Robotic radical prostatectomy

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

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

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

11. Operating room equipment

12. SURGICAL TECHNIQUE

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

14. I nitial transperitoneal view detailing the relevant landmarks within the male pelvis

15. 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

16. 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.

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

18. 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

19. 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

20. Ligation of Prostatic pedicle

21. 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

22. 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

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

24. 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.

25. POSTOPERATIVE MANAGEMENT drain may be placed through one of the 8-mm robotic trocar sites 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. 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.

26. 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

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

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

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

30. ONCOLOGIC OUTCOMES Surgical Margins: 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: provide a more accurate assessment of oncologic control than margin status RALP and RRP offer similar disease control when performed by experienced surgeons, even in high-risk settings.

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

32. THANK YOU