Radical prostatectomy: Standard approach, retzius sparing, and single port

Preoperative considerations

Prior to surgery, all patients are counseled on the benefits of a heart healthy diet, regular exercise, smoking cessation, and (if indicated) weight loss. Should the patient be sedentary, it is recommended that they walk 1 to 2 miles daily in preparation for the surgery. Finally, also to assist in the recovery of sexual function, a nightly low-dose phosphodiesterase (PDE-5) inhibitor (i.e., 5 mg tadalafil or 20 mg sildenafil) is prescribed for all patients undergoing RARP.

Patient positioning

All procedures are performed under general anesthesia. The patient is positioned securely on the operating table with stirrups (or flat/supine), prepped, and draped ( Fig. 12.1 ). Hips are flexed to reduce risk of stretch injury to the femoral and obturator nerves as they exit the pelvis. After standard “time-out” procedures are completed, a Foley catheter is placed into the bladder and then a Veress needle is placed into the peritoneum at Palmer’s point in the left upper quadrant, or a Hassan approach can be used. A pneumoperitoneum of 15 to 20 mm Hg is established. The camera port is placed just above the umbilicus, followed by the remaining five ports, all under direct vision. As depicted in Fig. 12.2 , all incisions for port insertion are transverse in an effort to reduce the rate of incisional hernias and improve cosmesis. For example, a Cochrane review in 2005 examined 16 prospective randomized control trials with a total of 3072 patients between midline and transverse incisions. Not only were the transverse incisions less painful for the patients, but they were also less prone to rupture, dehiscence, and incisional hernia formation. Similarly, Halm et al. found that transverse incisions were significantly thinner than vertical incisions—findings which paralleled our series of 900 consecutive RARP patients.

In a retrospective query by Beck et al., rates of incisional hernias varied by method of reporting: for patients with vertical incisions, the rates of incisional hernias ranged from 4.9% (36/735) when relying on patient ad hoc self-reporting to 9.4% (18/192) if patients were interrogated by email. In comparison, only one incisional hernia occurred in the group of patients with transverse incisions, or a rate of 0.6% (1/165). In adjusted analysis, the vertical midline incisions increased the risk of hernias more than 11-fold. However, other than incision direction, other independent predictors of incisional hernias were older age, larger prostates, and increasing body mass index. Cosmesis of transverse incisions were also improved. This healing process is likely facilitated by the reduction of tension on the skin.

Once all ports are positioned, the AirSeal insufflator is activated, and the pneumoperitoneum is reduced to 8 to 10 mm Hg for the duration of the procedure. The patient is then repositioned into the Trendelenburg position, allowing gravity to pull the abdominal contents out of the pelvis, facilitating access to the bladder and prostate, and reducing the risk of injury to abdominal organs. The legs are separated to facilitate docking of the da Vinci robot.

Releasing the bladder

The bladder is released by incising the peritoneum from the right obliterated umbilical artery to the left obliterated umbilical artery. The incision is then extended down to the vas deferens (VD) and deep into the perirectal space. This pathway facilitates retraction of the bladder and rectum out of the pelvis to improve space. The anterior prostatic fat (APF) is dissected to skeletonize the puboprostatic ligaments for optimal visualization of the apex. It is further dissected off the anterior prostatic capsule from the apex to the bladder neck. This step helps to visualize the border between the prostate and bladder neck. In addition, the fat pad is sent for a pathologic examination in case the pathologist reports a positive surgical margin (PSM) and to evaluate for lymph nodes.

If a PSM is seen anteriorly, the APF can be evaluated for residual cancer—results of which are typically negative. In addition, in 2007, Finley et al. published a retrospective case series, showing approximately 15% of men to have lymph nodes in the APF, with a positivity rate of 1% to 2%.

Endopelvic fascia

The endopelvic fascia is initially incised laterally closer to muscle than the nerve in an effort to fully expose the NVBs. Visualization of the NVB facilitates visualization and reduces traction injury. During this process, continuous retraction of the prostate is key. At the apex of the prostate, the Myer muscle is completely released laterally to visualize and protect the prostatic apex, NVB, and urethra while exposing the dorsal venous complex (DVC) and remaining apical structures. Cold sterile water (at 4°C) is used to irrigate bleeders and prevent thermal spread and injury.

Anterior and posterior bladder neck

The site of transection of the anterior bladder neck is visually facilitated by retracting the Foley balloon. Cautery should be set at 2 to 3, and once clearly into muscle, the dissection is performed largely without cautery to better differentiate the muscle, prostate, and urethra. Cautery is used to open the urethra with good hemostasis. Transection of the bladder from the prostate is facilitated with retraction of the left hand with continuous sufficient force to maximize visualization. Once the bladder is entered, the prostate can be further retracted with the fourth arm (rather than via the catheter).

