robotic instruments and operative steps

1. Robotic radical
prostatectomy
DR DARSHAN PATEL
UROLOGY RESIDENT
RUBY HALL CLINIC

2. ADVANTAGE OF ROBOTIC
PROSTATECTOMTY
 Minimal Bleeding Faster return to normal daily activities.
 Reduced hospital stay Significantly less pain and scarring.
 Lower blood transfusion rates.
 Improved preservation of physical appearance.
 Three (3) D vision enables surgeon to perform Prostate excision with
cancer.
 Reduced risk of Post Surgery incontinence (control over urinary and fecal
discharge) and Impotency.

3. Patient selection
 Patients should have a pathologically confirmed
 cancer clinically confined within the prostate (stage T1 or T2) or
 a cancer that extends beyond the margins of the prostate (T3) but still
seems amenable to surgical extirpation with a wide resection.
 Based on the 2013 American Urological Association (AUA), radiographic
staging with CT and bone scan is recommended only for patients with:
suspected locally advanced disease, Gleason score of 8 or greater
or prostate-specific antigen (PSA) level greater than 20 ng/mL.

4. Absolute contraindication
 uncorrectable bleeding diatheses ,
 inability to undergo general anesthesia because of severe cardiopulmonary
compromise.

5. Relative contraindication
 who have a history of prior complex lower abdominal and pelvic surgery
 prior transurethral resection of the prostate(TURP)

6. INSTRUMENTATION
ROBOTIC-ASSISTED LAPAROSCOPIC PROSTATECTOMY
 • da Vinci Si or Xi HD Surgical System
 • Endowrist Maryland bipolar forceps or PK dissector
 • Endowrist curved monopolar scissors
 • Endowrist ProGrasp forceps
 • Endowrist large needle drivers (two)
 • InSite Vision System with 0-degree and 30-degree lens
 • 12-mm trocars (two)
 • 8-mm metal robotic trocars (three if using a fourth robotic arm)
 • 18-Fr urethral catheter
 • Small and medium-large Hem-o-lok clips (Teleflex Medical)
 • 0 polydioxanone suture for dorsal venous complex
 • 2-0 polydioxanone suture for posterior reconstruction
 • 3-0 Monocryl double-armed suture for anastomosis

7. • da Vinci Si HD Surgical System

8. Da vinci Si system Da vinci Xi system

10. PREOPERATIVE PREPARATION
 Bowel Preparation
 Informed Consent
 Pre anaesthetic work up
 Patient positioning
 Operative room equipment

11. Patient Positioning
o supine position in steep
Trendelenburg
o arms and hands carefully tucked
and padded at the sides
o Sequential compression stocking
devices are placed on both legs
and activated
o patient’s legs may be placed in
stirrups in the low lithotomy
position
o secured firmly to the table using
heavy cloth tape and egg-crate
padding across the chest

12. Operating room equipment

13. SURGICAL TECHNIQUE

14. Abdominal Access, Insufflation, and
Trocar Placement
o 5mm ports x 1 in RHC
o 12mm camera port supraumbilical,
12mm RLQ
o 8mm robotic ports x 2 in R and L
midclav lines, about 17cm from pubic
symphysis
o 8mm robotic port in LLQ

15. Initial transperitoneal view detailing the
relevant landmarks within the male pelvis

16. Developing the Space of Retzius
 initial step is entry and development of the space of Retzius.
 The bladder is dissected from the anterior abdominal wall by
dividing the urachus high above the bladder and incising the
peritoneum bilaterally immediately lateral to the medial
umbilical ligaments
 Lateral dissection upto
 crossing of the medial umbilical ligaments and vas deferens to
ensure optimal mobilityof the bladder

18. Ligation of the deep dorsal venous
complex
 Securing the deep DVC as far distal
from the prostatic apex as possible
can help minimize iatrogenic entry
into the prostatic apex during later
division of the DVC.
 profuse bleeding, is less apparent
because of the tamponade effect on
venous bleeding offered by the
pneumoperitoneum even when the
DVC is inadvertently entered.

19. Bladder Neck Identification and
Transection
Several maneuvers for
identification
1. point of transition of the prevesical fat to
the anterior prostate.
2. caudal retraction of an inflated urethral
catheter balloon
3. retract the dome of the bladder in a
cephalad direction
4. bimanual palpation or pinch of the
bladder neck using the tips of two robotic
or laparoscopic instruments.

