Robotic simple prostatectomy

Introduction

Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms (LUTS) and bladder outlet obstruction (BOO) in men. The prevalence of this pathology increases with male aging. In the fourth decade of life, BPH is demonstrable in 30% to 40% of men, and its prevalence increases almost linearly to 70% to 80% in those older than 80 years.

Despite recent advances in the endourological management of BPH, the treatment of LUTS caused by large prostatic adenoma (>80 mL) remains a challenge. Currently, open simple prostatectomy (OSP) remains one of the standard treatments in this situation, ^, providing not only long-term improvement of LUTS, urinary flow, quality of life (QOL), International Prostate Symptom Score (IPSS), but also decreasing post-void residual (PVR) bladder volumes and offering lower reoperation rates when compared with some endoscopic treatments. Surgical techniques commonly used are the Freyer (transvesical approach) or Millin procedures (trans-capsular approach), both with acceptable results. However, OSP has also been associated with high rates of urosepsis, reoperation, prolonged catheterization time, perioperative transfusion, and prolonged length of hospital stay.

In 2002, Mariano et al. described the laparoscopic simple prostatectomy (LSP) technique, combining the benefits of OSP with the potential advantages of a minimally invasive approach. Years later, Sotelo et al. published the first series of robotic-assisted simple prostatectomy (RASP), describing seven patients undergoing suprapubic transperitoneal transvesical approach with interesting outcomes.

Initially, the RASP was classified as an experimental procedure in the 2010 American Urological Association (AUA) guidelines, considering that there were insufficient data to support RASP as a standard treatment option. ^, However, in this last edition of the AUA guidelines, RASP was deemed as a feasible and safe procedure when performed by experienced robotic surgeons, based on the current literature available. Similarly, in the current European Association of Urology (EAU) guidelines, minimally invasive simple prostatectomy (MISP) was considered feasible and effective in men with prostate sizes greater than 80 mL; however, in order to demonstrate superiority over OSP and other endoscopic methods, randomized clinical trials are necessary.

Indications

Current indications of RASP are similar to traditional indications for OSP: ^,

Large prostates (prostate volume over 80 to 100 mL) with LUTS refractory to medical treatment;
Refractory urinary retention secondary to BPH;
Recurrent bladder stones, infections, or gross hematuria due to BPH;
BOO refractory to medical therapy;
Symptomatic BOO with diverticulum; and
Renal insufficiency secondary to BPH.

KEY STEPS

1.
Access, pneumoperitoneum, port placement, and docking
2.
Cystotomy on the bladder dome
3.
Fix/suspend each bladder wall to the lateral peritoneum
4.
Identify the trigonal area and bladder mucosa, incision around the prostate
5.
Circumferential and apical adenoma dissection
6.
Apical urethral transection and adenoma removal
7.
Urethrovesical closure and 18 Fr two-way Foley catheter is placed into the bladder
8.
Cystotomy closure
9.
Adenoma placed in retrieval bag, ports removed and closure

SPECIAL EQUIPMENT REQUIRED

Robotic instruments
Fenestrated bipolar forceps
Monopolar scissors
Prograsp forceps
Large needle holders × 2
Sutures
Urethrovesical Anastomosis: 2-0 Quill suture (Monoderm—RB-1 17 mm 1/2 circle—16-cm × 16 cm)
Bladder closure: 2-0 polyglactin suture (SH 20 mm 1/2 circle—20 cm)
Others
AirSeal insufflator
10 mm Hem-O-lok
Hem-O-lok clip appliers

Evolution of our surgical technique

The benefits of robotic surgery for simple prostatectomy have been emphasized in multiple recent series, and multiple surgical techniques have been described. ^, Our personal technique has evolved along the last decade; we have tested different surgical approaches until we established our current standard, the transvesical RASP with urethrovesical anastomosis (UVA). In this chapter, we describe our surgical technique, different approaches, and the benefits and drawbacks of each.

Below, we will start by describing the main stages of our transperitoneal RASP technique, and, after this, we will present the evolution of this approach based on our personal experience. Recently, we recorded a video with three different ways to perform this surgery.

Patient position and ports placement

Under general anesthesia, the patient is placed in lithotomy position at a steep Trendelenburg angle with padding of pressure points, similar to an RARP procedure. We use a bean bag for adequate patient positioning to the surgical table ( Fig. 17.1 ).

Fig. 17.1, Patient Position on the Table.

An 18 Fr Foley catheter is inserted into the bladder and six ports are placed across the abdomen similar to RARP: the camera port just above the umbilical scar, three 8-mm arm ports, a 12-mm assistant port in the right flank, and a 5 mm for suction in the right upper quadrant ( Fig. 17.2 ). These surgical steps are similar in all surgical approaches we have adopted.