The interior of the bladder is inspected. The intent is to enter the muscular/vascular space behind the detrusor (or the posterior bladder neck). This will preserve the full thickness of the posterior bladder as it is transected from right to left. Immediately behind the posterior bladder are the longitudinal muscle and multiple vessels that need cauterization. This muscular/vascular layer is later incorporated into the Rocco stitch.

Seminal vesicles and rectum

An important potential advantage of this approach compared with the posterior approach is that the hypogastric nerves innervating the seminal vesicles (SVs) and the bladder neck are not transected. In our center’s experience, the key to mobilization of the SVs is to focus on lifting the SVs with minimal traction to the surrounding hypogastric nerves, which are important for the sensation of orgasm. The SVs are then used to lift the prostate for separation from the rectum. The Denonvilliers’ fascia is incised sharply until the perirectal fat or interfacial plane is seen. Dissection of the plane between the prostate and rectum is facilitated by the surgeon’s left-hand instrument elevating the prostate as the assistant retracts gently but firmly on the rectum with the sucker as needed. The dissection is carried distally to the apex.

Thermal and athermal transection of the prostatic pedicles and the neurovascular bundles

With the introduction of the da Vinci robot for a laparoscopic approach to radical prostatectomy, bipolar thermal energy was essentially the only means to control the prostatic vascular pedicles between 2001 and 2004. However, electrocautery was shown to injure recovery of the cavernosal nerves in a canine model by Ong and associates in 2004. In 2005, our group was one of the initial teams to demonstrate in men that an athermal approach to the prostatic vascular pedicles significantly improved erectile function recovery, as compared with bipolar cautery. Three-month potency recovery rates in a cohort of selected men (younger than 66 years) with preoperative International Index of Erectile Function (IIEF-5) scores of 22 to 25, when using bipolar cautery compared with an athermal approach, improved from 8% to 32%, suggesting significant axonal injury due to thermal damage. However, at 2 years, erections satisfactory for intercourse recovered surprisingly with bipolar (70%) as compared with athermal (90%).

In 2012, a consensus statement on RARP recommended that the simplest solution to avoid thermal injury is to not use thermal energy altogether—especially near the NVB. Although complete avoidance of cautery has its slated thermal advantages, this method necessitates the use of clips, which requires traction with potential associated injury. An alternative to this technique is a “clipless” technique using monopolar cautery. An exploration by Mandhani and colleagues in 2008 showed that monopolar cautery was more efficient in coagulation; hence it could be applied for shorter periods and with reduced thermal spread. Indeed, these findings were echoed by Hofmann et al. in 2021, finding that a cut and “touch monopolar cautery” technique when transecting the prostatic vascular pedicle had equal sexual function recovery as compared with an athermal technique in men undergoing nerve sparing RARP. Overall, the judicious use of monopolar cautery can control bleeders and minimize traction injury. When used in short bursts (i.e., intermediate 35W monopolar cautery), the addition of cooled (4°C) irrigation can even further limit the spread of heat from the site of cautery as well as optimize visualization of bleeding vessels.

The dorsal venous complex and maximization of urethral length

During control of the DVC and urethral transection, it is important to maximize membranous urethral length (MUL). The first exploration of MUL as both a preoperative innate indicator of early urinary continence recovery and as a technical characteristic amenable to surgical manipulation was by Coakley et al. in 2002. Their study suggested that men with a longer multiparametric magnetic resonance imaging (mpMRI)-assessed MUL were “predetermined” to benefit from a faster and more complete recovery of urinary continence after open radical prostatectomy. The findings in 2004 were expanded in a radical prostatectomy series by van Randenborgh and colleagues, wherein they demonstrated that surgically maximizing preservation of MUL improved pad-free continence rates from 76% to 88%. Their findings were reconfirmed in 2011 by Schlomm et al., demonstrating significant improvement in 1-week pad-free continence following surgical technique maximization of the MUL. Surgical maximization was then applied to RARP by Hakimi et al. and Ko et al. Both illustrated a systematic approach to maximization of MUL during RARP. Results demonstrated that 30-day and 1-year pad-free continence rates increased from 28.2% to 55.6% and 88.7% to 93.8%, respectively. In adjusted analysis, the maximization of MUL more than doubled the likelihood of urinary continence recovery. ^,

Maximization of urethral length is illustrated in Fig. 12.1 , as each millimeter of preserved urethral length correlates with improved 30-day pad-free continence. To maximize preservation of the membranous urethra, the DVC is transected without ligation, allowing for full rotation of the prostate and circumferential tension-reduced release of the external striated muscle and the membranous urethra. The DVC is then oversewn with a 4-0 V-lock suture in all cases to prevent late or delayed venous bleeding. Arterial bleeding along the nerves is individually sutured with 4-0 Vicryl. The prostatic pedicles are oversewn with a 3-0 V-lock suture for arterial control but more importantly for late venous hemostatic security. Continence recovery and potency outcomes with these techniques are summarized in Fig. 12.3 .

