2 ANKARA ROBOTIC UROLOGY SYMPOSIUM AND COURSE BOOK Urology Course Bo… · 2 Organizing Committee...

Edited by: A. Erdem Canda, MD (Ankara, Turkey)

2ND ANKARA ROBOTIC UROLOGY SYMPOSIUM AND COURSE BOOK

Date:

7-9. June. 2013Venue:

YILDIRIM BEYAZIT UNIVERSITY, SCHOOL OF MEDICINEANKARA ATATÜRK TRAINING AND RESEARCH HOSPITAL

Meeting Hall, Bilkent, Ankara - Turkey

5

th

year in Robotic Urology (2009-2013):

more than 550 cases in 5 years

www.robotictimes.org

Robotic RadicalProstatectomy

Robotic PartialNephrectomy

RoboticPyeloplasty

Greenlight LaserProstatectomy

Robotic �exibleuretero-renoscopy

LIVE SURGERIES

ISBN: 978-605-85925-0-6

2013

www.robotictimes.org 2

Organizing Committee

Members (in alphabetical order)

PresidentM. Derya Balbay, MD

Istanbul, Turkey

SecretaryA. Erdem Canda, MD

Ankara, Turkey

Ziya Akbulut, MDAnkara, Turkey

Yasar Ozgök, MDAnkara, Turkey

Serkan Altinova, MDAnkara, Turkey

A. Tunc Ozdemir, MDİstanbul, Turkey

Ali Fuat Atmaca, MDAnkara, Turkey

Lutfi Tunc, MDAnkara, Turkey

Ali Serdar Gözen, MDHeilbronn, Germany

Invited Robotic Surgeonss

John W. Davis, MD, FACSAssociate Professor

Department of Urology University of Texas

MD Anderson Cancer Center Houston, TX, USA

Kevin C. Zorn, MD, FRCSC, FACSDirector of Robotic Surgery

Assistant Professor Department of Urology University of Montreal

Hospital Center Hospital St. Luc Montreal, Canada

Ali Serdar Gözen, MD, FEBUESUT Training Group MemberAssociate Professor of Urology

SLK Kliniken HeilbronnThe University of Heidelberg

Heilbronn, Germany

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Dear Colleagues,

Starting from the early 2000s, da Vinci Robotic System has been utilized mostly for the surgical treatment of localized prostate cancer and continued to grow rapidly all around the world. In 2012, 85% of the surgical operations performed in USA with the diagnosis of prostate cancer have been done with the use of da Vinci surgical robot. Recent data have shown us that with robotic radical prostatectomy, oncologic results are at least equal to or even better compared with the open surgery while providing significant improvement in functional outcomes such as decreased incontinence and impotence rates in addition to decrease in surgical complications and also leading to early recovery. The superiority of robotic surgery basically stems from carrying out the procedure in a bloodless field with improved 3-D vision with better illumination and magnification providing closer look at the tissues.

Prostate cancer is not the only ailment treated with the use of surgical robot. Soon after being satisfied with the results of radical prostatectomy, many surgical urological treatments have been done with the robot including radical and partial nephrectomies, nephroureterectomies, radical cystectomies with or without intracorporeal urinary diversions, pyeloplasties and sacral colpopexy operations.

Proving itself mostly in the field of urology surgeons in other fields of medicine started to convert robotic surgery such as Ob&Gyn, ENT, General Surgery, Cardiovascular and Thoracic Surgeons. It is anticipated that both the nuımber of specialties and surgical procedures done by the robot will be increased in the future.

As robotic surgeons, we should follow to keep up with the increasing indications and surgical techniques utilized in our field and share our experiences with our colleagues to improve ourselves and help our patients. This has been the main driving force to organize such a meeting in Ankara, one of the earliest and most experienced robotic urology centers not only in this country but also in the near vicinity.

It has been a privilege and honor to have very well known famous robotic urologic surgeons both in the world and across the country as speakers and live surgery performers to inspire all of us. I also hope that this meeting will be fruitful in helping to expand our knowledge and providing future collaborations.

Warmest regards,

M. Derya Balbay, MDProfessor of UrologyPresident of the 2nd Ankara Robotic Urology Symposium & Course

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List of Authors

Ziya Akbulut (Turkey)

Serkan Altinova (Turkey)

Burak Argun (Turkey)

Erem Asil (Turkey)

Ali Fuat Atmaca (Turkey)

M. Derya Balbay (Turkey)

A. Erdem Canda (Turkey)

H. Ibrahim Cimen (Turkey)

Bayram Dogan (Turkey)

Bahri Gök (Turkey)

Ali Serdar Gözen (Germany)

A. Egemen Isgoren (Turkey)

Selcuk Keskin (Turkey)

Metin Kilic (Turkey)

Ali Riza Kural (Turkey)

Roger F. V. O’Donova (Canada)

M. Fuat Ozcan (Turkey)

Jens Rassweiler (Germany)

Ali Ihsan Taşçı (Turkey)

Ilter Tufek (Turkey)

Gul Yildirim (Turkey)

Kevin C. Zorn (Canada)

(In alphabetical order)

TABLE OF CONTENTS

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Table of Contents

I. DESCRIPTION OF SURGICAL ROBOTIC SYSTEM (Da Vinci-S) and HOW TO ASSIST IN ROBOTIC UROLOGIC SURGICAL PROCEDURES

1. Description of the Da Vinci-S surgical robotic system and Robotic Operating Room Nursing: Robot-assisted radical prostatectomy and radical cystectomy procedures.

G. Yildirim and A. E. Isgoren

2. Assisting during robotic assisted transperitoneal laparoscopic pyeloplasty.

M. Kilic and E. Asil

3. Tasks of the assistant surgeon at robot-assisted laparoscopic transperitoneal partial nephrectomy.

A. E. Isgoren, Z. Akbulut, S. Altinova and M. F. Ozcan

4. Assisting in Robotic Extended Pelvic Lymph Node Dissection (Prostate & Bladder Cancer).

B. Gök and A. E. Canda

5. Tasks of the assistant surgeon during robotic assisted radical prostatectomy (RARP).

A. E. Canda and M. D. Balbay

6. Tasks of the assistant surgeon at nerve-sparing robotic assisted radical cystectomy (RARC).

B. Dogan, A. E. Canda and A. E. Isgoren

7. Assisting in Robotic Intracorporeal Studer Pouch Reconstruction.

H. I. Cimen and A. E. Canda

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II. SURGICAL TECHNIQUES

1. Robot Assisted Radical Prostatectomy: Step-By-Step Surgical Technique.

R. F. V. O’Donova and K. C. Zorn

2. Extraperitoneal Retrograde Robotic Radical Prostatectomy: The Heilbronn Technique.

A. S. Gözen and J. Rasssweiler

3. Surgical Technique: Robotic-assisted laparoscopic radical prostatectomy (RARP).

A. E. Canda, Z. Akbulut, A. F. Atmaca, S. Altinova and M. D. Balbay

4. How to use the 4th arm of the Da Vinci surgical robot efficiently during robotic-assisted radical prostatectomy (RARP).

A. E. Canda and M. D. Balbay

5. Robotic-assisted laparoscopic radical cystoprostatectomy and intracorporeal urinary diversion (Studer pouch or ileal conduit) for bladder cancer.

A. E. Canda, A. F. Atmaca and M. D. Balbay

6. Robotic Bilateral Extended Pelvic Lymph Node Dissection Following Robotic Radical Cystectomy in Bladder Cancer.

A. E. Canda, A. E. Isgoren and E. Asil

7. Robotic Intracorporeal Studer Pouch Construction.

M. D. Balbay

8. Fascia Sparing Intrafascial Nerve Sparing Robot-Assisted Radical Prostatectomy and Anatomic Vesicourethral Anastomosis:Point of Technique

A. I. Tasci

9. Clinical Importance of Apical Anatomy and Various Approaches to Control The Dorsal Vein Complex During Robot Assisted Radical Prostatectomy

A. R. Kural, I. Tufek, S. Keskin and B. Argun

III. SYMPOSIUM & COURSE PROGRAM

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I. DESCRIPTION OF SURGICAL ROBOTIC SYSTEM (Da Vinci-S) and HOW TO ASSIST IN ROBOTIC UROLOGIC

SURGICAL PROCEDURES

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Description of the Da Vinci-S surgical robotic systemRobotic Operating Room Nursing: Robot-assisted radical prostatectomy and radical cystectomy procedures

Introduction

The da Vinci Surgical System consists of three main components; surgeon console, patient-side cart and vision system.

