Indications and Contraindications
Prostate cancer is risk stratified on the basis of prostate-specific antigen (PSA), tumor grade, and clinical stage. Low-risk disease is defined by a PSA level lower than 10 ng/mL, a Gleason score of 6 or less, and clinical stage T1c or T2a. 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.
Considering this, the surgeon should take into account the patient’s life expectancy; overall health; tumor characteristics; and urinary, sexual, and bowel functions when counseling the patient about management options. Men with clinically localized prostate cancer should be presented all management options, including active surveillance, radiation therapy, and radical prostatectomy, and the unique risks and benefits of each. Radical prostatectomy is intended to cure patients in whom prostate cancer is truly localized. 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.
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, most 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 steep Trendelenburg position and for rhabdomyolysis if operative times are long. Finally, neoadjuvant androgen deprivation, multiple prostate biopsies, and the surgical management of benign prostatic hyperplasia (BPH) 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 ECG, a chest x-ray, a complete blood cell count, a basic metabolic panel, a coagulation profile, and a urinalysis specimen, with culture if indicated, 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 Urology 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, Calif.) comfortably with ample room for the surgical team and anesthesia staff in the configuration shown in Figure 33-1 . At our institution we use the da Vinci Si HD 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 Figure 33-2 . The hand and wrists are padded, with the thumb oriented upward in an anatomically neutral position.
A split leg table or stirrups may be used to abduct the patient’s legs, allowing access to the perineum during the case. When a split leg table is used, the hips are flexed gently. Be careful not to overflex the hips because this can lead to 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. Sequential compression devices are placed and activated.
The patient’s upper body is secured with foam padding and heavy cloth tape across the xyphoid 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 ( Figure 33-3 ). A 12-mm trocar is used for the endoscope and camera. This is placed approximately 15 to 17 cm superior to the pubic symphysis and generally just above 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 left robotic trocar to accommodate the fourth robotic arm. The surgical assistant uses a 12-mm trocar in the right 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. Finally, a 5-mm trocar is placed in the right upper quadrant at the apex of a triangle made between the assistant trocar and the right pararectus trocar that is mainly used for suction and irrigation.
Procedure (See )
LRP and RALP can be approached transperitoneally or extraperitoneally. The transperitoneal approach is presented here with predominant focus on the posterior approach. Specific steps salient to the anterior 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. The 12-mm camera trocar is placed first under direct vision with a visual obturator. Once the camera trocar has been placed, the patient is placed in the steep Trendelenburg position, which allows the bowels to fall cephalad and out of the pelvic cavity. The 8-mm robotic trocars and the 12-mm and 5-mm assistant trocars are then placed under direct laparoscopic vision. The da Vinci robot is then positioned between the patient’s legs, and the robotic arms are docked.
The robotic camera is inserted through the camera trocar. At our institution we exclusively use a 0-degree lens; however, an angled 30-degree lens may be used on the basis of surgeon preference. The robotic instruments are inserted under direct vision. A curved monopoly scissor, Maryland bipolar forceps (Intuitive Surgical, Sunnyvale, Calif.), and ProGrasp forceps (Intuitive Surgical, Sunnyvale, Calif.) 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 ( Figure 33-4 ).
Step 2: Dissection of the Seminal Vesicles and Vas Deferens
The transperitoneal posterior approach begins with dissection of the seminal vesicles (SVs) and vas deferens. The ProGrasp forceps is used to retract the sigmoid colon out of the pelvic cavity. The vas deferens is identified as it courses over the medial umbilical ligaments. The overlying peritoneum is incised, and the vas is traced medially to its coalescence with the ipsilateral SV where it is clipped and divided. The contralateral vas is then dissected. The assistant provides countertraction by lifting the bladder anteriorly in the midline, and the SVs are then dissected. The posterior dissection is carried out first and can be done bluntly. The anterior dissection of the SVs should be performed meticulously because small vessels are frequently encountered entering from the anterior lateral aspect of the SVs. These vessels are clipped with Hem-o-lok clips (Weck Closure Systems, Research Triangle Park, N.C.) and divided sharply with cold scissors to avoid thermal injury to the nearby neurovascular bundle (NVB) ( Figure 33-5 ).
Step 3: Posterior Dissection of the Prostate
The vasa and SVs are lifted anteriorly with the ProGrasp forceps. The assistant provides counter traction by applying downward pressure on the midline rectum with a suction-irrigator. A 2- to 3-cm horizontal incision is made through the cul-de-sac approximately 0.5 cm below the base of the SVs. In patients with low risk, nonpalpable disease, the posterior dissection plane is developed between the prostatic fascia anteriorly and Denonvilliers fascia posteriorly to facilitate later release of the NVB located along the posterolateral surface of the prostate. In cases of palpable intermediate- or high-risk disease, the posterior dissection is carried one layer deeper, penetrating through Denonvilliers fascia down to the prerectal fat plane. This provides an additional layer of tissue coverage (i.e., Denonvilliers fascia) along the posterior surface of the excised specimen. The plane is developed with gentle sweeping motions, gradually moving toward the prostate apex. Wide dissection of the rectum off the posterior prostate is critical to minimize the risk of rectal injury during later parts of the operation ( Fig. 33-6 ).