Extraperitoneal Robotic-assisted Radical Prostatectomy
- 1Patient set-up
- Placement of the trocars and docking of the robotic arms
- Dissection of endopelvic fascia
- Identification of puboprostatic ligaments
- Ligation of the DVC
- Bladder neck dissection
- Incision of bladder neck
- Retraction of catheter and bladder
- Dissection of the posterior bladder neck
- Preparation of the seminal vesicles
- Mobilization of the seminal vesicles
- Stripping Denonvillier’s fascia
- Dissection of prostatic pedicles
- Dissection of the neurovascular bundles
- Dissection of the prostatic apex and DVC
- Dissection of the urethra
- Initial step of vesicourethral anastomosis
- Completion of the vesicourethral anastomosis
The patient is secured to the operating table and placed in 10-15 deg Trendelenburg position.
6 trocars are used for Extraperitoneal Robotic-assisted Radical Prostatectomy
Incision of the endopelvic fascia is not done when an intrafascial approach is planned. For inter- and extrafascial approaches, the endopelvic fascia is incised
The puboprostatic ligaments may be preserved in order to maintain the anatomy of the urethral support mechanism.
Using a 0 Vicryl suture on a CT-1 needle, the DVC is ligated
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.
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
The catheter may be retracted by a fourth robotic arm if available, and the bladder retracted by the assistant surgeon
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.
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.
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.
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.
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 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 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.
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.
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.
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.