Surgical console: It is located in the same operating room with the patient and the surgeon controls the console in sitting position and performs the procedure. The surgeon uses the hand pieces to control the robotic arms and the foot pedals for electrocautery (monopolar and bipolar), to shift between robotic arms (clutch) and to control lens.

Patient-side cart: This part has 4 robotic arms that are connected to the patient. The robotic arms hold the instruments and the 3D camera. This part is controlled by the console surgeon. Three of the arms are to hold the endowrist instruments that can act as scissors, or unipolar or bipolar electrocautery or tissue holder depending to the instrument used.

1Ankara Ataturk Training & Research Hospital, Robotic Surgery Operating Room, Ankara, Turkey (Robotic Surgery Nurse)2Ankara Ataturk Training & Research Hospital, Department of Urology, Ankara, Turkey (Urologist)

Gül Yıldırım1 A. Egemen Isgoren2

Correspondence:Gul Yildirim (Robotic Surgery Operating Room Nurse) Ankara Ataturk Training & Research Hospital, Robotic Surgery Operating Room, Bilkent 06800, Ankara – TurkeyE-mail: [email protected]

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Vision System: This part includes the system for creating the vision for the assisting surgeon on the patient bedside. Sometimes a 3D monitor might also exist as we have in our robotic surgery operating room which we think is very important for educational purposes and facilitates learning.

Instrument Arm Draping:

In order to facilitate this step while keeping sterility precautions and safety, draping should be done by a scrub

nurse and a circulating nurse together. The arms are draped systematically moving from left to right or right to left. Once an arm is draped, the scrub nurse should move the draped arm away from the undraped arm.

• Wear the drape over the instrument arm axis• Place the base of sterile adapter into the instrument arm

carriage and push until until it clicks into place• The wheels on the adapter will spin and three beeps will

be heard to indicate that the system recognizes correctly• Move the drape back along the instrument arm towards

the tower• Seat the cannula mount molding• Wrap all white drape straps around the instrument arm

and fix

Camera Arm Draping:• Wear the drape over the instrument arm axis• Move the drape back along the instrument arm towards

the tower• Seat the cannula mount molding• Take the camera arm sterile adapter to the drape, remove

the adhesive strip cover, and press the backside of the camera arm sterile adapter to the adhesive strip

• Wrap all white drape straps around the camera arm and fix

Camera Head Draping:• Attach the endoscope to the sterile endoscope adapter

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• Insert the endoscope into the drape• Push the sterile endoscope adapter through the elastic

end of the drape until the drape completely surrounds the sterile adapter

• Attach the drape to the endoscope using sterile adhesive tape

• The circulating nurse attaches the camera head to the endoscope sterile adapter, and pulls the drape along the cable in sterile fashion

The endoscope and endoscopic instruments and accessories should be checked for any possible problems prior to procedure. After that, the circulating nurse selects the endoscope angle and type, sets the white balance, calibrates the endoscope and scope align by using target alignment in an order.

The patient is positioned in supine position and legs are kept slightly apart for allowing to place the patient-side cart properly between the legs. Both arms should be draped by the patient’s side and the patient has to be secured on the table by using chest belt and shoulder pads to avoid any movement. Then, the patient is positioned in steep (30o) Trendelenburg position. After the patient is secured and eletrocautery plate is placed, the operation field is cleaned and covered in sterile fashion. Thereafter, robot-compatible monopolar and bipolar eletrocautery cables, laparoscopic suction instrument, bifurcated robotic light guide cable, and laparoscopic insufflation tube are connected by scrub

nurse. Thermos bottle filled with sterile hot saline for using to prevent fogging of the endoscope and sterile gauze placed in it to avoid damage of the endoscope tip. The transurethral catheter is inserted and the bladder is emptied by using the catheter tip syringe. Following pneumoperitoneum is achieved (12-14 mm Hg pressure), transabdominal trocars are placed by the surgeon. The goals of port placement are to avoid patient-side robotic arm collisions and to maximize instrument and endoscope range of motion. Once trocars are inserted on the patient’s abdomen, operating room technician drives the patient-side cart between the legs of the patient close to the perineum. Then, the patient-side cart is positioned and fixed. Care should be taken to avoid contact of the robotic arms with the patient’s body. All equipments and surgical, laparoscopic and robotic instruments should be available for use before starting the surgical procedure.

Surgical, Laparoscopic and Robotic Instruments for Robot-assisted Radical Prostatectomy

Surgical Instruments: • Scalpel, 15 no. (n=1)• Kocher Forceps (n=4)• Kelly Hemostatic Forceps (n=2)• Backhaus Forceps (n=2)• Tissue Forceps (n:2)• Metzenbaum Scissors (n=1)• Needle Holder (n=1)

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• Universal Scissors, Straight (n=1)• Farabeuf Wound Retractor (n=2)• Kidney Tray (n=1)• Round Bowl (n=1)

Laparoscopic Instruments:• Thermos Bottle (n=1)• Veress Neddle (n=2)• Laparoscopic Curved Scissors (n=1)• Laparoscopic Grasper (n=1)• Laparoscopic Neddle Driver (n=1)• Laparoscopic Suction Instrument (n=1)• Laparoscopic Insufflation Cable and Tube (n=1)• Hem-o-lok® Clip Applicator, Large (n=1)• Hem-o-lok® Clip, Large (4 cartidges, each contains 6

clips)• Trocar, 12 mm (n=2)

Robotic Instruments:• Monopolar Curved Scissors, 8 mm (n=1)• Maryland Bipolar Forceps, 8 mm (n=1)• Prograsp Forceps , 8 mm (n=1)• Needle Driver, 8 mm (n=2)• Robotic Trocar, 8 mm (n=3)• Seal (n=3)• Tip Cover (n=1)• Camera Head Adapter (n=1)• Camera Arm Adapter (n=1)• Camera Head Drape (n=1)• Camera Arm Drape (n=1)• Instrument Arm Drape (n=3)• Robot-Compatible Eletrocautery Cable, Monopolar

and Bipolar (n=1, for each) • Bifurcated Light Guide Cable (n=1)• 3D Endoscope, 0 degree lens (n=1)• Target Alignment (n=1)

Surgical Supplies:• Syringe, 20 cc (n=2)• Syringe, Catheter Tip 50 cc (n=1)• Transurethral Catheter, 20 fr (n=2)• Lodge Drain (n=1)• Sterile Lubricant (n=2)• Surgical Gloves• Sterile Urine Bag• Sterile Ruler and Pen (n=1, for each)• Specimen Retrieval Bag, 10 mm (n=1)

Sutures:• 0 polyglactin (vicryl), 40 mm ½ tapered needle. Thread

length is prepared as 25 cm for ligation of dorsal venous complex (n=1)

• 3-0 polydioxanone (PDS), 16 mm ½ tapered needle. Two sutures are used, thread length of each side is prepared as 19 cm length that are tied to each other. This suture is used for posterior rabdhomyosphincter reconstruction (n=2)

• 3-0 polydioxanone (PDS), 16 mm ½ tapered needle. Two sutures are used, thread length of each side is prepared as 19 cm length that are tied to each other. This suture is used for urethra-vesical anastomosis (n=2)

• 0 polyglactin (vicryl), 40 mm ½ tapered needle for fascia closure (n=1)

• 2-0 polyglactin (vicryl), 26 mm ½ cutting neddle (n=1) and 2-0 polypropylene (Prolene), 26 mm 1/3 cutting needle (n=1) for wound closure.

• 0 silk, 40 mm ½ cutting needle, used for lodge drain fixation (n=1)

• Prior to the procedure, surgeon console, patient-side cart, vision cart and illuminator are powered on and robotic system should be checked whether it works properly.

