Surgeon 003 – Difficult RP

• 2018 case
• Early 60s Patient
• Pre-operative PSA of 9.9
• Biopsy pathology Gleason score 3+4=7
• T1c
• Unilateral nerve-sparing complete on the left side

Text Narration

Setup and initial approach | Bladder neck dissection | Nerve-sparing | Apical dissection | Anastomosis

Equipment:

 Si robot, 4 arms

Overall Set up: 

2 robotic arms in left lower quadrant, 12 mm midline camera trocar, 1 robotic arm 8 cm lateral to midline in right lower quadrant, 12 mm assistant port lateral to right robotic arm and 5 mm trocar in right upper quadrant between camera and right robotic arm. All robotic arms are placed along (roughly) a straight line drawn across the abdomen that is 1-2 fingerbreadths below umbilicus depending on the size of the abdomen. Instruments: 4^th arm (lateral left port) is ProGrasp, left arm is PK (for this case) or Maryland bipolar, right arm is monopolar scissor.

Initial Approach:

I make the midline incision first and almost always use the Veress needle until they've had prior umbilical hernia repair with mesh or a low midline scar. After the pneumoperitoneum has been established then I'll place a 12 mm trocar in the midline. If the patient is obese, I will place them in trendelenberg to place the ports. 

Initial Approach Tips and Tricks:

I only search for the vas deferens if I'm doing a lymph node dissection. I usually start with a zero lens and do not generally change to a 30 degree lens until I enter the bladder. For morbidly obese patients, I almost exclusively use the 30 degree lens for better visualization. I always do a lysis of colonic adhesions in left lower quadrant if the adhesions are beyond the level of the vas if I'm planning on doing a lymph node dissection. I usually will incise lateral to the umbilical ligaments initially and figure out where the pubic bone is before dropping the bladder.

Approach to Bladder neck dissection:

I place a stay suture (0-vicryl on CT-1 needle) on the peritoneal reflection at the dome of the bladder once it has been completely mobilized and bring that suture through the 5 mm port and have the assistant clamp the suture to the drape which provides great cranial traction on the bladder so the assistant doesn't have to provide that help. The superficial dorsal vein is ligated/divided and I remove the fat over the prostate. I open the endopelvic fascia on both sides. My goal is to identify the fat plane posteriorly and then identify the notch between the urethra and deep dorsal vein. I use the 4^th arm to bunch up the dorsal vein to better identify the notch between the urethra and dorsal vein. I then I use a PDS suture for to tie off the DVC and use the same suture for urethropexy. The assistant bounces the foley to identify the bladder/prostate junction. Typically, I will score the planned incision with cautery prior to opening the bladder. After opening the bladder, I retract the foley anteriorly (like most do) for traction on the prostate. I usually place the left arm (bipolar) into the bladder and spread in order to see where the trigone is and try to identify the ureteral orifices.

Bladder neck dissection tips and tricks:

When the assistant bounces the foley balloon and it is off to the side it either means there is a median lobe or a dominant lateral lobe which is useful to know prior to entry into the bladder. Prior to incision into the bladder, I have the assistant advance the foley so the balloon is not distorting the junction of the bladder and prostate. For very large median lobes I will occasionally place a large suture into the median lobe to help pull the prostate out of the pelvis. Occasionally the median lobe is a good handle to use instead of the foley once it has been identified. If I identify a large median lobe, I will release the foley and use the median lobe to provide anterior traction to dissect out the remainder of the bladder neck. I think this help to try and prevent making a larger-than-necessary bladder neck and, probably, helps to prevent getting too close to the ureters. Early on I left the foley on traction after the bladder neck had been dissected and kept this in place until I could see the vas deferens. But, I found that I could easily get lost and searching for the vas was difficult because I was underneath the vas deferens, especially in large glands. I have found that after the bladder neck has been adequately dissected and there is equal thickness of the bladder neck circumferentially, I let the foley retract back into the urethra and use the ProGrasp to grab the prostate to provide anterior traction which eliminated going into the wrong plane. For very large prostates, I will take down the pedicles before trying to dissect out a plane between the prostate and rectum.  

