2610 994479, 2613 603969, 6932480650
Rio, 26504, Achaia, Greece View Location
Extraperitoneal Robotic-assisted Radical Prostatectomy

  • 1Patient set-up
  • The patient is secured to the operating table and placed in 10-15 deg Trendelenburg position.

  • Placement of the trocars and docking of the robotic arms
  • 6 trocars are used for Extraperitoneal Robotic-assisted Radical Prostatectomy

  • Dissection of endopelvic fascia
  • Incision of the endopelvic fascia is not done when an intrafascial approach is planned. For inter- and extrafascial approaches, the endopelvic fascia is incised

  • Identification of puboprostatic ligaments
  • The puboprostatic ligaments may be preserved in order to maintain the anatomy of the urethral support mechanism.

  • Ligation of the DVC
  • Using a 0 Vicryl suture on a CT-1 needle, the DVC is ligated

  • Bladder neck dissection
  • Identification of the bladder neck is facilitated by pulling gently on the inflated foley catheter. The bladder neck is initially incised at 12 o’clock, and progresses laterally.

  • Incision of bladder neck
  • Once the bladder neck’s anterior surface is incised, the catheter is retracted to aid in the dissection of the posterior surface of the prostate and seminal vesicles

  • Retraction of catheter and bladder
  • The catheter may be retracted by a fourth robotic arm if available, and the bladder retracted by the assistant surgeon

  • Dissection of the posterior bladder neck
  • Care is taken in this step not to enter the prostate or to cause injury to the bladder (through-and-through incision). The correct plane is ascertained when the seminal vesicles and vasa deferentia are visualized.

  • Preparation of the seminal vesicles
  • The vasa deferentia may be clipped, and then transected. The seminal vesicles are prepared with sharp and blunt dissection, taking care not to injure the neurovascular bundle, which runs in proximity to the tips of the vesicles.

  • Mobilization of the seminal vesicles
  • When the seminal vesicles are completely freed, they may be retracted by the fourth robotic arm to aid in dissection of the posterior surface of the prostate.

  • Stripping Denonvillier’s fascia
  • If an intrafascial approach is planned, the dissection plane must remain on the inside of Denonvillier’s fascia. Care is taken not to injure the rectum running below the fascia and the NVB’s on the lateral aspects of this region.

  • Dissection of prostatic pedicles
  • The prostatic pedicles are prepared using the space prepared between the dissection of the endopelvic fascia and Denonvillier’s fascia. Dissection proceeds using an athermal technique and clips are used for vascular control. The dissection plane for the intrafascial technique is exactly on the prostatic capsule (look for the shiny surface).

  • Dissection of the neurovascular bundles
  • Dissection proceeds on the capsular surface, with antegrade liberation of the NVB from the prostate. Clips are used to secure hemostasis.

  • Dissection of the prostatic apex and DVC
  • Dissection of the prostatic apex and DVC proceeds with cephalad retraction of the prostate. Care is taken not to inadvertently transect the NVB. This step may be done with the monopolar scissors.

  • Dissection of the urethra
  • Initial sharp dissection of the plane between the prostate and the urethral sphincter is performed centrally, and until the catheter is visible. The catheter is then retracted into the urethra, and the posterior aspect of the urethra is sharply incised, as close to the prostate as possible.

  • Initial step of vesicourethral anastomosis
  • Continuous suturing of the vesicourethral anastomosis is performed with two 3-0 Vicryl sutures on RB-1 needles knotted together with a LapraTy clip. Each end of the suture will serve to construct one side of the anastomosis. Initially, a suture is placed (outside-in) in the bladder and then inside-out through the urethra. When three such passes are completed, the bladder is retracted to the urethra by tightening the sutures.

  • Completion of the vesicourethral anastomosis
  • The anastomosis sutures are completed on both sides and the sutures are tied on the dorsal aspect of the anastomosis. A silicon catheter is inserted and the watertightness of the anastomosis is checked.

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