• Surgical, Laparoscopic and Robotic Instruments for Robot-assisted Radical Cystectomy

Surgical Instruments: • Scalpel, 15 no. (n=1)

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• Kocher Forceps (n=4)• Kelly Hemostatic Forceps (n=2)• Backhaus Forceps (n=2)• Tissue Forceps (n=2)• Metzenbaum Scissors (n=1)• Needle Holder (n=1)• Universal Scissors, Straight (n=1)• Farabeuf Wound Retractor (n=2)• Kidney Tray (n=1)• Round Bowl (n=1)

Laparoscopic Instruments:• Thermos Bottle (n=1)• Veress Neddle (n=2)• Laparoscopic Curved Scissors (n=1)• Laparoscopic Grasper (n=1)• Laparoscopic Atraumatic Grasper (n=1)• Laparoscopic Neddle Driver (n=1)• Laparoscopic Suction Instrument (n=1)• Laparoscopic Insufflation Cable and Tube (n=1)• Laparoscopic Fan Retractor (n=1)• Laparoscopic Hook (n=1)• Laparoscopic Stapler, 60 mm (4 cartidges)• Ligasure®, 10 mm• Hem-o-lok® Clip Applicator, Large (n=1)• Hem-o-lok® Clip, Large (4 cartidges, each contains 6

clips)• Hem-o-lok® Clip Applicator, X-Large (n=1)• Hem-o-lok® Clip, X-Large (2 cartidges, each contains 6

clips)• Absorbable Clip Applicator (Lapro-Ty®)• Absorbable Clip, 8 mm (1 pack, contain 6 clips) (Lapro-

Ty®)• Trocar, 12 mm (n=2)• Trocar, 15 mm (n=1)

Robotic Instruments:• Monopolar Curved Scissors, 8 mm (n=1)• Maryland Bipolar Forceps, 8 mm (n=1)• Prograsp Forceps, 8 mm (n=1)• Needle Driver, 8 mm (n=2)• Cadiere Forceps (n=1)• Robotic Trocar, 8 mm (n=3)• Seal (n=3)• Tip Cover (n=1)• Camera Head Adapter (n=1)• Camera Arm Adapter (n=1)• Camera Head Drape (n=1)• Camera Arm Drape (n=1)• Instrument Arm Drape (n=3)• Robot-Compatible Eletrocautery Cable, Monopolar

and Bipolar (n=1, for each) • Bifurcated Light Guide Cable (n=1)• 3D Endoscope, 0 degree lens (n=1)

• 3D Endoscope, 30 degree lens (n=1)• Target Alignment (n=1)

Surgical Supplies:• Syringe, 20 cc (n=2)• Syringe, Catheter Tip 50 cc (n=1)• Transurethral Catheter, 20 fr (n=2)• Transurethral Silicone Catheter, 20 fr (n=1)• Urinary Diversion Catheter, 6 fr 70 cm (n:2) or double

pig-tail catheter, 6 fr 28 cm (n=2)• Vascular Tape, Thread length is prepared as 15 cm (n=1)• Lodge Drain (n=1)• Sterile Lubricant (n=2)• Surgical Gloves• Sterile Urine Bag• Sterile Ruler and Pen (n=1, for each)• Specimen Retrieval Bag, 10 mm (n=1)• Specimen Retrieval Bag, 15 mm (n=1)• Seldinger Dilatator Set (n=1) (Used for advancing the

urinary diversion catheter into the abdominal cavity)• Nelaton Catheter, 16 fr (n=1) (Used for inserting the

double pig-tail catheter by transurethral way into the abdominal cavity)

Sutures for Studer pouch procedure:• 0 polyglactin (vicryl), 40 mm ½ tapered needle. Thread

length is prepared as 25 cm for ligation of dorsal venous complex (n=1)

• 3-0 polydioxanone (PDS), 16 mm ½ tapered needle. Two sutures are used, thread length of each side is prepared as 19 cm length that are tied to each other. This suture is used for urethra-neobladder anastomosis (n=2)

• 2-0 poliglecaprone (monocryl), 20 mm ½ tapered needle. Thread length is prepared as 30 cm and a knot and an absorbable clip at the end of the suture for Studer pouch (n:3)

• 2-0 poliglecaprone (monocryl), 20 mm ½ tapered needle. Thread length is prepared as 30 cm

• 4-0 poliglecaprone (monocryl) or polydioxanone (PDS), 16 mm ½ tapered needle. Two sutures are used, thread length of each side is prepared as 16 cm length that are tied to each other. This suture is used for uretheral anastomosis (n=1)

• 2-0 polyglactin (vicryl), Thread length is prepared as 8 cm and tied to the hole of the middle part of hem-o-lok® clip (n=4)

• 0 polyglactin (vicryl), 40 mm ½ tapered needle for fascia closure (n=1)

• 2-0 polyglactin (vicryl), 26 mm ½ cutting neddle (n=1) and 2-0 polypropylene (Prolene), 26 mm 1/3 cutting needle (n=1) for wound closure.

• 0 silk, 40 mm ½ cutting needle, used for lodge drain fixation (n=1)

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Sutures for ileal loop procedure:

Unlike the Studer pouch procedure, the suture used for urethra-neobladder anastomosis and the sutures used to create Studer pouch are not prepared.

Prior to the procedure, surgeon console, patient-side cart, vision cart and illuminator are powered on and robotic system should be checked whether it works properly.

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Assisting during robotic assisted transperitoneal laparoscopic pyeloplasty

Robotic-assisted surgery has experienced intense growth in recent years. Robotic assistance has been used to facilitate complex laparoscopic procedures, in particular those involving intracorporeal suturing. Robotic pyeloplasty is a state of laparoscopic technique, which is performed in the same manner as the open surgery, except that 4-5 small incisions are used instead of a large flank or abdominal incision. Patients are given an oral bowel preparation the evening before surgery and provided appropriate antibiotic and thromboembolic prophylaxis as indicated.

Laparoscopic instruments:

1. Veress needle2. Two 12 mm sized, two 8 mm sized and one 5 mm sized

trocars 3. Curved Maryland endoscissors4. Maryland dissector5. Hook cautery6. Robotic needle driver7. Endoscopic clip applier8. Suction irrigator9. 0° and 30° laparoscope lens10. Camera and fiber optic cords11. 5 mm and 10 mm Hem-o-lok® clips12. Hot water bath for endoscopes

First connect system cables, optical channels, focus control, power cables and turn the system on. The system will then perform a self-test. During this time, do not attempt to manipulate the system. Then drape the patient cart arms. This takes a coordinated team effort between surgical technician and circulating nurse and uses system specific sterile drapes and accessories. Make sure the drapes are not too tight because this may decrease the motion of the robotic arms.

The camera arm is draped in a similar fashion. Taping the drape to the sterile adapter. The camera head is connected and the drape is inverted over the camera head and optical cables. Connect the light source to the endoscope with the sterile light cable. Perform a white balance. Then align the endoscope and set endoscope settings. Initial access to the peritoneum is typically achieved using the Veress needle in the umbilical or paramedian location. Veress needle is inserted and placement is verified with the hanging drop test and the abdomen is insufflated to 15 mmHg. The patient is positioned in the flank position with the affected side up. The patient-side cart approaches the patient’s back from the shoulder toward the umbilicus at a 45° angle (Picture 1). Once docked, the robotic arms will reach across the flank and angle back toward the upper quadrant. The assistant’s monitor may be positioned adjacent to the patient-side cart. After adequate general anesthesia the patient is repositioned in the flank position and all pressure points carefully padded with pillows or towels to prevent neuromuscular injury.

Picture 1: Operating room setup and surgical robot positioning for robotic-assisted laparoscopic pyeloplasty.

1Sevket Yilmaz Training & Research Hospital, Department of Urology, Bursa, Turkey2Ankara Ataturk Training & Research Hospital, Department of Urology, Ankara, Turkey

Metin Kilic1 Erem Asil2

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Overall, we use 4-5 trocars: One 12 mm sized trocar for the 3D camera, two 8 mm sized trocars for the robotic arms and one 12 mm sized trocar for assistant surgeon. Second asisstant port may be placed for liver retraction for the right sided pyelopasty procedure.

A) da Vinci endoscope, 12mm (Blue): place peri-umblical camera port; may shift laterally beyond rectus muscle in obese patients. B) Right da Vinci instrument port, 8 mm (Yellow): place port a hand breadth lateral to the camera port and at least 3 cm from the iliac crest C) da Vinci instrument port, 8 mm (Green): place port in a mirrorred fashion relative to right port a hand breadth lateral to the camera port and at least 3 cm from the costal margin. D) Primary assistant (Lower Quadrant) Port, 12 mm : place port at least 8 cm inferior to umblicus and at least 4 cm from the inferior instrument port (potential location for te 3rd da Vinci instrument arm port). E) Secondary assistant port, 5 mm : place port in upper quadrant and least a hand breadth superior to the camera port (Pictures 2 and 3).