I've found the PDS suture is much easier to slide knots with than Vicryl and I was tired of tearing sutures when ligating the DVC. I found that the stay suture in the bladder helps tremendously with the bladder neck and posterior dissection and helps to free up the assistant with helping me with suction retraction instead. I'm still using Hem-o-lock clips on the pedicles but have found that it is easier for me to place them robotically rather than having the assistant do it. 

Set up for Nerve Sparing:

The SVs have been dissected out. I grab the left SV and vas with the ProGrasp and the assistant grabs the right SV and vas in order to place tension on Denonviller’s fascia to identify the planned entry spot. 

Approach to Nerve Sparing:

I dissect out the plane between the rectum and the prostate and try to go as far to the apex as possible.  I use primarily sharp and blunt dissection when doing this to avoid a thermal rectal injury. Dissecting from medial to lateral (toward the neurovascular bundles) helps to prepare for nerve sparing. The ProGrasp is used to grab the base of the SV and prostate and rotated medially while placing clips over the pedicles. I usually try to incise the lateral prostatic fascia to develop that plane to help identify the contour of the prostate and to facilitate Hem-o-lock placement prior to taking down the pedicles. In difficult cases (large glands or a narrow pelvis) where I have not dissected the rectum off all the way to the apex, I will start laterally with nerve sparing and identify the prostate contour medially on one side.  I will then use this plane to dissect the remainder of the rectum off of the prostate. 

Tips and Tricks for nerve sparing:

There is always back bleeding on the prostate side when placing a clip on the pedicle. I typically prophylactically use the PK or bipolar to cauterize on the prostate side after placing a clip before cutting the pedicle. I use pinpoint monopolar or bipolar cautery once the large pedicles have been taken down as I progress from the mid gland toward the apex to prevent nuisance bleeding during the release of the neurovascular bundle. If there are large venous sinuses bleeding on the neurovascular bundle after removal of the prostate, I use a 3-0 Vicryl to oversew these areas to prevent thermal injury to the nerves.

Set up for Apical Dissection:

I use the ProGrasp to grab the base of the prostate to pull it out of the pelvis and place it on tension. The foley is pulled back into the prostate. 

Approach to Apical Dissection:

I use monopolar cautery to divide the dorsal vein. Once the bulk of the vein has been divided, I toggled from side to side to visualize the insertion of the urethra into the apex of the prostate. There are always veins (sometimes quite large) at the lateral aspect of the urethra toward the inferior aspect which will bleed if not cauterized. I will spot cauterize and peel the urethra toward the apex until I determine there is adequate urethral length. I typically try to dissect underneath the posterior aspect of the urethra with my left instrument prior to division of the urethra. With this instrument in place, I will pull up cranially and spread the instrument to place more tension on the urethra and then use the monopolar scissor to divide the urethra. 

Set up for Anastomosis:

During the anastomosis, I usually only need the assistant to help with perineal pressure during the first placement of the posterior urethral sutures. Once I have once suture in place, I can grab the suture to pull the urethra up and it makes it much easier to suture going forward. I use to 3-0 V-lock sutures tied at their ends (one dyed, one undyed) for the anastomosis. 

Approach for Anastomosis:

I run the left side first and start at the 5 o’clock position and carry this up to the 10 o’clock position. Once the left side is complete, I use the 4^th arm to hold this suture up which elevates the anastomosis up into clear view. I run the right side next and tie down the two V-lock sutures together. I then have the assistant place the final catheter while tying down the sutures. 

Tip and Tricks for the anastomosis:

If the patient has a very retropubic prostate, I have occasionally placed a stay suture in the anterior urethra after division before transecting the urethra completely. I initially was using Monocryl suture for the anastomosis but found that the sutures tended to slip open unless constant tension was maintained therefore I switched over to V-lock sutures and my leak rate decreased significantly. If the ureteral orifices are very close to the bladder neck, I place a pediatric feeding tube cut to 6-8 inches with a Hem-o-lock at the end and place these in the ureteral orifices for identification during suture placement for the anastomosis. Once the posterior layer is complete and there is no longer a concern for injuring the ureteral orifices, I will remove the feeding tubes.