Fig. 17.2, Port Placement for Robot-Assisted Simple Prostatectomy Procedure.

Our initial technique: RASP through the retzius space with bladder neck incision or a midline cystotomy

Initially, the anterior peritoneum is incised and the Retzius space is dissected. Periprostatic and perivesical fats are then removed to expose the bladder neck. We no longer open the endopelvic fascia nor ligate the dorsal venous complex (DVC). After surpassing the learning curve, we believe those steps are not necessary and the procedure can be performed with minimal bleeding without DVC ligation. However, during initial procedures, the endopelvic fascia was opened laterally to the reflection of the puboprostatic ligaments bilaterally and the DVC ligated using a 12-inch monofilament polyglytone suture on a CT-1 needle, as described in prior studies. ^,

Transverse bladder neck incision

The prostate adenoma may be accessed in different ways. We initially described a 1 to 2.5 cm transverse incision in the anterior vesicoprostatic junction, ^, similar to the anterior bladder neck dissection performed in a RARP ( Fig. 17.3 ). This approach allows easy identification of ureteral meatus and allows the bladder mucosa to be sectioned in the plane of the adenoma and the prostate capsule. Most robotic surgeons are familiar with this anatomy due to prior experience with RARP. The major disadvantage of this approach is the need of a larger transverse incision for larger adenomas, risking injury of the neurovascular bundle laterally.

Fig. 17.3, Transverse Incision in the Anterior Vesicoprostatic Junction.

Due to this limitation, we have evolved our transvesical access to a proximal midline cystotomy after the Retzius dissection, as also described by other authors. ^, This approach allows better access to larger adenomas without the risk of neurovascular bundle injury. The decision on which approach to use depends mainly on the surgeon’s personal experience, but these advantages and disadvantages should be taken into consideration ( Fig. 17.4 ).

Fig. 17.4, Different Approaches to Accessing the Prostate Adenoma.

Dissection of prostate adenoma

The plane between the adenoma and the prostatic capsule is identified and incised over the posterior bladder neck; the adenoma is dissected using a combination of cautery, traction, and blunt dissection. This dissection should start posteriorly, preventing blood spillage from the anterior dissection into the posterior plane. The adenoma is then mobilized from the capsule anteriorly and laterally ( Fig. 17.5 ). Occasionally, a 0-polyglactin stay suture can be used for counter traction of the prostate adenoma during the dissection. Finally, the prostatic urethra is carefully sectioned, avoiding injury to the urinary sphincter, and the adenoma finally is removed. Two 2-0 poliglecaprone sutures are placed at 5 and 7 o’clock positions in the vesicoprostatic junction for additional hemostasis; however, this step is not mandatory if the surgeon has found the correct avascular plane. Hemostasis is revised and bleeding vessels are cauterized or ligated with absorbable sutures.

Fig. 17.5, The adenoma is tractioned and its posterior plane is dissected.

Reconstruction: Advancement of the bladder neck mucosa or urethrovesical anastomosis

In the classical “trigonization” technique, the mucosa of the posterior bladder neck is then advanced to the distal urethral mucosa using two figure-of-eight 2-0 polyglactin sutures or using a continuous 3-0 poliglecaprone suture. The idea is to reapproximate the mucosa to reconstruct the anatomy of the prostatic fossa and promote hemostasis. We described a modified reconstruction technique which includes three surgical steps: plication of the posterior prostatic capsule, modified van Velthoven continuous UVA, and suture of the anterior prostatic capsule to the anterior bladder wall. In this approach, after the resection of the adenoma, the posterior capsule was plicated using two 12.5 cm 3-0 poliglecaprone sutures (on RB 1 needles) tied together. The proximal edge of the capsule was approximated to the distal capsule using one arm of the continuous suture. The posterior bladder neck was then sutured to the posterior urethra using the other arm of the suture. A continuous modified van Velthoven UVA was then performed. Two 20-cm 3-0 poliglecaprone sutures of different colors (on RB 1 needles) were tied together with 10 knots to provide a bolster for the anastomosis. The posterior part of the UVA was performed with one arm of the suture ( Fig. 17.6 ), in a clockwise direction, from the 5 to 9 o’clock positions. This step was followed by completion of the anterior anastomosis with the second arm of the suture, in counterclockwise fashion. ( Fig. 17.7 A–C shows needle pathway.) This modified technique of RASP has potential advantages: reduced blood loss, lower blood transfusion rates, shorter length of hospital stay, and no need for postoperative continuous bladder irrigation.

Fig. 17.6, After plication of the posterior prostatic capsule, the posterior bladder neck is sutured to the posterior urethra.

Fig. 17.7, Anterior Vesicourethral Anastomosis.

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