Indications and contraindications
Prostate cancer is risk stratified on the basis of prostate-specific antigen (PSA), tumor grade, and clinical stage. Very low-risk disease is defined as a PSA level level lower than 10 ng/mL, a Gleason score of 6 or less, clinical stage T1–T2a with <34% of biopsy cores positive, and no single core >50% involved with PSA density <0.15 ng/mL. Low-risk disease is defined by a PSA level lower than 10 ng/mL, a Gleason score of 6 or less, and clinical stage T1–T2a that does not meet the criteria defined by very low-risk disease. Intermediate-risk patients are those with a PSA level between 10 and 20 ng/mL, a Gleason score of 7, or clinical stage T2b, who otherwise do not qualify as high risk. High-risk patients include those with a PSA level above 20 ng/mL, a Gleason score of 8 to 10, or clinical stage T2c. New evidence suggests that men with low- and intermediate-risk disease may not benefit from definitive management, whereas recurrence rates are high after local control of high-risk prostate cancer. New advances in genetic testing have provided additional tools (in addition to prostate magnetic resonance imaging) to help the urologist in deciding which patients to biopsy as well as risk stratify patients with a known diagnosis of prostate cancer. Genetic tests such as SelectMDx (MDx Health, Irvine, CA) and 4Kscore (Opko Health, Elmwood Park, NJ) can be performed on urine, blood, and noncancerous tissue to help urologists counsel patients on the likelihood of detecting clinically significant prostate cancer. Similarly, tissue-based tests such as OncotypeDX (Exact Sciences, Madison, WI) and Decipher (Decipher Biosciences, San Diego, CA) help urologists counsel newly diagnosed prostate cancer patients regarding their risk of adverse pathology as well as risk of metastasis and death after treatment.
As with any surgical intervention, the surgeon should take into account the entirety of the patient clinical picture when counseling about management options. These variables include the patient’s life expectancy; overall health; tumor characteristics; and urinary, sexual, and bowel function. Men with clinically localized prostate cancer should be presented with the unique risks and benefits of all management options, which include active surveillance, radiation therapy, radical prostatectomy, and the emerging role of focal therapy.
Radical prostatectomy is intended to cure patients in whom prostate cancer is truly localized and who are surgical candidates. Patients who have incomplete excision or lymph node-positive disease are at risk for recurrence and progression. To date, it is unclear to what extent pelvic lymph node dissection (PLND) benefits survival. There are limited retrospective series that have demonstrated that patients with clinically positive nodes (cN1 with pathologically node positive) have similar survival outcomes when compared to patients with occult node positivity (cN0 and pathologically N1). At this time, the surgical approach for clinically node-positive patients should be reserved for the clinical trial setting.
Radical retropubic prostatectomy has long been the gold standard for definitive surgical therapy, but it has been challenged by less invasive approaches such as laparoscopic radical prostatectomy (LRP) and robotic-assisted laparoscopic prostatectomy (RALP). Today, more than 85% of prostatectomies are performed via a minimally invasive approach. With greater experience, there are few contraindications to LRP and RALP as compared with open surgery.
Absolute contraindications to LRP or RALP include the inability of the patient to undergo general anesthesia because of severe cardiopulmonary comorbidity and uncorrectable bleeding diatheses. Prior abdominal or pelvic surgery increases technical difficulty for transperitoneal RALP especially, but it is not an absolute contraindication. Salvage surgery after primary treatment failure should be approached with caution and is associated with increased risk of urinary incontinence and rectal injury. Morbid obesity may place the patient at risk for respiratory compromise while positioned in the steep Trendelenburg position and for rhabdomyolysis (particularly if the patient is in the lithotomy position) should operative times be long. Finally, neoadjuvant androgen deprivation, multiple prostate biopsies, and the surgical management of benign prostatic hyperplasia can increase technical difficulty and alter anatomic landmarks but are not absolute contraindications to surgery.
Patient preoperative evaluation and preparation
Patients are seen preoperatively for a complete history and physical examination, with special attention paid to medical comorbidities and surgical history. An electrocardiogram, a chest x-ray, a complete blood cell count, a basic metabolic panel, a coagulation profile, and a urinalysis specimen with culture are obtained. Informed consent is obtained for both laparoscopic surgery and open conversion. Patients are counseled on the risk of bleeding, transfusion, infection, injury to adjacent organs, incisional hernia, impotence, and incontinence. The risks of general anesthesia must also be discussed because laparoscopic prostatectomy cannot be performed with the patient under regional anesthesia. It is our practice to obtain a baseline assessment of urinary symptoms with the International Prostate Symptom Score and erectile function with the Sexual Health Inventory of Men. This allows for improved counseling regarding a realistic forecast of the return of urinary and erectile function.
Bowel preparation varies by surgeon. Magnesium citrate and clear liquids may be started the day before surgery; however, some surgeons prefer to use only a fleet enema on the morning of the operation. Broad-spectrum antibiotics are administered intravenously within 1 hour of incision in accordance with the American Urological Association guidelines.
Operating room configuration and patient positioning
The operating room should be large enough to accommodate the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) comfortably with ample room for the surgical team and anesthesia staff in the configuration shown in Fig. 31.1 . At our institution, we use the da Vinci Xi Surgical System with a four-arm technique.