20. Dissection of seminal vesicles and vasa
deferentia
 After bladder neck transection, the
seminal vesicles and vasa
deferentia are individually
identified, dissected, and divided,
minimizing electrocautery if
possible to prevent damage to the
nearby NVBs

21. Development of the plane between
the prostate and rectum.
 The Denonvilliers fascia is an inferior extension
of the peritoneal cul-de-sac that lies between
the prostate and rectum.
 With an intrafascial or interfascial dissection,
Denonvilliers fascia can be separated from the
posterior prostate by careful blunt and sharp
dissection.
 The separation can be carried all the way to the
prostatic apex and laterally to the medial aspect
of the prostatic pedicle

22. Ligation of Prostatic pedicle

23. Entering into the interfascial plane of dissection for neurovascular bundle
(NVB) preservation. The levator fascia is first incised along the anteromedial
aspect of the midprostate, allowing entry into the interfascial plane of
dissection

24. Apical Dissection
 common location for tumor involvement
and the most common site of positive
margins
 avoid entry into the anterior prostate
during division of the deep DVC
 limited use of electrocautery is preferred
during the prostatic apical dissection and
division of the urethra

25. Pelvic Lymphadenectomy and
Entrapment of Specimens
 prior mobilization of the bladder allows for excellent
exposure of the obturator lymph node region and iliac
vessels

26. Bladder Neck Reconstruction
Running vesicourethral anastomosis. The posterior anastomosis
is reapproximated after preplacing two or three suture throws
on either side starting at the 6 o’clock position and cinching the
sutures by lifting anteriorly.

27. POSTOPERATIVE MANAGEMENT
 drain may be placed through one of the 8-mm robotic trocar sites
o drain typically can be removed on the first or second postoperative day
 Parenteral narcotic medications may be required for the first 24 hours
 With 1 week or more of an indwelling urethral catheter, the vast majority of
patients are able to void adequately with minimal risk for urinary retention
and need for catheter replacement.
o Need for urethrogram on surgeons preference.and if wants to removed before 1
week.
 Most patients can tolerate a regular diet within 24 hours of surgery return to
their preoperative activities shortly after catheter removal but must avoid
strenuous activity up to 3 to 4 weeks after surgery.

28. PERIOPERATIVE OUTCOMES
 OPERATIVE TIME:
 typically longer with LRP or RALP compared with open surgery, especially early in a
surgeon’s experience
 At experienced centers of excellence with LRP, operative times less than 3 to 4
hours
 Postoperative Pain:
 minimally invasive nature resulting in less postoperative pain than comparative
open approaches
 Intraoperative Blood Loss:
 antegrade approach used during LRP and RALP allows earlier control of the
prostatic pedicles and late division of the deep DVC compared with RRP

29.  Hospital Stay:
 shorter length of hospital stay and lower probability of prolong hospitalization

30. Functional Outcomes
 URINARY INCONTINENCE:
o With LRP and RALP, visualization of the prostatic apex is typically superb.
o allow precise dissection of the prostatic apex with limited trauma to the
periurethral striated sphincter and genitourinary diaphragm.
o tension-free, watertight anastomosis under the superior and direct
visualization
o urinary incontinence improves substantially within the first 3 to 6 months

31.  ERECTILE DYSFUNCTION:
o depends on precise and meticulous separation of the cavernous nerves within the
NVB from the prostate gland
o Thompson and colleagues (2014) reported higher sexual function scores after
transition to RALP compared to RRP
 Critical to post operative recovery of potency
o avoidance of traction,
o direct manipulation,
o hemostatic energy sources, and
o performance of a meticulous interfascial dissection during NVB preservation

32. ONCOLOGIC OUTCOMES
 Surgical Margins:
o adhering to specific surgical principles can help reduce site-specific positive
margins at the apex, bladder neck, and posterolateral regions of the prostate
 Biochemical Recurrence:
o provide a more accurate assessment of oncologic control than margin status
o RALP and RRP offer similar disease control when performed by experienced
surgeons, even in high-risk settings.

33. COMPLICATION
 Complications Related to Patient Positioning
 Vascular and Bowel Injury
 Rectal Injury
 Thromboembolic Complications
 Anastomotic Complications
 Bleeding and Transfusion
 Equipment Malfunction

34. THANK YOU