibility of discovering prostate cancer within the specimen upon pathological analysis, despite appropriate preoperative screening.
Operating room configuration and patient positioning
As with most minimally invasive pelvic surgeries, the patient is positioned in the low dorsal lithotomy position ( Fig. 30.1 ). Venodyne boots should be placed for the procedure, and subcutaneous administration of heparin can be considered. After induction of general anesthesia and placement of an endotracheal tube, the patient’s legs are placed within stirrups. The knees should not be flexed beyond 90 degrees to prevent pressure/compression of the popliteal vasculature. Care must also be taken to prevent pressure on the lateral aspect of the knee, which could result in peroneal nerve injury. Excess hip flexion and/or abduction must also be avoided to prevent lateral femoral cutaneous, femoral, or sciatic nerve injuries. The patient’s arms are tucked at their sides. Finally, the patient is secured to the surgical bed, and all pressure points are padded. Shoulder braces are no longer used to position the patient due to risk of brachial plexus injury. The patient is placed into a steep Trendelenburg position. For extraperitoneal approaches, minimal Trendelenburg positioning is needed. A Foley catheter should be placed sterilely into the bladder prior to trocar placement.
For a transabdominal approach, pneumoperitoneum can be obtained via Veress needle or Hassan techniques. We prefer the use of Veress needle insertion into the umbilicus to establish pneumoperitoneum. Opening pressures should be less than 5–10 mm Hg, and insufflation is typically taken to 15 mm Hg. For patients who have had prior lower abdominal or pelvic surgeries, alternative Veress needle insertion sites (e.g., subcostal) can be used instead. Once insufflation is complete, an initial 8-mm robotic camera trocar can be placed at or near the umbilicus. If the patient has had prior surgery in this area, the Hassan technique can be used. Alternatively, a second Veress needle can be placed through the incision, and if there is immediate return of air, this suggests there are few, if any, adhesions and provides some assurance that the trocar can be safely placed.
Once the trocar is in place, the laparoscopic camera can be brought into the abdomen to inspect for any Veress needle or trocar injuries and/or any aberrant anatomy. The remaining trocars can be placed under direct visualization to prevent intraabdominal injury. Port placement mimics that of the robotic radical prostatectomy and typically includes robotic trocars placed to the left and right of the midline and a fourth robotic trocar placed more laterally ( Fig. 30.2 ). We prefer to use an 8- or 12-mm AirSeal trocar (SurgiQuest, Milford, CT) on the contralateral side to the fourth robotic trocar for use as an assistant port. An additional 5-mm assistant port can be placed cephalad between the camera and robotic trocars. The robot can then be brought in for docking.
A strictly laparoscopic approach to the simple prostatectomy has trocar placement very similar to the robotics as described above. A 10-mm camera port is placed in the midline after establishing pneumoperitoneum. Next, the remaining trocars can be placed under direct visualization. As with robotic procedures, an 8- or 12-mm lateral AirSeal trocar can be used ( Fig. 30.3 ).
For a transperitoneal approach, a 12–15 mm infraumbilical incision is made. The anterior rectus fascia is then identified and incised transversely to expose the bellies of the rectus muscles. The muscle bellies are then bluntly separated in the midline to expose the posterior rectus sheath. Blunt finger dissection then takes place inferiorly in the plane between the posterior rectus sheath and the posterior aspect of the muscle bellies. With this, a 12-mm balloon trocar can now be inserted down toward the pubic bone and inflated under direct visualization to develop the extraperitoneal space. When performed correctly, the pubic arch and inferior epigastric vessels (located ventrally) should be clearly identified. Once pneumoextraperitoneum is established, the four additional trocars can then be placed in a similar fashion to that of laparoscopic/robotic approaches. Care should be taken to try and adequately space the trocars to prevent clashing ( Fig. 30.2 ).
Procedures ( )
Mimicking the various approaches taken with open simple prostatectomy, the robotic simple prostatectomy can be performed in multiple ways. Both transperitoneal and extraperitoneal abdominal approaches have been well described. In approaching the resection of the prostate adenoma, a transvesical (suprapubic) or a transcapsular (retropubic) method can be used.
Robotic transperitoneal suprapubic prostatectomy
Mobilization of the bladder
After the robotic trocars are placed, the pelvis is inspected for any injuries during port placement and for any aberrant anatomy. The anterior abdomen is inspected, and the medial umbilical ligaments are identified ( Fig. 30.4 ). The peritoneum is then incised lateral to the obliterated ligament to enter the preperitoneal space ( Fig. 30.5 ). A combination of blunt and sharp dissection can be used to drop the bladder as dissection is taken down into the pelvis to develop the space of Retzius.