The bedside surgical assistant should be well versed in laparoscopy and troubleshooting the robotic system. The scrub technician must also be familiar with docking the robot and exchanging robotic instruments. Finally, the anesthesiologist must be aware of the physiologic nuances of laparoscopy and steep Trendelenburg positioning. Adequate communication between team members is essential to a smooth operation.
After induction of general anesthesia, the arm boards are removed, and the patient’s arms are tucked to the side with two draw sheets and foam padding as shown in Fig. 31.2 . The hand and wrists are padded, with the thumb oriented upward in an anatomically neutral position.
Depending on the robotic system utilized, a split-leg table or stirrups may be used to abduct the patient’s legs, resulting in robotic docking between the patient’s legs and allowing access to the perineum during the case. When a split-leg table is used, the hips are flexed gently. Surgeons should take care not to overflex the hips as this may result in femoral nerve stretch injuries. Care should also be taken when stirrups are used because pressure injuries can occur at the calf if operative times are long. In the case of the da Vinci Xi Surgical System, patients can be placed in the supine position without stirrups or a split-leg table. This is enabled by the rotating arm of the Xi system, which allows for robotic sidecar docking lateral to the patient. However, surgeons may still choose to use stirrups or a split-leg table should optimal perineal access be necessary. Sequential compression devices are placed and activated.
The patient’s upper body is secured with foam padding and heavy cloth tape across the xiphoid process. This prevents the patient from sliding backward when placed in the steep Trendelenburg position. An orogastric tube is placed to decompress the stomach. The abdomen is shaved, prepped, and draped in the usual sterile fashion. The penis is prepped into the field, and a 16-French urethral catheter is placed.
A total of six trocars are used for transperitoneal RALP and are described here based a da Vinci Xi configuration ( Fig. 31.3 ). An 8-mm trocar is used for the endoscope and camera. This is placed approximately 15 to 17 cm superior to the pubic symphysis and within the curvature of the umbilicus. Two 8-mm metal robotic trocars are placed in a pararectus position, approximately 8 cm lateral and slightly caudal to the camera trocar. An additional 8-mm robotic trocar is placed approximately 8 cm lateral to the right robotic trocar to accommodate the fourth robotic arm. The surgical assistant uses an 8-mm AirSeal (ConMed, Utica, NY) trocar in the left lower quadrant just superior medial to the anterior superior iliac spine at the same level as the pararectus trocars that are used for passage of clips and suture. Some surgeons may choose to place this assistant trocar in the right lower quadrant depending on their choice. Finally, a 5-mm trocar (mainly used for suction and irrigation) is placed in the left upper quadrant at the apex of a triangle made between the assistant trocar and the left pararectus trocar.
Procedure ( )
LRP and RALP can be approached transperitoneally or extraperitoneally. The transperitoneal approach is presented here with predominant focus on the anterior approach. Specific steps salient to the posterior approach (otherwise known as the Montsouris retrovesical approach) to robotic prostatectomy are also highlighted.
Step 1: Abdominal access and trocar placement
In a transperitoneal approach, pneumoperitoneum is established with a Veress needle, which is inserted at the base of the umbilicus. Alternatively, an open Hasson technique may be used. The abdomen is insufflated to a pressure of 12 mm Hg. Pneumoperitoneum can be decreased to 8 mm Hg as the case progresses to aid in return of bowel function, provided visualization and hemostasis are adequate. The 8-mm camera trocar is placed first under direct vision with a visual obturator. The 8-mm robotic trocars and the 12-mm and 5-mm assistant trocars are then placed under direct laparoscopic vision. Once the camera trocar has been positioned, the patient is placed in the steep Trendelenburg position, which allows the bowels to fall cephalad and out of the pelvic cavity. The da Vinci robot may then positioned either between the patient’s legs or from the side as described, and the robotic arms are docked.
The robotic camera is inserted through the camera trocar. At our institution, we exclusively use an angled 30-degree lens; however, a zero-degree lens may be used on the basis of surgeon preference. The robotic instruments are inserted under direct vision. A curved monopolar scissor, fenestrated bipolar forceps (Intuitive Surgical, Sunnyvale, CA), and ProGrasp forceps (Intuitive Surgical, Sunnyvale, CA) are used in the right, left, and third arms, respectively.
On entry into the abdomen, anatomic landmarks are identified, including the internal inguinal rings, urachus, and medial umbilical ligaments. The peritoneum and bowel are inspected for adhesions, which are taken down sharply ( Fig. 31.4 ).
Step 2: Developing the space of retzius
The transperitoneal anterior approach begins with dissection of the bladder and exposure of the space of Retzius. The space of Retzius is entered by incising the peritoneum just lateral to the medial umbilical ligaments. The left hand is used to provide steady traction on the bladder inferiorly to visualize the appropriate plane of dissection. The surgeon must carry the dissection caudally until the pubic arch is seen. The bladder is then mobilized posterolaterally to the level of the vas deferens as the vas deferens crosses over the medial umbilical ligament, ensuring a tension-free vesicourethral anastomosis ( Fig. 31.5 ).