Picture 2: Trocars placement of right side robotic-assisted laparoscopic pyeloplasty.

Picture 3: Trocars placement of left side robotic-assisted laparoscopic pyeloplasty.

After abdominal access is obtained, the patient cart is maneuvered into position to align the patient cart tower, camera arm and target anatomy. One member of the surgical team drives the patient cart while another one guides the driver. Again use the port clutch for gross movements of the instrument arms and the instrument clutch for the final position. When all of the robotic arms are connected, the surgical team should check each of the arms for proper working distance and make sure the arms are not compressing the patient. The endoscope is inserted by placing the lens into the trocar. Each instrument should be placed into the patient under laparoscopic vision. The initial steps of the procedure are purely laparoscopic. Assistant surgeon checks the intra-abdominal pressure (14-15 mm Hg) frequently. When colon is mobilized medially along the white line of Toldt, assistant surgeon help the retraction aspirates the smoke for not blur the vision (Picture 4).

Picture 4: Colon is mobilized medially along the white line of Toldt.

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When the ureter is identified, assistant surgeon retracts the ureter upward. Therefore, console surgeon works in a more comfortable way. The dissection continues to the renal pelvis. The ureter is spatulated laterally and resect any redundant renal pelvis. The assistant surgeon aspirates the urine and blood also irrigates the area with sterile saline in order to supply a clear vision (Picture 5). The medial edge of the renal pelvis is incised 2 cm above the narrowed segment and the endoscopic scissors are used to spatulate the ureter laterally and resect any redundant renal pelvis. After the posterior wall of anastomosis is completed, assistant surgeon inserts a 5-F ureteral j stent to the operating area. The pyeloplasty anastomosis is then completed using a 4–0 polyglactin suture on an RB-1 needle.

Picture 5: Incision of renal pelvis.

Once robotic assisted surgery is completed, assistant surgeon removes all of the instruments, followed by the endoscope. The arms are disconnected from the trocars and the patient cart is undocked. The proximal end of the stent is replaced into the renal pelvis just prior to closing the anterior wall of the anastomosis. Suction drain is brought out through the lateral port and secured. Fascial defects 10 mm or larger in size are closed, and the abdomen is desufflated. Patients are given 24 hours of parenteral antibiotic prophylaxis. The drain is generally removed when output is less than 50 mL per 24 hours. The stent is removed on 4-6 weeks after the surgery. Follow-up includes a radionuclide renal scan at 3 months.

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Tasks of the assistant surgeon at robot-assisted laparoscopic transperitoneal partial nephrectomy

Introduction

Kidney tumors are increasingly being diagnosed incidentally, with a smaller size and earlier stage, mostly in asymptomatic patients. Over the past decade, management of the T1 renal mass has focused on nephron-sparing surgery. Although, open partial nephrectomy currently remains as a standard of care for partial nephrectomy, robotic partial nephrectomy has played an increasing role in the technique of preserving renal function by decreasing warm ischemia time, as well as optimizing outcomes of hemorrhage. Robot-assisted laparoscopic partial nephrectomy is utilizing reconstructive capability, decreasing intracorporeal suturing time, technical feasibility and safety. Articulated instrumentation and three-dimensional vision facilitates resection, collecting system reconstruction and renorrhaphy.

Patient Position

Whilst the patient is in supine position, following induction of anesthesia, a urinary catheter is inserted and then the patient is rotated to the 30 to 45 degree flank-up position. The legs are separated and protected with pillows between them, in order to relieve any weight on pressure points, while the legs are slightly flexed at the knees. All other bony points, including shoulders and hips, are protected by pillows or towels. The head and neck are supported and an axillary pillow is placed to prevent brachial plexus injury. The table is broken at the level of the umbilicus by approximately 10–15 degree (Figure 1).

Figure 1: Patient position

Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training & Research Hospital, Department of Urology, Ankara, Turkey

A. Egemen Isgoren Ziya Akbulut Serkan Altinova M. Fuat Ozcan

Correspondence:A. Egemen Isgoren, MD Ankara Ataturk Training & Research Hospital, Department of Urology, Bilkent 06800, Ankara – TurkeyE-mail: [email protected]

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The patient is positioned on the table towards the edge of the table facing the assistant surgeon. The patient’s arms are slightly flexed at the elbow and the arm boards are positioned approximately 100–110 degrees towards the head. The patient’s thoracic and lumbar areas are supported in the lateral position with table attachments and securely fixed to the table to prevent any movement during the procedure. The patient is firmly supported with Velcro tapes across both forearms and secured with a belt at the level of the pelvis.

Intra-abdominal CO2 pressure

During the procedure intra-abdominal pressure is set to 12-14 mmHg.

Trocar Placement

Various methods can be used to enter the peritoneal cavity. These include Veress needle access, VersaStep port insertion, the open mini-laparotomy technique and the optical cutting trocar device (Visiport).

Port placement will vary depending on patient habitus, tumor location and camera angle consideration. Port sites should be kept at least >3 cm to avoid interference, and all accessory ports should be maintained at least 4 cm from the robotic ports.

Overall, four or five trocars are used (Figure 2);• Camera port (12 mm) is placed at the level of umbilicus

(A)• Inferior robotic instrument port (8 mm) is placed in a

hand breadth lateral to the camera port and at least 3 cm from the iliac crest (B)

• Superior robotic instrument port (8 mm) is placed in a hand breadth lateral to the camera port and at least 3 cm from the costal margin in a mirrored fashion relative to the inferior robotic instrument port (C)

• Primary assistant port (12 mm) is placed at least 8 cm caudally to umbilicus and at least 4 cm from the inferior instrument port (D)

• Secondary assistant port (5-10 mm) may be placed in the midline 2 cm below the xyphoid process for liver retraction (E)

• In obese patients, all trocar sites are moved laterally

Figure 2: Port placement

Once abdominal access is obtained, operating room technician approaches the patient-side cart to the patient posteriorly and docks at a 15 degree angle towards the patient head aligning center column, hilum and camera port side by guidance of bedside assistant surgeon and the patient-side cart is parked. Then the robotic arms are docked in order. The camera arm is placed first. Care should be taken to avoid contact of the robotic arms with the patient’s body and the surgical team should check the each arm for proper working distance. Each instrument should be placed into the abdominal cavity under laparoscopic vision.

Step by step tasks of bedside assistant surgeon

The bedside assistant surgeon is located on the front side of the patient and uses 12 mm assistant port (Figure 3). During the console surgeon performs the procedure, the bedside assistant surgeon assists with the tip of the laparoscopic suction by irrigating, aspirating the blood and the smoke, retracting the tissues, presents the vascular tape and sutures with the laparoscopic needle holder, cuts and removes out the sutures with the laparoscopic curved scissors, and applies the clips to the points that the console surgeon requests and also checks the intra-abdominal pressure frequently.

Figure 3: Operation room setup

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• Surgery starts with mobilizing the colon medially along the white line of Toldt. The bedside assistant surgeon helps by retracting, aspirating the blood and the smoke in order to provide a clear vision (Figure 4).

Figure 4: Traction and suction while dissecting the white line of Toldt

• Then, the ureter is identified and the bedside assistant surgeon retracts the ureter upward. The dissection continues towards the renal hilum to find and dissect the renal artery and vein (Figure 5).

Figure 5: Traction of the ureter upward

• After that, the lower pole of the kidney is elevated and the pedicle is freed from the surrounding structures. The bedside assistant surgeon helps by retracting the tissues, and irrigating and aspirating the blood. Additionally, the bedside assistant surgeon presents the vascular tape that provides the convenience of placing vascular clamps subsequently (Figures 6 and 7).

Figure 6: Elevating the lower pole, retracting the tissue and irrigating and aspirating the blood

Figure 7: Vascular tape

• Next, the Gerota fascia is opened and tumor is located. The bedside assistant surgeon helps by retracting the tissues (Figure 6).

• Vascular clamps are carefully placed by bedside assistant surgeon (Figure 8).

Figure 8: Placing the vascular clamps

• Subsequently, the renal capsule is incised about 5 mm away from the tumor by monopolar electro-cautery. The bedside assistant surgeon provides a clear vision by aspirating the blood and smoke (Figure 9).

