Robotic-Assisted Laparoscopic Radical Prostatectomy

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Robotic-Assisted Laparoscopic Radical
Prostatectomy

• Thomas E. Ahlering, MD
• Professor of Urology
• University of California, Irvine

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Patient Selection

• Indications
• Organ-confined prostate cancer
• Life-expectancy gt 10 years
• Contraindications
• Significant medical comorbidities
• Metastatic disease
• Multiple prior abdominal surgeries (relative)

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Equipment Required

• da Vinci Robot
• 18 F foley catheter (2)
• Knife with 15 blade
• Kelly clamp
• Trocars 12 mm (2), 5 mm, 8 mm for robotic
  instruments (2)
• Robotic instruments
• Electrocautery scissors
• Bipolar forceps
• Needle driver (2)
• Laparoscopic instruments
• Suction-irrigator with long (25 cm) tip
• Atraumatic bowel forceps
• Scissors
• Grasping forceps with teeth (locking handle)
• Needle driver
• EndoGIA stapler (45 mm vascular load,
  articulating handle)
• 10 mm specimen retrieval bag
• Bulldog clamps (straight curved) with
  applicator
• Suture 3-0 monocryl, 4-0 vicryl

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Patient Positioning

• Supine position, arms tucked at sides
• Legs placed on spreader bars
• Abducted 30?
• Lowered 45?
• Extreme (25?) Trendelenburg position

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Patient Positioning
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Port Placement

• Veress needle placed 6 cm lateral to umbilicus to
  insufflate to 20 mm Hg
• Draw lines between umbilicus and femoral artery
  to estimate position of medial umbilical
  ligaments
• 12 mm camera port cephalad to umbilicus (lt22 cm
  from pubis)
• 12 mm assistant port 2 cm cephalad to iliac crest
• Robotic instrument ports (8 mm) 14.5-17 cm from
  pubic symphysis, gt10 cm from camera port, and gt8
  cm lateral to midline
• Suction port (5 mm) ¼ distance between robotic
  instrument port and camera port and 30? cephalad
  from camera port

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Port Placement
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Port Placement
HEAD
FEET
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Steps of the procedure(click to play video clip)
1. Placing the ports
2. Dropping the bladder
3. Defatting the prostate
4. Opening endopelvic fascia
5. Stapling the dorsal vein complex
6. Transecting the bladder neck
7. Dissecting the vas and seminal vesicles
8. Preserving the neurovascular bundles
9. Transecting the urethra
10. Suturing the vascular pedicles
11. The vesicourethral anastomosis
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Technical points Tips

• Cautery with the scissor jaws open is more
  effective than with them closed
• Use the bipolar forceps like a mini-retractor to
  expose tissue planes
• If there is some oozing from the stapled edge of
  the dorsal vein complex, apply a small (2 cm)
  sponge. A little pressure combined with the
  pneumoperitoneum will stop most bleeding
• Frequent irrigation helps clear the field,
  especially during transection of the bladder neck
  and urethra and during nerve sparing

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Technical points Caveats

• Ensure excellent hemostasis as a bloody field
  will absorb light and make visualization
  difficult
• Beware of damaging the pelvic sidewall with the
  robotic arms outside of the field of vision
• When transecting the bladder neck, avoid the
  temptation to start in the midline rather, work
  from a lateral to medial direction on each side

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Credits

• Surgeon Thomas Ahlering, MD
• Professor of Urology
• Director of Urologic Oncology
• UC Irvine Medical Center
• Orange, CA 92868
• 714-456-6068
• tahlerin_at_uci.edu
• Bedside assistant and video editor
• James F. Borin, MD
• Clinical Instructor
• Laparoscopy/Endourology fellow
• UC Irvine Medical Center
• 714-456-3431
• jborin_at_aya.yale.edu