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Robotic radical prostatectomy at the Vattikuti Urology Institute

Authors

Abstract

This video demonstrates how a robotic radical prostatectomy is performed at a high volume center in the United States of America. The authors have an extensive experience in robotic prostate surgery and describe the technique in detail.

Classification

complex cases, robotic

Keywords

prostate, robotic surgery, radical prostatectomy

Media type

Duration

12'30''

Publication

2006-10

Popular

Favorites

Audio

E-publication

WeBSurg.com, Oct 2006;6(10).
URL: http://www.websurg.com/doi-vd01en2018.htm

Robotic radical prostatectomy at the Vattikuti Urology Institute

1. Robotic set-up presentation 00'10''

In recent years, many centers are offering minimally invasive surgical treatments for localized prostate cancer with laparoscopic or robotic approaches. Our technique is known as the Vattikuti Institute prostatectomy or VIP. This video is intended to demonstrate the details of our current approach. The DaVinci surgical system uses a sophisticated master-slave device. The surgical cart has 3 multijointed arms with one controlling a binocular endoscope and the other 2 controlling articulated instruments. This is the slave component of the system, which is controlled by the surgeon’s console. The surgeon console has 2 master arms. The surgeon moves the master and the movements are translated in real time in the movements of the instrument tips. The masters also provide a force feedback to the operating surgeon’s hand. The masters can be made to control camera movements by pressing a foot pedal. The 2nd pedal is a clutch. Pressing this pedal disengages the slave arms from the master arms. A third pedal controls covering. The surgeon has a stereoscopic or 3-D display of the operating field. The control pedal permits the surgeon to choose and adjust various display and control options. The vision cart houses light sources, camera control units, camera signal synchronizers and pneumo-insufflator. We use 2 telescopes, zero degrees and 30 degrees. Robotic instruments used by the surgeon include monopolar hook cautery, bipolar Marilyn graspers, round-tipped robotic scissors and robotic needle drivers. The assistants use atraumatic graspers, a suction irrigator with a long suction cannula, laparoscopic scissors and occasionally laparoscopic hemlock clip appliers. The surgical team, the Vattikuti Institute prostatectomy team includes one console-side and 2 patients-side surgeons, and a scrub nurse. The operating surgeon sits at the console and is not scrubbed. The patient-side team is scrubbed and presents the operative field to the operating surgeon.

2. Patient position 02'18''

We place the patient in a lithotomy position. All pressure points are padded. The arms are tucked in by the sides and the patient is secured to the table using tapes. The table is moved to a steep Trendelenburg position. The bladder is drained with a Foley catheter connected to a drainage bag.

3. Trocar placement 02'35''

The pneumoperitoneum is created with a Veress needle introduced through a peri-umbilical incision. Pneumopressure of 20 mm Hg is achieved before port placement. A 12 mm port is introduced on the left side of the umbilicus for the binocular scope. The remaining ports are placed under vision using the 30-degree up lens. The 8mm metal ports are used for the robotic instrument arms. They are placed on either side of the camera port. The right robotic port is placed between the right anterior axillary line and the right mid-clavicular line 2 inches below the camera port. A 12mm port is placed on the right side. This port is positioned 2 inches above the iliac crest lateral to the anterior axillary line. A 5mm port is placed between the camera port and the right robotic port for suction, irrigation, and passage for the laparoscopic scissors. A left 8mm robotic port is placed at a location that mirrors the position of the right robotic port. A 5mm left assistant port is placed on the left side lateral to the left anterior axillary line, 2 inches below the level of the umbilicus. The robot draped with sterile drapes is then docked to the robotic ports.

4. Start of procedure 03'50''

Development of the extraperitoneal space The peritoneal cavity is inspected using a 30-degree upward looking lens. A transverse peritoneal incision is made extending from the left to the right medial umbilical ligament. Incision is extended in an inverted U-shape to the level of the vas deferens on either side. The extraperitoneal space is developed after transecting lateral to the medial umbilical ligaments. Both the assistants provide traction, counter-traction to facilitate the dissection. This dissection allows the bladder, prostate and bowel to drop posterior and the remainder of the operation can be performed extraperitoneally. At the end of this dissection, the prostate covered with periprostatic fascia and bladder covered with a layer of fat is seen. Lymph node dissection The tissue overlying the external iliac vein is incised and the lymph node package is pushed medially. The dissection starts with the lymph node of Cloquet at the femoral canal and continues towards the bifurcation of the iliac vessels. The obturator nerve lies on the floor of this dissection and is carefully preserved. The lymph node package is removed through the 12mm port and sent for permanent section.

