Robotic-assisted laparoscopic radical prostatectomy (RALP)

The objective of this film is to demonstrate our operative technique of robotic-assisted laparoscopic radical prostatectomy by Richard Gaston from the Saint Augustin Clinic in Bordeaux. Robotic radical prostatectomy has been performed in our clinic since December 2005. We currently use the Intuitive 4 arm DaVinci system.

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Robotic-assisted laparoscopic radical prostatectomy (RALP)

Authors

R Gaston, N Fernandes, P Bargao

Abstract

The objective of this film is to demonstrate our operative technique of robotic-assisted laparoscopic radical prostatectomy by Richard Gaston from the Saint Augustin Clinic in Bordeaux. Robotic radical prostatectomy has been performed in our clinic since December 2005. We currently use the Intuitive 4 arm DaVinci system.

Classification

robotic

Keywords

Robotic-assisted, laparoscopic radical prostatectomy, RALP

Media type

Surgical video

Duration

29'19''

Publication

2011-07

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E-publication

WeBSurg.com, Jul 2011;11(07).
URL: http://www.websurg.com/doi-vd01en3188.htm

Robotic-assisted laparoscopic radical prostatectomy (RALP)

1. Patient preparation and trocar placement 00'00''

This is a case of a 48-year-old man with T1c disease, PSA 4.7, Gleason 3 + 3. Two out of the six scores were positive on the left side, and the right side was clear of disease. The patient is prepared and draped in the supine position with the legs abducted. A urinary catheter is inserted. The ports are placed as shown in the picture. The 12mm optical port is placed in the supra-umbilical position and subsequent ports are placed under direct vision following the establishment of the pneumoperitoneum: two on the left side of the patient, the first three finger’s breadths from the iliac crest in the anterior axillary line, the second just cranial to the camera port and lateral to the rectus sheath. On the right side, the final robotic port is placed in the midpoint between the umbilicus and the anterior superior iliac spine. Two 5mm assistant ports are placed either side of the robotic port as shown. After placement of the ports, the patient is placed in a maximal Trendelenburg position and the DaVinci robot is brought into the operating table.

2. Preperitoneal space dissection 01'28''

After abdominal inspection, the space of Retzius is created by dividing the anterior peritoneum and dissecting the bladder from the anterior abdominal wall, the lateral margins of dissection are the vas deferens, which can easily be seen. The superficial fat tissue is then removed from the endopelvic fascia. The junction between the prostate and the bladder neck is easily recognized. This technique allows for an excellent preservation of the neurovascular bundles

3. Right lateral prostate dissection – nerve sparing 02'38''

Dissection is carried out in a simultaneous apical and retrograde fashion on the lateral surface of the prostate. It starts with the ligation of small veins at the prostate base, opening of the endopelvic and prostate fascias just above the prostate in a 2 o’clock position. It then continues with sharp and blunt dissection, preserving the entire neurovascular bundle, from the base to the prostate apex. The Denonvilliers’ fascia is incised, allowing us to reach the posterior surface of the prostate and to continue its dissection. Again good vision is achieved by the use of the third robotic arm. The assistant’s second port is used for clip application. This technique and the DaVinci system allow to stay close to the prostate, minimizing the risk of positive margins and maximizing the preservation of the neurovascular bundles. At this stage, monopolar diathermy can be occasionally used as we are far away from the bundles. Here, we can clearly see that the posterior and the right sides of the prostate are free.

4. Dissection of the right vas deferent, right seminal vesicle and left vas deferent 05'11''

The next step is the division of the right vas deferent, right seminal vesicle and left vas deferent. A 5mm clip is placed on the small artery of the seminal vesicle. The use of the suction device by the assistant aids the surgeon by offering him an excellent vision at this stage. In this low risk prostate cancer case, the tip of the seminal vesicle is left in place for better preservation of the neurovascular bundle. Counter-traction using the left grasper of the DaVinci robotic system is very helpful. Once the right side has been completely mobilized, dissection of the left deferent duct is started in a similar way, dividing it just before cutting the bladder neck.

5. Urethral dissection 08'37''

Here, we can see the dissection on the right side of the urethra. This is achieved carefully in order to keep the urethra intact. Fine dissection is required to isolate the urethra. The surgeon then moves to the left side that is mobilized in order to pass the scissors and the grasper under the posterior aspect of the urethra. Here, we clearly demonstrate that the bladder neck is being preserved and can now be divided using cold cut scissors.

6. Division of bladder neck 11'04''

This technique clearly demonstrates maximal preservation of the bladder neck. Once it has been divided, we continue to the left lateral dissection of the prostate.

7. Left lateral prostate dissection – nerve sparing 11'32''

The left side is technically more challenging than the right side due to the positioning of the robotic arms. Again, hemostasis in this area is achieved with the sole use of 5mm clips. No electrocautery should be used. Dissection is performed in a simultaneous apical and retrograde fashion on the lateral surface of the prostate. The use of the fourth arm on the DaVinci system allows for constant stable traction on the prostate, aiding dissection at all stages. Once the lateral dissection has occurred on the left side, the left seminal vesicle is divided and the dissection of the posterior surface of the prostate is carried out, reaching the apex.

8. Anterior dissection 13'24''

The prostate is now only held in place by its apical attachments. As you can see, it is possible, by means of the robot, to dissect and pass with the scissors and grasper in the plane between the urethra and the pubovesical complex, isolating the urethra in a much better fashion. Santorini’s plexus can be divided without the need for a prior suture. Occasional monopolar diathermy is used. Once Santorini’s plexus has been divided, the apex and the urethra can be clearly seen.

9. Specimen excision 14'40''

The urethra is freed of all its attachments, allowing the scissors to pass posteriorly and to be seen at the other end. Now it can be divided. Here, we see an excellent preservation of the urethral stump. We can clearly see the preservation of the neurovascular bundles. Santorini’s plexus is ligated with a running suture of monocryl 3/0.

10. Urethrovesical anastomosis 16'36''

The urethrovesical anastomosis is then started with a running suture, beginning in a 3 o’clock position on the bladder with an outside-in stitch, and, likewise, in a 3 o’clock position on the urethra, but here with an inside-out stitch. The knot is tied with the help of the assistant applying traction. The next stitch is passed behind the initial and enters the bladder in a 5 o’clock position. The anastomosis is continued with the aid of the urethral catheter to guide the needle into the urethra. Constant tension for the anastomosis is placed by the assistant’s grasper and it is completed by returning across the anterior surface in a 3 o’clock position. The suture is ligated, the needle is removed, and the anastomosis is checked with the inflated balloon and instillation of normal saline solution. In this case, no drain was left in.