Open perineal radical prostatectomy was first described by Young in 1905 and remained the most common approach for surgical treatment of prostate cancer until the mid-1970s. The retropubic technique, initially described by Millin in 1947, was popularized in the early 1980s, thanks to the development of the Walsh anatomic approach. Still during the 1980s, Weiss and colleagues applied the techniques of cavernous nerve sparing described by Walsh and coworkers to open perineal radical prostatectomy. Nowadays, among the surgeons still opting for open surgery in the treatment of localized prostate cancer, the retropubic approach represents the preferred technique by most, although this preference seems to be based more on surgeon preferences rather than on the available evidence.
Robot-assisted radical prostatectomy was first described in Europe in the early 2000s. Its use rapidly expanded over the last two decades. Currently, robot-assisted radical prostatectomy performed by transperitoneal approach represents the most performed surgical approach for prostate cancer in the United States.
Laydner et al. first investigated the applicability of the da Vinci Si robotic system (Intuitive Surgical, Sunnyvale, California, United States) for the perineal approach to robot-assisted radical prostatectomy. The authors evaluated the feasibility of perineal robotic radical prostatectomy in preclinical models, then Kaouk leading the same group reported perineal robotic radical prostatectomy successfully completed in four patients who did not require concomitant pelvic lymph-nodes dissection, applying a single port robotic perineal approach by using the da Vinci Si robotic platform.
Again, the Cleveland Clinic group investigated the feasibility of perineal robot-assisted radical prostatectomy on a cadaver model. The novel SP1098 da Vinci robotic platform was used. The use of the single-port purpose-built robotic platform allowed the authors to describe, for the first time, the feasibility of robotic perineal pelvic lymph-nodes dissection. In parallel, Tuğcu and colleagues described “The Tugcu Bakirkoy” perineal robotic radical prostatectomy with pelvic lymph-nodes dissection in seven patients, using the da Vinci Xi HD Surgical System (Intuitive Surgical, Inc., Sunnyvale, California, United States) on single Gel-port platform.
Surgical technique for perineal robotic radical prostatectomy with single-site multiport approach (R-LESS)
To achieve the perineal access, scalpel, tissue forceps, Metzenbaum scissors, Allis and right-angle forceps, as well as Richardson retractors are used. A GelPOINT Mini Advanced Access Platform (Applied Medical, Rancho Santa Margarita, California, United States) is used, including an Alexis wound retractor and a GelSeal Cap (Applied Medical) ( Fig. 5.1 ).
The da Vinci Si system is used in a 3-arms configuration. One 12-mm port for the robotic optic, one 10-mm port for the assistant, and two 8-mm robotic ports are inserted through the GelSeal Cap in a diamond-shape configuration. An additional 5-mm port for the assistant can also be placed ( Fig. 5.2 ).
A 0-degree robotic scope is used. Robotic monopolar curved scissors (Hot Shears) and robotic needle driver are used in the right hand. A robotic grasper (ProGrasp forceps) is used in the left hand.
Prostate assessment and patient positioning
The patient is placed in the lithotomy position ( Fig. 5.3 ).
Digital rectal examination, cystoscopy, and transrectal ultrasonography should be preoperatively performed to get an estimate of the prostate size. The patient is taped to the surgical table. The Trendelenburg position can be applied if needed.
Perineal access and robot docking
A procedure analog to the Belt approach is performed, retracting the external sphincter muscle superiorly. The single port device is inserted into the wound, and CO 2 insufflation is obtained. The robot is brought into the field and docked from behind the head ( Fig. 5.6 ).
Enough room for the anesthesiology team to access the head, the neck, and the chest of the patient is available from either side.
Robotic procedure step-by-step
The recto-urethralis muscle is identified and divided. The bedside assistant provides crucial information to the console surgeon while performing digital rectal examination. The levator ani fibers are split aside, and the posterior aspect of the Denonvilliers fascia is identified and incised, preserving the neurovascular bundles intact. The posterior plane of the prostate, the vas deferens, and the seminal vesicles are dissected. The prostatic pedicles are clipped and divided.
The prostatic apex is dissected, the urethra is transected, and the Foley catheter is clipped and cut ( Fig. 5.7 ).
The proximal portion of the catheter is used as a handle for retraction. The anterior and lateral planes of the prostate are dissected. The bladder neck junction is identified and dissected off from the prostate. The catheter clip is removed to deflate the balloon and the specimen is divided from the bladder ( Fig. 5.8 ).
A second Foley catheter is inserted to guide the vesicourethral anastomosis, performed according to the Van Velthoven technique ( Fig. 5.9 ).
After completion, the water-tightness of the anastomosis is tested with instillation of 200 mL of saline in the bladder. The robot is undocked, and the single-port device is removed. The specimen is retrieved through the perineal incision. The perineal fascial and the subcutaneous planes are re-approximated, and the skin incision is sutured.
Surgical technique for transperineal single-port robot-assisted radical prostatectomy performed by using the single-port surgical platform
The recent development of the purpose-built single-port (SP) robotic platform has prompted the re-discovery of the transperineal approach to radical prostatectomy.
The intracorporeal triangulation of the double-jointed instruments and the fully wristed three-dimensional optics do contribute to resolving the external clashing typical with the previous-generation multiarms robotic platform, allowing surgery to be performed in a narrow surgical field.
Positioning, perineal access, and port placement
After the perineal access is gained as mentioned above for the multiport approach (see Section 5.2 ) and the GelPOINT device (Applied Medical, Rancho Santa Margarita, CA, United States) is inserted, the 2.5-cm specialized, multichannel single-port trocar is placed. This novel single port accommodates three 6-mm robotic instruments and a 10×12-mm articulating camera ( Fig. 5.10 ).
The robotic device is then docked ( Fig. 5.11 ).