5. 3D simulation (1st step) 05'21''

Bladder neck transection The bladder neck is separated from the prostatic base to expose the anterior layer of the Denonvilliers’ fascia, which is incised to expose the vasa deferentia and the seminal vesicles. The vasa are cut. The seminal vesicles are dissected and then they are retracted upwards. The posterior layer of the Denonvilliers’ fascia is separated from the posterior prostatic fascia in the midline to expose the prostatic pedicles on both sides. A 30-degree lens looking down aids in the delineation of the prostatovesical junction. The Foley balloon is deflated. With experience, one can identify a shallow groove between the prostate and the bladder. The assistants retract and lift the anterior bladder wall, which aids in this identification. The bladder neck is incised using an electrocautery hook. After the anterior bladder neck is incised, the left side assistant grasps the tip of the catheter with firm anterior traction. This exposes the posterior bladder neck, which is incised. The posterior bladder neck is gradually dissected away from the prostate. The anterior layer of the Denonvilliers’ fascia covering the vasa deferentia and the seminal vesicles is now exposed. This layer is incised precisely exposing the vasa and the seminal vesicles. The left side assistant provides upward traction to the posterior base of the prostate. First, the vasa are skeletonized, transected and then held upward providing further traction for the dissection of the seminal vesicles. Both the vas and the seminal vesicles are grasped and the posterior prostate is retracted upwards allowing exposure of the posterior layer of the Denonvilliers’ fascia. An incision is made in this fascia and a plane is developed between the posterior prostate and the Denonvilliers’ fascia. The remaining attachments between the bladder and the prostate are divided to expose the lateral pedicles of the prostate. The base of the ipsilateral seminal vesicle is retracted superomedially by the contralateral assistant and the prostatic pedicle is delineated and divided.The pedicle lies anterior to the pelvic plexus and neurovascular bundle and includes only prostatic blood supply. The pedicles are controlled by individually coagulating vessels by bipolar cauterization.

6. 3D simulation (2nd step) 07'51''

Nerve preservation Standard nerve preservation and VIP is based on the principles reported by Walsh. The posterolateral neurovascular bundles are sharply dissected off the prostate leaving neurovascular bundles on the prostatic fossa. However, we and others have demonstrated that additional nerve fibers are also found sparsely spread over the lateral aspect of the prostate. In the veil procedure after the blood vessels of the prostatic pedicles are controlled and cut, the lateral prostatic fascia with all nerve and blood vessels is separated from the prostate by sharp scissors dissection. The neurovascular complex supported by lateral pelvic fascia stays with the patient. This fascia with nerves is the veil of Aphrodite. The plane between the prostatic capsule and the inter-periprostatic fascial layer is developed from its cranial most extent. This allows the surgeon to enter a plane between the prostatic fascia and the prostate. This plane is deep to the venous sinuses of the Santorini plexus. The assistants provide superomedial prostate retraction and lateral retraction on tissues adjacent to the neurovascular bundle. Careful sharp and blunt dissection of the neurovascular bundle and the contiguous lateral periprostatic fascia is performed until the entire periprostatic fascia up to the ipsilateral pubourethral aspect of the puboprostatic ligament is mobilized in continuity of the lateral aspect of the prostate apex. This plane is mostly avascular, except anteriorly where the fascia is fused with the puboprostatic ligament capsule and venous plexus. Once the lateral prostatic fascia is dissected off the prostate from all sides, the dorsal vein is controlled by overrunning suture with 2/0 Vicryl on RB-1 needle. Incision of the dorsal venous complex and urethra A plane between the urethra and dorsal venous complex is gently developed to expose the anterior urethral wall. To minimize the possibility of a positive apical margin, the anterior wall of the urethra is transected with the scissors a few millimetres distal to the apex of the prostate. The freed specimen is then placed in an Endocatch® bag. The prostate is removed following the completion of the anastomosis. Completed veil is demonstrated.

7. Suture of the urethra with the bladder 10'28''

The urethrovesical anastomosis MVAC suture is used for the urethrovesical anastomosis. The suture is prepared by tying two 3/0 monocryl on RB-1 needles 7 inches in length back to back. One suture is dyed and another is undyed. The suture is now a double arm suture with a pledget of knots. The suture is started with a violet dyed monocryl arm on the posterior bladder wall at the 4 o’clock position outside in. The urethral bite is made inside out at the corresponding site. After 3 such bites placed in a clockwise direction, which cover a major portion of the posterior aspect of the anastomosis, the bladder is brought down by tightening the suture. Tightening the suture in this way reduces the risk of the sutures cutting through the urethral stump. A Connell stitch is then taken at the bladder, thereby changing the direction of passage of the needle, so that additional needle passes are outside in on the urethra and inside out on the bladder. The suture may be locked at this point. The left side assistant maintains gentle traction of the dyed arm of the suture while the remaining portion of the anastomosis is completed using the undyed arm passed in a counter-clockwise fashion. The dyed and undyed arms of the suture are then tied together to complete the anastomosis. A new 20 French Foley catheter is introduced and balloon inflated to 20 to 30 CC. The bladder is filled with 250 CC of saline to test the integrity of the anastomosis. A suction drain is placed through one of the 5mm ports.

8. End of procedure 12'41''

The entrapped specimen is removed after enlarging the umbilical port incision as required. The incision is closed in layers. The port site incisions are closed with subcutaneous suture and steristrips.

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