Anterior Approach to Robotic Radical Prostatectomy

Introduction

Robot-assisted radical prostatectomy (RARP) has become a common approach to surgical management of prostate cancer (PCa). By some reports, this approach has become more common than open radical prostatectomy (RP) over the last several years. As a result of the wide and rapid adoption of this technology, multiple different approaches have emerged. These approaches include the anterior transperitoneal prostatectomy (ARARP), the posterior RARP (PRARP), and the extraperitoneal RARP. The primary difference between the ARARP and the PRARP is the timing of the dissection of the seminal vesicles (SVs) and vasa deferentia. However, as will be demonstrated, the variety in approaches to ARARP is extensive, and many surgeons have described innovations in their approach.

This chapter is dedicated to describing the ARARP technique. PRARP and extraperitoneal RARP are described in detail elsewhere in this text. Note that the present chapter was written with the DaVinci Si model in mind. However, the great majority of the concepts and techniques described herein are applicable to the DaVinci Standard, S and Xi platforms.

Patient selection

Generally, patients who are good candidates for a RARP overlap with good candidates for open RP. Patients who benefit the most have organ-confined disease and a good life expectancy. The age cutoff for RARP and RP is not well defined, but life expectancy is considered a better selection criterion than absolute age. Contraindications to laparoscopic surgery include uncorrected bleeding diathesis, hemoperitoneum, and hemodynamic instability. However, factors that were traditionally considered contraindications for a minimally invasive approach, such as peritonitis, pelvic radiation, prior abdominal surgery, and so on, have rapidly become less significant. There are several anatomic and physiologic considerations when selecting patients for RARP.

Patient setup

Prior to the procedure, it is important to review all pertinent patient data, including age, BMI, PSA, digital rectal exam, biopsy information, prostate size, as well as preoperative urinary and sexual function scores.

General endotracheal anesthesia is required. Preoperative antibiotics should be given, generally in the form of first- or second-generation cephalosporin, or an aminoglycoside with metronidazole or clindamycin. Once preoperative VTE-prophylaxis is administered and an orogastric tube is in place, the abdomen is shaved above the pubic symphysis.

After positioning, the anesthesia team should double check all IV lines and blood pressure cuffs, as they may lose access to these when the patient is positioned. The patient is then placed in a dorsal lithotomy or split leg position. If the position is lithotomy, stirrups should be used; we prefer Yellowfin type (Allen Medical, Acton, MA). Attention should be paid to the exact position of the hips, ankles, feet, and overall position of the pelvis, before and after placing the patient into Trendelenburg. Femoral nerve stretch or common peroneal nerve compression is preventable at this stage.

Arms are tucked at the sides in anatomic position with plenty of foam padding, with the thumbs facing upward toward the ceiling. Alternatively, arm boards, sleds, or even beanbags have been described, and may be helpful if the patient is morbidly obese. The patient should be secured to the table in some fashion to prevent excessive cranial migration after being placed in steep Trendelenburg. We prefer using foam padding and elastic foam tape in a crisscross fashion over the torso, ensuring proper support for the top of the shoulders. The table is then placed in steep Trendelenburg position. The patient should be checked for any excessive migration and shoulder pressure. If the patient slides excessively, we recommend leveling the patient and redoing the positioning and padding to avoid positioning-related injuries. At this point, peak inspiratory pressures and endotracheal tube position should be monitored by the anesthesia team. If any modifications need to be made in the ventilator settings it is best to do so prior to docking.

At this point a proper digital rectal exam can be performed, and a belladonna and opiate suppository may be placed to minimize postoperative bladder spasm. A digital rectal exam just prior to surgery can help with surgical planning, especially in the setting of bulky disease.

Skin preparation can be performed with any agent, though we prefer a chlorhexidine–alcohol solution. The prepped area should include the abdomen from ziphoid superiorly, laterally to the tucked arms, and inferiorly to include the perineum and upper thighs. The abdomen and penis should be draped with towels, excluding the scrotum; the towels can be stapled to the skin to prevent contamination. After draping, an 18-French Foley catheter is placed, so that it can be accessed from the sterile field.

Access

Veress needle access to the peritoneal cavity is achieved through a 12 mm midline incision. Since the left side of the abdomen receives two ports versus three on the right, this midline camera port incision can be placed just above or just to the left of the umbilicus. Alternatively, if there is concern for bowel adhesions from a prior midline incision, the Veress can be placed through a lateral rectus puncture. Some surgeons prefer a Hasson approach, though this can sometimes result in leakage of the pneumoperitoneum. The Hasson approach can also be a helpful alternative in cases of difficult Veress needle access. However, in our experience, the Veress needle has been safe and effective in the vast majority of cases.

We prefer to insufflate the abdomen to 20 mmHg during port placement and reduce this to 15 mmHg for the remainder of the case. The Veress needle is then removed and the midline 12 mm port is placed. This can be done blindly or under direct vision using a 10 mm 0° laparoscopic camera through a clear plastic semiblunt trocar (for example, Ethicon XCEL Bladeless 12 mm Trocar; Ethicon, Somerville, NJ). Global inspection of the peritoneal cavity should be performed at this point to ensure that there are no inadvertent bowel or vascular injuries. At this point, the remainder of the ports can be placed under direct vision.

Our preferred port placement is depicted in Figure 36.1 . We prefer placing the lateral-most ports as wide as possible before placing the more medial ports to maximize the available working space. The medial ports are then distributed with a minimum of one hand-breadth (approximately 8 cm) between each robotic port. Alternatively, some surgeons prefer to place the assistant port on the left.

After port placement, the pneumoperitoneum is reduced to 12–15 mmHg. The robotic patient side cart is then driven in by the circulating nurse and docked between the patient’s legs.