Rocco and van velthoven anastomosis

The posterior anastomosis of the bladder neck is stabilized with the Rocco stitch, which has been shown to significantly reduce postoperative hematoma and bladder neck contractures. A 3-0 V-lock begins at the bladder, incorporating the cut edge of the Denonvilliers’ fascia and then the posterior bladder detrusor. The next suture is intended to incorporate as much of the muscular structural support behind the urethra as possible. Only the bladder should be pulled toward the urethra to avoid pulling and tearing out from the urethral side. Following this step, the standard single-knot Van Velthoven anastomosis is used (see Fig. 12.2 ). Starting at the 5 o’clock position in the full thickness of the bladder neck, six consecutive sutures are thrown, and the bladder is cinched down to the urethra. The suture is then run clockwise to the 10 o’clock position, followed by a suture run counterclockwise to the 12 o’clock position. The two are then ligated together at that position.

Pelvic lymph node dissection

The therapeutic role of pelvic lymph node dissection (PLND)—whether standard or extended—remains controversial. The potential benefits of a PLND should be weighed against increased morbidity of the procedure: increased lymphocele formation and lower extremity lymphedema are significant risks to the performance of a PLND. Although greater lymph node yield may be diagnostic and may facilitate accurate pathologic staging, it is not clear whether there is a therapeutic benefit.

Hernia repair

Some patients have preexisting inguinal hernias that should be fixed at the time of RARP. Occult hernias are usually only detected at surgery. If a hernia is not corrected, there is significant evidence it will become symptomatic and will need to be repaired, usually within the first year or two. The benefits of hernia repair with mesh at the time of RARP should be considered.

Removal of the prostate

Prior to removing the prostate and undocking the robot, a final hemostatic check of the entire surgical field is performed. The remaining robot arms are undocked, and the robot is pulled out of the operative field. The camera port is extended laterally as needed, and the specimen bag is firmly pulled in large circular motions to extract the bag via the smallest possible incision. The fascia is then closed transversely with two looped 0-PDS sutures starting laterally on both sides and ligated to each other in the midline.

General recommendations

Beginning the first day after surgery, an early ambulation protocol out of bed in a chair and walking except for “needed naps” is followed for all patients. We stress sitting upright in a chair and walking as much as tolerated. We counsel patients to walk 0.5 mile on postoperative day one and 1 mile or more the following days until the catheter is removed. A total of 97% to 98% of patients are discharged from the hospital the same day or the following morning. All patients are discharged with a urinary catheter in place. Two urine collection bags are provided to facilitate daily and nightly wear. The catheter is generally removed after 6 to 7 days. Cystograms are rarely indicated and only in the event of persistent visual hematuria or after significant bladder neck reconstruction. After catheter removal, patients are asked to track their daily urinary pad use until 3 days of pad-free status returns, which will be documented by mailing in a “pad-free” postcard or daily urinary pad log confirming continence. In addition, if after the first week post-catheter removal a patient is using two or more “wet” urinary pads, an explicit explanation of Kegel exercises to reinforce muscle memory contraction of the external sphincter with standing, stooping, etc. is provided. An anticholinergic medication for 2 to 3 months is recommended to reduce the time to pad-free status if the Kegel exercises do not demonstrate significant early improvement.

Sexual function recovery

Regarding sexual function recovery, patients are advised to take a daily dose of a PDE-5 inhibitor (preferably at nighttime). Patients are advised that sexual function recovery may occur over 1 to 2 years post-RARP. However, waiting for 1 to 2 years is problematic for both surgeons and their learning curve and patients and their sexual quality of life. Essentially all metrics have been or are “Yes/No” such as IIEF-5 scores of 15 or 17, or a score of 3 to 5 on question #5 of the IIEF-5, or a “Yes” to erections adequate for sexual intercourse (the so-called ESI). IIEF-5 scores less than 15 have little or no metric quality. Several years ago, we worked on a means to find a metric question at the first 3-month follow-up to help qualitatively predict men at risk for long-term (2+ years) erectile dysfunction (ED). We introduced the question, “What percent of erection fullness do you have now as compared to prior to surgery?” This metric showed a much clearer picture of partial recovery as compared with IIEF-5 scores less than 15 and was subsequently validated. For example, men who report less than 30% fullness at 3 months had the greatest risk of impotence, whereas men with 3-month scores greater than 30% had a 70% to 80% rate of recovery by 2 years. Furthermore, men with scores greater than 50% typically recovered within the next 6 to 9 months. We also noted that, when men had an erection fullness score of 75+% compared with preoperatively, greater than 95% said “Yes” to ESI and had IIEF-5 scores of 17+. Lastly, men with scores less than 30% at 3 months were encouraged to begin vacuum devices or injection therapy, because less than 20% recovered.