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Understanding Robotic Prostate Surgery

Robotic Prostate Cancer TeamWe have prepared a summary for all patients planning on radical prostatectomy. This comprehensive review covers all expectations of:

  • Preparing for surgery
  • Hospitalization (pain control, diet, length of stay)
  • Discharge after your surgery
  • Clinic follow-up
  • Time for catheter placement and removal

There are 11 basic steps to robotic radical prostatectomy.

Port Position1) Port position and robotic docking  After general anesthesia has been provided by the anesthesia team, the patient is well padded to the operative table and placed in a steep-Trandelenburg position (head down tilt). This maneuver helps bring the intestines toward the diaphragm and away from the pelvic during surgery.

Once completed, a Foley catheter is placed to drain the bladder. A small Veress needle is then used to insufflate the peritoneum through a small 12mm periumbilical incision. The pressure inside the abdominal space, referred to as peritoneum, is increased to 20mmHg so as to safely allow placement of all remaining ports. The configuration of all ports is mapped out using geometrics of anatomic landmarks (pubic bone, umbilicus and hip bones — see above). Depending on the institution, surgeon preference and da Vinci robot, port placement may vary. To the right is an example of the University of Chicago port placement.

2) Pelvic lymph node dissection

As with most cancer-surgeries, sampling of regional lymph nodes is the most accurate way to properly stage one’s disease. In our experience, an average of 10-20 lymph nodes are removed during this process and requires approximately 30-45 minutes to complete. Anatomic landmarks for the dissection includes the:

  • Ureter
  • Iliac vessels
  • Pelvic sidewall
  • Node of Cloquet
  • Median umbilical ligament
  • Obturator nerve

All lymphatic and fatty tissue in this small package (average size of 1-2 fingers per side) is then enclosed in a laparoscopic retrieval bag.

3) Seminal vesicle and vas deferens dissection

Depending on the surgical team and their experience, the seminal vesicles can either be approached initially (posterior approach) or after the bladder neck has been transected (anterior approach). At Weiss Memorial Hospital, we prefer the initial posterior approach for several reasons.

Retrovesical dissection of the seminal vesicles (SV) and vas deferens (VD), in our hands, is the first step of radical prostatectomy. Several advantages are offered by this initial dissection:

  • Larger working area
  • Improved tissue visualization
  • Safe and reliable posterior bladder neck transection

Figure 1: A curvi-linear incision is created using the monopolar scissors midway between the anterior rectal wall and the assistant’s grasper. 

Figure 2: With the assistant’s retraction, the anterior surface area to the robotic surgeon is demonstrated.  


 
Figure 3: Blunt dissection then continues laterally which generally uncovers several perforating SV vessels that are controlled with either spot bipolar cautery or a vascular clip.

 

 

 

 

4) Retzius space and Endopelvic dissection

The anterior aspect of the bladder (Retzius space) is a thin, flimsy layer composed of loose alveolar tissue. The dissection through this layer is relatively avascular and performed with the combination of blunt instrument dissection and sharp scissor incision. In general, this aspect of surgery takes less than five minutes to properly perform.

The endopelvic fascia (EPF) is exposed after adequate defatting of the prostatic apex. Blunt dissection of both lateral prostatic spaces is then performed to set up for control of the dorsal venous complex — a network of large veins which run along the anterior prostatic surface. Care is made, especially at the apex of the prostate not to injure the rhabdosphincter of the pelvic floor to ensure no compromise in urinary control recovery.

5) Dorsal venous complex control

The dorsal vein leaves the penis under Buck’s fascia and penetrates the urogenital diaphragm dividing into three major branches — the superficial branch and the right and left lateral plexus.  The superficial branch is the centrally located vein overlying the prostate and bladder neck.  It is easily visualized early in retropubic operations and has communicating branches over the bladder and often into the pelvic sidewall.  The lateral venous plexus travel posterolaterally toward the bladder neck and then communicate freely with the obturator and vesical plexus.

Once exposed, the large complex of veins are controlled with the use of a suture. During open retropubic surgery, significant blood loss may occur during this process. With the benefit of pneumoperitoneum (peritoneal gas pressure), improved instrument dexterity in the narrow confines of the male pelvis and optimal visualization, blood loss is significantly reduced.

6) Bladder neck transection

This aspect of the surgery separates the prostate from the bladder. Experience is required to identify the proper location for transection. Care must be taken to avoid entering the prostate during this step of the procedure.  Furthermore, the ureteral orifices (pinpoint holes draining urine into the bladder) must be identified and avoided.  Bladder neck transection is typically performed with sharp scissors and electrocautery.  The anterior bladder neck is opened, revealing the foley catheter. The assistant grasps the foley catheter and provides anterior traction on the prostate.  The posterior bladder neck is subsequently divided, revealing the previously dissected vasa deferentia and seminal vesicles.    

7) Vascular pedicle control

The blood supply enters the prostate on each side of the gland and must be carefully divided to prevent excess blood loss and to preserve the neurovascular bundles controlling erectile function. The assistant grasps the vasa deferentia and seminal vesicles and provides anterior traction.  Several techniques are available to divide the vascular pedicles, including bipolar cautery, hemostatic clips, or other energy-based sealants.  

8) Neurovascular bundle dissection

The neurovascular bundles run along the posterolateral aspect of the prostate on both sides. Release of the neurovascular bundles requires a combination of blunt and sharp dissection along with the judicious use of bipolar cautery.  The nerves are peeled away from the prostate starting at the base and finishing at the apex of the gland.  Different levels of nerve sparing can be performed (see figure at right) depending on how close to the surface of the prostate the dissection is carried out.  The closer to the prostate, the more complete the nerve sparing. The farther away from the prostate capsule, the more tissue to serve as a buffer if disease has grown out of the gland.

This dissection is very delicate and requires significant experience and surgical expertise. Care must be taken to avoid entering the prostate capsule and leaving a positive surgical margin. 

In select patients, full nerve sparing is carried out in the interfascial plane; the closest to the prostate capsule. For men with risk of disease beyond the capsule, an extrafascial or wide dissection is undertaken.

9) Urethral transection

The prostate at its apex must next be separated from the urethra to complete the gland resection.  The previously ligated dorsal venous complex is now transected with scissor electrocautery and the underlying urethra is sharply divided at its junction with the prostate. This aspect of the procedure requires expertise and meticulous dissection to avoid injury to the urinary control muscles and to prevent a positive surgical margin. Care must also be made to avoid any injury to the neurovascular bundles which were previously preserved. After division of the urethra, the prostate is completely free and is placed into a bag for later removal.  

10) Vesicourethral anastamosis

The bladder and urethral stump are sewn back together utilizing a continuous running suture. On average, 12-14 sutures are performed to complete the anastamosis which is assured to be watertight before finishing the procedure. 

11) Case completion

A final inspection is made to ensure there is no active bleeding, and a closed suction drain is positioned into the pelvis to collect any remaining fluid in the abdominal cavity. The drain is typically left in place for less than 24 hours and removed prior to discharge home. The robot is disconnected and moved out of the surgical field. After the prostate is removed through the small incision above the belly button, all port sites are closed with sutures beneath the skin surface.