The Technique of Robotic Nerve-Sparing Prostatectomy

Introduction

The following chapter will describe the evolution of radical prostatectomy with a special concentration on the technique of robotic-assisted radical prostatectomy (RARP) that was developed and established at the Vattikuti Urology Institute at Henry Ford Hospital in Detroit, Michigan.

Historical perspective

Radical prostatectomy was considered a morbid procedure, marred by blood loss, poor visualization, as well as high rates of postoperative urinary incontinence and erectile dysfunction. This changed in 1982, when Walsh and Donker published their technique for a novel anatomic approach to radical prostatectomy. This technique took in consideration periprostatic anatomy and blood supply in order to minimize blood loss and overall morbidity. Moreover, they identified the pelvic plexus as the autonomic innervation of the corpora cavernosum, which is responsible for the neurophysiologic control of erectile function. They described a neurovascular bundle (NVB) that courses in a dorsolateral fashion to the prostate, between the rectum and urethra, and proposed that injury to this structure can result in erectile dysfunction. Walsh proposed that the lateral pelvic fascia should be incised anterior to the NVB, and that lateral pedicles should be divided close to the prostate in order to avoid damaging the NVB. This was the first description of open “nerve-sparing” radical prostatectomy (ORP), which later on became the gold standard technique for treating prostate cancer patients who seek surgery.

Evolution of nerve-sparing with robotic surgery

After the description of nerve-sparing radical prostatectomy by Walsh and Donker, there were many efforts to enhance the understanding of the periprostatic neuroanatomy, with the objective of improving the surgical technique of “nerve-sparing” radical prostatectomy, and consequently improve postoperative functional outcomes. In this context, the introduction of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) represented a breakthrough, because it allowed for a 12-fold magnification, three-dimensional view, and articulated robotic arm, providing wristed, seven-degree motion. In 2000–2001, Menon et al. established the first robotic urologic program in the world, describing for the first time the Vattikuti Institute Prostatectomy (VIP). This procedure underwent several technical improvements over the years ( Table 35.1 ). In the following sections, we will be focusing on the description of the most contemporary VIP technique.

Table 35.1

Technical Changes in Vattikuti Institute Prostatectomy Over the Years

Year	Technique	Benefit
2001	Initial approach to bladder neck	Decrease operating time
2002	Running anastomosis	Decrease leak, and stricture
2002	Avoid monopolar cautery after seminal vesical transaction	Not evident
2003	“Veil” nerve-sparing	Improve postoperative erectile function
2004	Anterior traction on the bladder to identify bladder neck	Easier transference of skill
2004	Delayed ligation of the dorsal venous complex	More precise urethral transaction, decrease positive apical margins
2004	Not opening the endopelvic fascia	Earlier recovery of urinary continence
2005	Fully athermal nerve-sparing technique	Earlier recovery of urinary continence
2007	Double-layer anastomosis	Unchanged continence, decrease urinary leak
2008	Use of percutaneous suprapubic tube instead of urinary catheter	Decrease patient discomfort, and earlier recovery of urinary continence
2008	Primary hypogastric node dissection for low- to intermediate-risk disease	Increased node positivity
2010	Barbed anastomotic suture	Decrease anastomotic time
2011	Modified organ retrieval for examination (MORE) using GelPoint access	Palpation-oriented frozen section biopsies to assess surgical margins

Vattikuti Institute prostatectomy

Indications and Contraindications

Indications for RARP are generally similar to those for ORP. Specifically, patients with low-/intermediate-risk PCa with 10 or more years life expectancy, as well as those with high-risk PCa, are considered good candidates for surgery. It is noteworthy that in the case of high-risk tumors RARP and ORP are considered as the first step in a multimodal treatment approach. However, recent reports showed that up to about 50% of patients can benefit from complete cancer control with surgery alone.

During RARP, patients are exposed to pneumoperitoneum and steep Trendelenberg position, which might create difficulties in ventilation. For this reason, obstructive pulmonary disease and cardiac output abnormalities are considered as relative contraindications. Previous abdominal surgery might increase the complexity of the case, but should not be considered as contraindication. Factors such as morbid obesity, large prostate, large median lobe, and surgery in the salvage setting may present difficulties and are better reserved for surgeons with high expertise.

Preoperative Workup

These might vary according to local guidelines and specific hospital policy. In general, anticoagulant and antiplatelet drugs are ceased before surgery, while prophylactic antibiotics and thromboprophylaxis are started. A laxative is given the night before surgery. In case of patients with aggressive tumor characteristics, a mechanical bowel preparation should be used. This would allow a clean environment, in case of rectal opening due to rectal involvement.

Patient Positioning and Preparation

The patient is placed in the lithotomy position with arms secured to the sides and all pressure points protected using foam pads. The patient is fastened to the table with tape and straps. The thumbnails should face the ceiling and the arms held lax to avoid peripheral nerve compression. The legs are separated in flexion and abduction to allow the patient sidecart sufficient access. Sequential compression devices are placed on the calves. The abdomen down to the upper thighs is prepped with antiseptic and then draped. The bladder is drained with an 18F Foley catheter that is secured to the side so that the assistant can manipulate it during the operation. Intravenous fluids are limited to <1 L during surgery to reduce excessive urine production, which can obscure the view and necessitate copious suctioning.

Instrumentation

1.
Nondisposable
- a.
  Monopolar hook
- b.
  Fenestrated bipolar forceps
- c.
  Round tip scissors
- d.
  Large needle driver
- e.
  8-mm instrument cannula
- f.
  GORE_ Suture Passer (WL Gore & Associates, Flagstaff, AZ)
2.
Disposable
- a.
  12 × 100 mm and 5 × 100 mm laparoscopic ports (Kii Fios First Entry port, Applied Medical, Rancho Santa Margarita, CA)
- b.
  Endopath ^® Veress needle (Ethicon Endo-Surgery, Blue Ash, OH)
- c.
  StrykeFlow 2 suction irrigator (Stryker, Kalamazoo, MI)
- d.
  Hem-o-Lok clips (Weck, Teleflex Medical, NC)
- e.
  3-0 barbed polyglyconate suture (V-Loc ^® , Covidien, Mansfield, MA)
- f.
  No. 15 scalpel blade,
- g.
  10 mm Endopouch ^® bag (Ethicon Endo-Surgery, Blue Ash, OH)
- h.
  Rutner 14F percutaneous suprapubic catheter (Cook Medical, Bloomington, IN)
- i.
  Polypropylene CT-1 needle (Ethicon, Somerville, NJ)
- j.
  1 PDS™ CT-1 needle (Ethicon, Somerville, NJ)
- k.
  4-0 Monocryl™ suture (Ethicon, Somerville, NJ)
- l.
  Polypropylene button (Ethicon Endo-Surgery, Blue Ash, OH)
- m.
  Mastisol ^® adhesive (Eloquest, Ferndale, MI)
- n.
  Steri-Strip™ (3M, St Paul, MN)
3.
Optional
- a.
  Monopolar curved scissors
- b.
  Maryland bipolar forceps
- c.
  Harmonic™ACE curved shears
- d.
  12 × 130 mm balloon port for camera (Kii Balloon Blunt Tip System, Applied Medical, Rancho Santa Margarita, CA)
- e.
  GelPoint Advanced Access Platform (Applied Medical, Rancho Santa Margarita, CA)

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