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Figure 9: Resection of tumor, retracting the tissue, irrigating and aspirating the blood

• Once the tumor is excised, the bedside assistant surgeon introduces the specimen to the specimen retrieval bag, and the console surgeon inserts the specimen in to the specimen retrieval bag (Figure 10).

Figure 10: Introducing the specimen into the specimen retrieval bag

• Later, the bedside assistant surgeon presents the suture for collecting system reconstruction and renorrhaphy. Ischaemia is terminated after the first stitch and placement of the surgycell roll. This early declamping reduces ischaemia time (Figure 11).

• While the console surgeon is placing the sutures, the bedside assistant surgeon applies the clips which prevents the suture loose and helps by aspirating the blood in order to provide clear vision (Figure 11).

Figure 11: Clipping, aspirating the blood and presenting the surgycell

• The sutures are cut by laparoscopic scissors and removed out by laparoscopic needle holder (Figure 12).

Figure 12: Apply the clips and cut the suture

• Fibrin glue is applied over the suture line and between the approximated edges of the parenchyma to avoid delayed bleeding.

• Finally, the vascular tapes are cut and removed out by bedside assistant surgeon.

• Once robotic assisted surgery is completed, all of the instruments are removed followed by the endoscope. The arms are disconnected from the trocars and the patient cart is undocked by bedside assistant surgeon.

• Suction drain is placed through the lateral port and secured, the abdomen is desufflated, and fascial defects 10 mm or larger in size are repaired.

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Assisting in Robotic Extended Pelvic Lymph Node Dissection (Prostate & Bladder Cancer)

• Extended pelvic lymph node dissection borders for bladder cancer include;• Lateral borders: genitofemoral nerve, psoas muscle

and ureters• Medial borders: internal iliac veins and corners of

neurovascular bundles crossing endopelvic fascia• Superior borders: inferior mesenteric artery and

superior mesenteric vein• Inferior borders: Cloquet lymp node, cooper

ligament and pelvic floor• External, internal and common iliac nodes;

obturator, presacral, interbifurcatio, preaortik and precaval lymph nodes are included

• Extended pelvic lymph node borders for prostate cancer include;• Lateral border: genitofemoral nerve• Medial border: bladder wall• Distal border: Cloquet lymp node• Proximal border: 2 cm above of common iliac

artery bifurcatio

• Same principles apply for assistance of robotic lymph node dissection in prostate and bladder cancer surgery

Picture 1. Abdominal trocar placement for RARP procedure.R: robotic port (8 mm)C: camera port (12 mm)Assistant surgeon port: 12 mm

Overall, we use 5 trocars;

1- Camera port (12 mm): located 2 cm above the umblicus

2- Two robotic ports (for 1st and 3rd robotic arms, 8 mm): at the level of umblicus and bilaterally 8 cms far away from the camera port


Bahri Gök A. Erdem Canda

Correspondence:Bahri Gök, MD Resident in UrologyAnkara Ataturk Training & Research HospitalDepartment of Urology Ankara, TurkeyE-mail: [email protected]

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3- At the right side: 4th robotic port (8mm), 3 cm above of iliac crest

4- 12 mm assistant port, left abdominal region: at the level of umblicus, between robotic port and camera port

• In our technique the bedside assistant is located on the left hand side of the patient and uses a 12 mm sized trocar for assistance

• Assistant surgeon checks the intra-abdominal pressure frequently

• The patient is taken to 30 degrees Trendelenburg position

• Intra-abdominal pressure is decreased to 10 mmHg for optimal visualization of venous structures

• 0 degree 3D optic lens is used for lymph node dissection• 1st robotic arm is used for Maryland monopolar scissor

and 2nd robotic arm is used for bipolar forceps during lymph node dissection

• Small lymphatic structures could be coagulated using mono or bipolar cautery. Hemoclips are also could be used when necessary.

Picture 2. Endoscopic clip application.

• Small bleedings should be aspirated by endoscopic suction to obtain a better visualization for the console surgeon.

Picture 3. Suction aspirating blood during lymph node dissection.• Surrounding tissues such as bowel segments should

retracted away from the surgical field by using an endoscopic suction to obtain a clear area for the operating console surgeon during lymph node dissection. In addition, using an aspirator maintains the ability of aspirating small bleedings.

Picture 4. Endoscopic suction making gentle traction and aspiration.

• While applying a hemoclip or hem-o-Lock clip, endoscopic clips should be positioned parallel to the vessels

• After both right and left specimens are taken into the endobag, intraabdominal pressure should be decreased and bleeding control should be made

2013


Tasks of the assistant surgeon during robotic assisted radical prostatectomy (RARP):

Robotic-assisted radical prostatectomy (RARP) is frequently being performed for the surgical treatment of localized prostate cancer. The Da-Vinci-S and Si surgical robots have 4 arms that are all used during RARP. Three of the robotic arms are used for robotic instruments and one arm is used for the 3D camera. Using the 4th robotic arm efficiently might significantly facilitate the RARP procedure for the operating console surgeon.

The training of the assistant surgeon who is assisting the console surgeon throughout the procedure is very important. A well-trained and experienced assistant surgeon will without any doubt facilitate the surgical procedure great deal.

Herein, we explained the tasks of the assistant surgeon with demonstrative surgical pictures during the RARP procedure.

Abdominal trocar placement for RARP procedure.

R: robotic port (8 mm)C: camera port (12 mm)Assistant surgeon port: 12 mm

Overall, we use 5 trocars:One 12 mm sized trocar for the cameraThree 8 mm sized trocars for the robotic arms One 12 mm sized trocar for assistant surgeon: We use the 4th arm of the Da Vinci-S surgical robot on the right side of the patient and we use Prograsp for the 4th-arm throughout the RARP procedure.

• In our technique the bedside assistant is located on the left hand side of the patient and uses a 12 mm sized trocar.

• Assistant surgeon checks the intra-abdominal pressure frequently.

The assistant surgeon hooks up the peritoneum overlying the bladder with the tip of the endoscopic suction while the console surgeon dissects the seminal vesicles and the vas deferences. This maneuver creates a larger space for the console surgeon to work more in a more confortable way (Picture 1).

Correspondence:

A. Erdem Canda1

1Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training & Research Hospital, Department of Urology, Ankara, Turkey2Memorial Sisli Hospital, Department of Urology, Istanbul, Turkey

A. Erdem Canda, MD Associate Professor of UrologyYildirim Beyazit Universtiy, School of Medicine Ankara Ataturk Training & Research Hospital Department of UrologyBilkent 06800, Ankara – Turkey www.erdemcanda.comE-mail: [email protected]

M. Derya Balbay2

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Picture 1. Tip of the endoscopic suction hooks up the perito-neum overlying the bladder.

The assistant surgeon applies endoscopic clips to the tip and lateral sides of the seminal vesicles to control the vessels entering the seminal vesicles at this level (Picture 2).

Picture 2. Application of Hem-o-Lock clips

The assistant surgeon aspirates the blood and also irrigates the area with sterile saline in order to supply a clear vision for the operating console surgeon before and during opening the Denonvillier’s fascia (Picture 3).

Picture 3. Suction aspirating blood around the Denonvillier’s fascia.

The assistant surgeon aspirates the smoke with the suction while the console surgeon dissects the medial umblical ligaments (folds). During performing this dissection, the camera stays usually close to the area of dissection and the smoke could easily blur the vision (Picture 4).

Picture 4. Endoscopic suction aspirating the smoke.

The assistant surgeon grasps and removes out the fat tissue that console surgeon excises over and around the prostate and the endopelvic fascia with the endoscopic tissue grasper (Picture 5).

Picture 5. Endoscopic grasper grasping the fat tissue.

Assistant surgeon presents the dorsal venous suture with the laparoscopic needle holder (Picture 6).

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Picture 6. Assistant surgeon presenting the suture.

Assistant surgeon cuts the dorsal venous suture with laparoscopic scissors and removes it with the laparoscopic needleholder (Pictures 7 and 8).

Picture 7. Assistant surgeon cutting the dorsal venous suture with laparoscopic scissors.

Picture 8. Removing the cut suture with laparoscopic needle-holder.

While the console surgeon dissects the area between the prostate in order to expose the urethra, the assistant surgeon aspirates the blood and smoke around this anatomical place and exposes the tissue details to the console surgeon (Picture 9).

Picture 9. Endoscopic suction clearing the area between the prostate and the bladder.

