Robotic-assisted laparoscopic radical prostatectomy

This video demonstrates robotic radical prostatectomy performed by a highly experienced surgeon. The additional advantages conferred by the dexterity of the multiple robotic instruments in performing this complex surgery is apparent. This video is recommended for urologists with an interest in prostate surgery.

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Robotic-assisted laparoscopic radical prostatectomy

Authors

F Annino, DM Burke, T Piéchaud

Abstract

This video demonstrates robotic radical prostatectomy performed by a highly experienced surgeon. The additional advantages conferred by the dexterity of the multiple robotic instruments in performing this complex surgery is apparent. This video is recommended for urologists with an interest in prostate surgery.

Classification

robotic

Keywords

prostate surgery, robotic radical prostatectomy, robotics

Media type

Surgical video

Duration

15'30''

Publication

2007-09

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Subtitles

E-publication

WeBSurg.com, Sept 2007;7(09).
URL: http://www.websurg.com/doi-vd01en2164.htm

Robotic-assisted laparoscopic radical prostatectomy

1. Patient preparation and trocar placement 00'16''

We would like to present our operative technique of robotic-assisted laparoscopic prostatectomy by Thierry Piechaud from the St Augustin Clinic in Bordeaux. Robotic radical prostatectomy is being performed in our clinic since December 2005. We currently use the Intuitive 4 arm DaVinci system. This case of a 55-year-old man with T1c disease, PSA 5.6, Gleason 3 + 3. Three out of the 6 scores were positive on the left side, 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 schematic representation. The 12mm optical port is placed in the supra-umbilical position and subsequent ports are placed under direct vision following the establishment of a pneumoperitoneum: two on the patient’s left, the first three finger’s breadths from the iliac crest in the anterior axillary line, the 2nd 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 position.

2. Pre-peritoneal space dissection 01'50''

After abdominal inspection, the space of Retzius is created by division of the anterior peritoneum and dissection of 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.

3. Urethral dissection 02'39''

Here we can see the dissection on the right side of the urethra. Care is taken to keep the urethra intact. The right side is continued to be mobilized. Fine dissection is required to isolate the urethra. We then transfer to the left side, mobilizing this in order to pass our scissors and our grasp under the posterior aspect of the urethra. Here we clearly demonstrate that the bladder neck is being preserved. The bladder neck can now be divided using cold cut scissors.

4. Division of bladder neck 04'08''

This technique clearly demonstrates maximal preservation of the bladder neck. Once the bladder neck has been divided, we continue to the posterior dissection of the prostate. The lateral borders are left intact at this stage.

5. Posterior dissection of prostate 04'40''

We incise the fascia of Denonvilliers; this enables us to see the posterior surface of the prostate and subsequently isolate the vas deferens and the seminal vesicles. Some lateral dissection is required. The use of 5mm clips aids the hemostasis and avoids the use of electrocautery. The vas deferens is isolated and subsequently divided.

6. Dissection of vas deferens and seminal vesicles 05'53''

Once the vas deferens has been divided, dissection of the seminal vesicles can take place. A small 5mm clip is placed on the small artery to the seminal vesicles. The assistant’s use of the sucker aids the surgeon with excellent vision at this stage. Counter-traction can be applied using both the left grasps of the DaVinci robotic system. Once the right side has been completely mobilized, we then start dissection of the left side in a similar fashion with division of the left vas deferens. Here counter-traction can be applied with the assistant’s grasp or the robotic arm. Here we have an excellent view of the posterior aspect of the prostate. We then start the lateral mobilization of the neurovascular pedicles. Great care is used here to avoid the use of electrocautery and hemostasis is achieved by using 5mm clips.

7. Lateral dissection 08'02''

Using this technique, we have excellent preservation of the neurovascular bundles. Dissection is continued in an apical fashion on the posterior lateral surface of the prostate. Again good vision is achieved by use of traction from the assistant’s sucker and the third robotic arm. The assistant’s second port is used for the clip application. Using this technique and the DaVinci system, it allows us to stay close to the prostate minimizing the risk of positive margin but maximizing the preservation of the neurovascular bundles. Once the apex has been reached, we can return to the anterior lateral aspect of the prostate and dissection is continued in an apical fashion using a combination of sharp and blunt dissection. At this stage, monopolar diathermy can occasionally be used as we are far away from the neurovascular bundles. Here we can clearly see the posterior and the right side of the prostate is free. The procedure will then be repeated on the left side in a similar fashion. 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 in this area. The use of the 4th arm on the DaVinci system allows constant stable traction on the prostate aiding dissection at all stages. Once the posterior lateral dissection has occurred on the left side, we again dissect the anterior aspect of the prostate.

8. Anterior dissection 12'14''

The prostate is now only held in place by its apical attachments. The Santorini plexus can be divided without the need of a prior suture. Occasional monopolar diathermy is needed. Once the Santorini plexus has been divided, the apex and the urethra can clearly be seen.

9. Specimen excision 13'10''

The urethra is freed of all of its attachments and the scissors placed posteriorly behind it and to the other end is seen. It can then be divided. Here we see an excellent preservation of the urethral stump. We can clearly see preservation of the neurovascular bundles. The urethrovesical anastomosis is then commenced. We commence in the 3 o’clock position on the bladder with an outside to in stitch and likewise in a 3 o’clock position on the urethra but here with an inside to out stitch.

10. Anastomosis 13'59''

The knot is then tied with the help of the assistant applying traction. The next stitch is passed behind your initial stitch 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 aided by the assistant’s grasp. The anastomosis is completed by returning across the anterior surface and around to the 3 o’clock position. Care is taken not to puncture the urethral catheter. The suture is ligated and the needle removed and the anastomosis checked with the inflated balloon and the infiltration of normal saline to check for leakage.