Following the console surgeon dissects the prostatic pedicle, the assistant surgeon applies endoscopic clips to the exact place the console surgeon requests (Picture 10).

Picture 10. Endoscopic clip application.

During high anterior release neurovascular bundle preservation, the console surgeon dissects the prostatic fascia (intra or inter-fascial). During this step, the assistant surgeon makes a gentle traction with the use of an endoscopic suction to the dissected prostatic fascia in order to better show the area to the console surgeon. Additionally, the assistant surgeon aspirates the blood that might interfere the vision during high anterior release (Picture 11).

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Picture 11. Endoscopic suction making gentle traction and aspiration over the prostate (left side).

During the console surgeon performs apical prostatic dissection and urethral dissection, the assistant surgeon aspirates and irrigated this area with the endoscopic suction that shows the details of this important area to the console surgeon (Picture 12).

Picture 12. Endoscopic suction aspirating and irrigating the area during apical and urethral dissection.

Following completion of the radical prostatectomy, the assistant surgeon introduces the tissue endobag. The console surgeon inserts the prostate tissue in to the endobag (Picture 13).

Picture 13. Tissue endobag.

The assistant surgeon aspirates the blood and irrigates the area over the rectum and around the neurovascular bundles before starting the urethra-vesical anastomosis (Picture 13).

Picture 14. Suction aspirating the blood over the rectum and preserved neurovascular bundles (Picture 14).

(Robotic surgical pictures are obtained from Ankara Ataturk Training & Research Hospital, Robotic Urology archive)

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Tasks of the assistant surgeon at nerve-sparing robotic assisted radical cystectomy (RARC):

In our department, an experienced assistant surgeon who has assisted more than 50 cases of robotic-assisted radical prostatectomy procedures assists in robotic-assisted radical cystectomy (RARC).

Patient position

The patient is positioned in 30 degree steep Trendelenburg position and legs are kept slightly apart. Both arms are draped by the patient’s side and the patient is secured on the table by using chest belt and shoulder pads to avoid any movement.

Intra-abdominal CO2 pressure

During the procedure intra-abdominal pressure is set to 15 mmHg. Following completion of the RARC, pressure is decreased to 10-12 mmHg during robotic extended lymph node dissection in order to allow visualization of the major vascular structures.

Abdominal trocar sites

• Overall we use 6 trocars (Picture 1);• Camera port (12 mm) is placed 2 cm above the

umbilicus.• Left robotic trocar (8 mm) is placed 10 cm apart form

the camera port at the umbilicus level.• Right robotic trocars (8 mm), one of them is placed 8

cm apart from the camera port at the umbilicus level and the other is placed 3 cm vertically above the right iliac crest.

• Assistant surgeon trocar (12 mm) is placed between the camera and the left robotic trocar.

• Assistant surgeon trocar (15 mm) is placed 3 cm vertically above the left iliac crest.

Picture 1. Abdominal port placement

The bedside assistant surgeon is located on the left hand side

1Manisa State Hospital, Department of Urology, Manisa, Turkey2Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training & Research Hospital, Department of Urology, Ankara, Turkey3Ankara Ataturk Training & Research Hospital, Department of Urology, Ankara, Turkey

Bayram Dogan1 A. Erdem Canda2 A. Egemen Isgoren3

Correspondence:A. Erdem Canda, MD Associate Professor of UrologyYildirim Beyazit Universtiy, School of MedicineAnkara Ataturk Training & Research HospitalDepartment of UrologyBilkent 06800, Ankara – Turkeywww.erdemcanda.comE-mail: [email protected]

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of the patient and uses 12 mm and 15 mm trocars.

• Surgery starts with dissection of the ureters. Assistant surgeon retracts the ureter laterally and irrigates & aspirated the area of dissection (Picture 2)

Picture 2. Suction retracting the ureter laterally, irrigating & aspirating the area of dissection.

• The two consecutive Hem-o-Lok® clips are placed by the assistant surgeon at the very distal end of the ureter where it enters the bladder (Pictures 3 and 4)

Picture 3. Ureteral Hem-o-Lok® clip application.

Picture 4. Ureteral Hem-o-Lok® clip application.

• The assistant surgeon removes the excised distal ends of the ureters with endoscopic grasper to be sent for pathologic frozen section evaluation (Picture 5)

Picture 5. Endoscopic grasper is removing the excised distal ends of the ureters for frozen section evaluation.

• The peritoneum overlying the bladder is hooked up with the tip of the endoscopic suction device while the console surgeon dissects the seminal vesicles and the vas deferences (Picture 6)

Picture 6. Tip of the endoscopic suction hooks up the peritoneum overlying the bladder.

• Assistant surgeon retracts the seminal vesicles during dissection, irrigates & aspirates the area of dissection (Picture 7)

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Picture 7. Tip of the endoscopic suction hooks up the peritoneum overlying the bladder.

• Assistant surgeon applies Hem-o-Lok® clips to the tips of the seminal vesicles during neuro-vascular bundle preservation (Picture 8)

Picture 8. Hem-o-Lok® clip application to the tip of the seminal vesicle (SV).

• Lateral pedicules of the bladder are dissected by using

vessel sealing system (ie. Ligasure®) or endoscopic clips are applied to the exact place that the console surgeon requests (Pictures 9 and 10)

Picture 9. Right lateral bladder pedicle dissected by using vessel and tissue sealing system (ie. Ligasure®).

Picture 10. Right lateral bladder pedicle dissected by using endoscopic clips (Hem-o-Lok®).

• The bedside assistant surgeon aspirates the smoke with the suction while the console surgeon dissects the urachus and periton on the anterior abdominal wall (Picture 11)

Picture 11. Endoscopic suction aspirating smoke.

• Assistant surgeon uses the endoscopic liver retractor to retract the bowel segments posteriorly (Picture 12)

Picture 12. Endoscopic liver retractor is used to retract the bowel segments posteriorly.

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• Dorsal venous ligation suture is presented by laparoscopic needle holder, cut by laparoscopic scissors and removed out the cut suture by laparoscopic needle holder (Picture 13)

Picture 13. Assistant surgeon presents, cuts, and and removes the dorsal venous suture.

• Assistant surgeon aspirates the area with endoscopic suction during dissection of the prostatic apex (Picture 14)

Picture 14. Suction aspirating prostatic apex.

• During the console surgeon dissects the prostatic fascia, the bedside assistant surgeon makes a gentle traction with the use of an endoscopic suction in order to better show the area to the console surgeon (Picture 15)

Picture 15. Endoscopic suction making a gentle traction during high-anterior release NVB preservation.

• Assistant surgeon aspirates the area during urethral dissection and removes out the urethral tissue excised for pathologic frozen section evaluation (Pictures 16 and 17)

Picture 16. Endoscopic suction aspirating during urethral dissection.

Picture 17. Endoscopic grasper removing out the urethral tissue excised for frozen section.

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• After the completion of the radical cystectomy, the bedside assistant surgeon introduces the tissue endobag and the console surgeon inserts the specimen into the endoscopic specimen retrieval bag (Picture 18)

Picture 18. Specimen retrieval endobag.


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Assisting in Robotic Intracorporeal Studer Pouch Reconstruction

Patient position

Patient is placed in deep (30°) Trendelenburg position at the beginning of the procedure until the completion of robotic cystectomy, bilateral extended lymph node dissection and transposition of the left ureter under the mobilized sigmoid colon. During performing intracorporeal Studer pouch reconstruction, patient position is adjusted to mild (5°) Trendelenburg position.

Abdominal port locations

Overal, we use 6 trocars with the 4th-arm of the surgical robot placed on the patient’s right which provides easy control to the right-handed console surgeon. Camera port (12-mm) is placed to 2 cm above the umblicus. Two robotic trocars (8-mm) are placed 8 cm apart from the camera port at the level of the umblicus. An 8-mm sized robotic trocar is placed 3 cm vertically above from the right iliac crest for the 4th-arm. We use 2 asistant trocars on the left abdomen: A 15-mm trocar for introducing for tissue staplers for bowels and endobags for specimens is placed 3 cm vertically above from the left iliac crest and a 12-mm trocar is placed between the camera port and the 2nd-robotic arm (Figure 1).

Figure 1. Abdominal port locations for robotic radical cystectomy, bilateral extended pelvic lymph node dissection and intracorporeal Studer pouch reconstruction for bladder cancer.

Tasks of the bedside assistant surgeon:

• Checking the abdominal pressure• Maintaining appropriate exposure of the tissues for the

console surgeon: o Aspiration & irrigation

1Ardahan State Hospital, Department of Urology, Ardahan, Turkey2Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training & Research Hospital, Department of Urology, Ankara, Turkey

H. Ibrahim Cimen1 A. Erdem Canda2

Correspondence:Haci Ibrahim Cimen, MD Ardahan State HospitalDepartment of UrologyArdahan – TurkeyE-mail: [email protected]

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• Introducing and removing the robotic instruments• Helping to the console surgeon to control bleeding• Applying endoclips & tissue sealing devices • Putting the specimen into the endobag

• Introducing a nylon tape that is used to manipulate the ileum for urethro-ileal anastomosis (Figure 2):

Figure 2. Assistant surgeon introduces a nylon tape that the console surgeon uses to manipulate the ileum easily in the pelvis for urethro-ileal anastomosis.

• Perineal pressure for urethroileal anastomosis to identify urethra easily (Figure 3):

Figure 3. Assistant surgeon compresses the patient’s perineum to identify urethra and provide easier urehtro-ileal anastomosis for the console surgeon.

• Inserting the feeding tube after completion posterior wall of urethro-ileal anastomosis (Figure 4):

Figure 4. Assistant surgeon inserts the feeding tube that will be used for inserting the ureteral catheters in the following steps (after completion posterior wall of urethro-ileal anastomosis, green arrow shows completed posterior wall of urethro-ileal anastomosis).

• Introducing intestinal stapler through the 15 mm sized trocar for intestinal stapling (Figure 5):

Figure 5. Assistant surgeon inserts intestinal stapler through the 15 mm sized trocar and places it perpendicular across the ileum with adjacent 2 cm mesointestinum included.

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• Filling saline after completion of urethro-ileal and intestinal anatomosis to identify separated ileal segment for Studer Pouch (Figure 6):

Figure 6. Assistant surgeon fills the separated ileum for Studer pouch with saline to identify it easily.

• Inserting absorbable clips at the end of the posterior and anterior wall closure of the Studer Pouch (Figure 7):

Figure 7. Assistant surgeon inserts absorbable clips at the end of the posterior and anterior wall closure of the Studer Pouch. Herein, a clip is inserted after posterior wall closure (arrow).

• Inserting laparoscopic liver retractor to expose ureters for uretero-intestinal anastomosis (Figure 8):

Figure 8. Assistant surgeon inserts the endoscopic liver retractor (green arrow) to expose ureters for uretero-intestinal anastomosis.

• Introducing uretral and ureteral catheters (Figure 9):

Figure 9. Assistant surgeon inserts ureteral catheters (black arrow) through the feeding tube over a guide wire to the to the uretero-intestinal anostomosis site and fed up to the ureters and renal pelves.

• Checking the watertightness of the pouch• Extracting the endobag

Which instruments & devices are used?• Monopolar curved scissors• Maryland bipolar forceps• Cadiere forseps• Prograsp forceps• Large needle driver• 00 scope• Laparoscopic intestinal stapler• Tissue sealing device • Laparoscopic clip applicator• Laparoscopic aspirator/suction• Uretral & ureteral catheters


II. SURGICAL TECHNIQUES

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Robot Assisted Radical Prostatectomy: Step-By-Step Surgical Technique

INTRODUCTION

Radical prostatectomy remains the standard treatment for long-term cure of clinically localized prostate cancer, offering excellent oncologic outcomes, with cancer-specific survival approaching 95% at 15 years after surgery [1]. Retropubic radical prostatectomy (RRP), laparoscopic radical prostatectomy (LRP) and robot assisted radical prostatectomy (RARP) are safe options for treatment of patients with localized prostate cancer as they present similar overall complication rates [2]. Radical retropubic prostatectomy (RRP) has long been the most common surgical technique used to treat clinically localized prostate cancer (PCa). More recently, since 2004-2005, robot-

assisted radical prostatectomy (RARP) has been gaining increasing acceptance among patients and urologists, and it has become the dominant technique in the United States despite a paucity of prospective studies or randomized trials supporting its superiority over RRP [2]. RARP has been associated with decreased operative blood loss and decreased risk of transfusion when compared with retropubic radical prostatectomy [3-5]. It has also been described that, with experienced robotic surgeons, RARP yields lower positive surgical margins (PSM) rates and higher continence and potency rates [6]. Since there are no randomized trials and long-term follow-up studies that compare the three approaches definitive conclusions cannot yet be drawn.

Abstract: Radical prostatectomy remains the standard treatment for long-term cure of clinically localized prostate cancer, offering excellent oncologic outcomes, with cancer-specific survival approaching 95% at 15 years after surgery. The introduction of the “da Vinci Robotic Surgical System” (Intuitive Surgical, Sunnyvale, CA) has been another important step toward a minimally invasive approach to radical prostatectomy. Technologic peculiarities, such as three-dimensional vision, wristed instrumentation with seven degrees of freedom of motion, lack of tremor, a

10x-magnification and a comfortable seated position for the surgeon has added value to the surgeon and patient.

In this chapter, we describe the ten-step surgical technique for robot assisted radical prostatectomy that is currently used in our institution (University of Montreal Hospital Center (CHUM) – St-Luc’s Hospital). We use the four-arm da Vinci Si Surgical System. Our experience with RARP is now over 250 cases with the senior surgeon having performed over 1200 RARPs and we have continually refined our technique to improve patient outcomes.

University of Montreal Hospital Center (CHUM)- Hopital St. Luc Montréal, Québec, Canada

Roger F. Valdivieso O’Donova Kevin C. Zorn

Correspondence:Kevin C. Zorn, MD Assistant Professor of UrologyDirector of Robotic SurgeryUniversity of Montreal Health Center (CHUM)235, boul. René-Levesque Est, suite 301Montreal, QC, H2X 1N8 CanadaE-mail: [email protected]

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Nevertheless, RARP has become the leading option for treating patients with clinically localized prostate cancer in the United States, and it has been progressively expanding in other countries [2]. Surgeon experience and institutional volume of procedures strongly predict better outcomes in all relevant domains.

Moreover, RARP is feasible using either a transperitoneal or extraperitoneal approach. Most surgeons favor the transperitoneal access and approach over the extraperitoneal approach due to the greater working space and familiar landmarks of the pelvis and its contents. Although some studies have shown that an extraperitoneal approach yields shorter mean operative time, shorter time to full diet, shorter hospital stays and earlier return to continence [7] most studies have found little or no difference in operative time and perioperative outcomes between these two approaches [8-11]. It may nevertheless be preferable to use the extraperitoneal approach in patients with previous extensive abdominal surgery or the morbidly obese [12]. With the extraperitoneal approach, the peritoneum acts as a natural barrier, minimizing the potential for bowel injury and preventing the bowels from falling into the operative field and obscuring the surgeon’s view. Furthermore, this approach helps to confine any urine leak that may occur from the vesicourethral anastamosis within the extraperitoneal space. One limitation with the extraperitoneal approach is the reduced working space as compared with the relatively larger working space of the peritoneal cavity gained with transperitoneal access. Extended pelvic lymphadenectomy may also be more challenging with the extraperitoneal approach. Lastly, a higher CO2 absorption has been reported with extraperitoneal versus transperitoneal insufflation, requiring a higher minute volume to compensate for hypercarbia and associated acidosis [13].

Overall, whether to use one approach or the other is largely a matter of surgeon and institution preference and experience and there is no consistently demonstrated advantage for either approach.

PREOPERATIVE PREPARATIONS

Other than a thorough medical clearance with history and physical examination for any cardiopulmonary comorbidities and previous abdominal surgery, there is no specific bowel preparation to undergo this procedure. Patients are requested to start a liquid diet beginning at noon the day prior to surgery followed by NPO starting midnight the day of the surgery.

Approximately 6 weeks prior surgery, the main surgeon obtains informed consent during an outpatient consultation. During this meeting the advantages and the multiple risks are explained. We routinely provide our patients the AUA update summary of all possible complications that have been

reported with contemporary radical prostatectomy [14]. In short, decreased sexual function, urinary incontinence, incisional hernias, adjacent organ injury, conversion to open surgery and the risks involved with general anesthesia. The procedure is also explained to the patient and the experience of the main surgeon is highlighted. Patients are advised to stop taking all anticoagulants a week before surgery. However, some emerging evidence suggests that allowing continued low-dose nonsteroidal antiinflammatory drugs or aspirin associated with the occurrence of bleeding events and could be beneficial in preventing serious adverse cardiac thrombotic events [15]. Details of post-operative penile rehabilitation [16] and a pelvic floor rehabilitation program are provided prior to surgery to allow the patient to optimize post-operative function. Patients are also invited to watch informational videos created by the surgical team that are available on the Internet (http://www.youtube.com/user/drkevinzorn) for further information about the surgery. We have also offered our patients to see the 2-week post-operative diaries of the last 250 patients which is available on Facebook (https://www.facebook.com/pages/Robotic-Urology-Dr-Kevin-Zorn-Canada-Prostate-Center/111671516833) Finally, are encouraged to communicate any questions and/or concerns through e-mail with the main surgeon in order to optimize efficient care.

Surgical Team

The surgical team consists of the surgeon, surgical assistant (usually a trained urology resident), circulating nurse, scrub nurse, the anesthetist and respiratory therapist. Each member is knowledgeable in robotic assisted surgery and have been trained and credentialed as per our institutional robotic committee. All personel play a vital role to the proficiency of the surgical case.

Patient Positioning

Once the patient is under General Anesthesia, he is placed in Trandelenburg position at 20-25° and secured with the Allen’s Hug-u-vac steep trend positioner. This device is filled with soft microbeads that enable it to inflate and deflate evenly, when suction is applied. After positioning the patient, the device is deflated with a hand-held pump and its pliable shape conforms to the contours of the patient’s body preventing sliding. Arms are tucked in with foam rolls in the palms of the hands and ‘kidney’ shaped shoulder braces are carefully placed over the acromioclavicular joint to avoid brachial plexus injury. Sequential compression stockings are put in place over the thromboembolic (TED) stockings. The patient’s legs are placed in padded boot stirrups in the low lithotomy position. An orogastric tube may be placed to decompress the intestinal system. A 20-Fr Foley catheter is installed in order to drain the bladder to ensure that it is completely decompressed and outside of the field of port placement.

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Only after these medical acts have been complete, the patient is positioned at an inclination of 20-25 degrees. It has been demonstrated that patients undergoing this procedure in a steep Trendenlenburg position for 3-4h do not present significant cerebrovascular, respiratory or hemodynamic problems [17].

Ultimately, the abdominal, genital and perineal area is scrubbed with Solu-IV (Chlorexidine based disinfectant clear solution) followed by sterile draping.

ANESTHESIA CONSIDERATIONS

Because of the possibility of severe hemorrhage, which in laparoscopic surgery can be difficult to control, discontinuation of anticoagulants and antiplatelet agents must be ensured at a safe preoperative interval. Even though bleeding is rarely significant enough to require a transfusion, typing and screening of blood is performed for every patient. Crossmatching for units of blood for cases is not routine practice.

Any lines, monitors and patient protective devices are placed and secured before draping. Special care in regard to the endotracheal tube must be taken to avoid it from becoming kinked or pulled out. Once the robot is over the patient with its arms attached to the ports, the patient cannot be moved or cardiopulmonary resuscitative measures initiated unless the robot is first detached.

The use of pneumoperitoneum with the steep Trendenlenburg position is known to cause both respiratory and hemodynamic effects [14]. Among the respiratory effects there is a decreased functional residual capacity, decreased pulmonary compliance and increased peak airway pressures. This positioning also increases the workload of the heart and elevates the mean arterial pressure, central venous pressure and systemic vascular resistance.

Patients for RARP require general endotracheal anesthesia with mechanically controlled ventilations. Any of the anesthetic drugs may be used dependent on the patient’s cardiovascular status and presence of other co-morbidities. In order to achieve optimal pneumoperitoneum complete muscle relaxation is essential.

Other than the standard monitoring used in any general endotracheal anesthetic case, additional monitoring and/or intravenous fluid lines is dependent upon the patient’s medical condition and the experience of the operating team.

Intraoperative intravenous fluids are kept to a minimum (<2000 mL) because excessive urine output might obscure the operative field during vesico-urethral anastomosis. Fluid restriction might also minimize the facial, pharyngeal, and laryngeal edema that may occur from prolonged use of steep Trendenlenburg position.

Upon induction, 5000 units of Heparin are given subcutaneously and a first generation cephalosporin (Ancef) 1g IV is used as prophylaxis. Patients are also administered 10 mg of an Opium analgesic (Supeudol) suppository as it has been documented that it reduces catheter related bladder spasms as well as the overall consumption of narcotics in the post-operative first 24 hours [18].

THE SURGICAL PROCEDURE

1) Port Placement and Robot Docking

A Standard 6-port placement configuration is drawn on the patient’s abdomen prior to skin incisions. Pneumoperitoneum is established using a Verress needle through a 12mm sub-umbilical incision. An intraperitoneal pressure of 20mmHg is then achieved after which a 12-mm trocar is placed for insertion of the stereo endoscope. After pneumoperitoneum is established, primary inspection of the intraperitoneal cavity is performed to ensure that no injuries to the bowel or adjacent organs have occurred. Secondary trocars are then placed using laparoscopic guidance to avoid injuring main arteries of the abdominal wall (see Figure 1).

Overall, three 8-mm metallic robotic trocars are used by the working robotic arms of the surgeon while the assistant provides retraction, suction, and irrigation and passes clips and sutures via the 12-mm and 5-mm trocars placed along the patient’s right side. Finally, a total of 20ml of Marcaine is injected in all trocar incisions for post-operative anesthesia. A smoke evacuator is also used during the procedure to optimize vision.

Figure 1: Standard six-port placement for Robot Assisted Radical Prostatectomy. Two 12mm, three 8mm and one 5mm trocar are placed in the standard way providing sufficient distance between the camera and working ports to prevent internal or external collision of instruments.

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Robot Docking

The patient cart is maneuvered into position to align the patient cart tower, camera arm and target anatomy. One member of the surgical team maneuvers the patient cart while another one guides the driver. Room references are used to avoid any confusion during docking. The cart is pushed into position and the brakes at the base of the cart are hand tightened.

The camera arm is the first one connected to the patient and the instrument arms follow. Once all the robotic arms are connected, the surgical team checks each arm for proper working distance and makes sure the arms are not compressing the patient. The forth arm is docked on the right side of the patient while the bed-side assistant is situated on the patient’s left side.

2) Posterior Dissection

The surgical procedure begins with the posterior dissection of seminal vesicles and vas deferens. In our experience, starting with the posterior dissection has several advantages. It improves the working space as the prostate is still suspended anteriorly by intact puboprostatic ligaments. This provides better visualization of the structures to be dissected and consequently the amount of traction and thermal energy used in the dissection is limited. It provides a safer and more reliable posterior bladder neck transection later in the procedure. Moreover, when the surgeon has to transect through the bladder to liberate the prostate, an already dissected posterior plane is easily found. This is particularly advantageous in cases of large prostates, large median lobes, patients that had previous surgery at the bladder neck such as TURP or laser surgery at the prostate, as well for those patients whom have received previous radiotherapy. This initial step also serves for teaching of residents and fellows. Finally, starting with the posterior dissection serves as a warm up for more difficult steps later in the procedure.

Once docking is complete and the pneumoperitoneum is decreased to 14mmHg, the initial surgical step begins with direct visualization of the peritoneum overlying the bladder. The assistant is asked to provide upper anterior traction on the peritoneum using the Xomed Microfrance graspers. A curvilinear incision for access is made midway between the level of the Foley catheter impression and the anterior rectus wall. Monopolar scissors are used for incision of the peritoneum. Bipolar graspers are then used to dissect through and divide fibrovascular tissue to the desired plane (See Figure 2). Monopolar cautery is concomitantly used for division of all tissue between the bipolars from the left to right direction. Through the dissection of the retroprostatic tissue, the vas deferens and accompanying arteries are exposed.

Figure 2: Posterior Dissection. A: With the bedside assistant providing anterior upper traction on the peritoneum using the Xomed Microfrance graspers and posterior downward traction using the suction tip, access through the peritoneum is granted and the vas deferens and seminal vesicles are exposed. B: Both the seminal vesicles and transected vas deferens are liberated.

Division of Vas Deferens:

The vas deferens are then divided bilaterally with bipolar control of both arteries. The monopolar scissor blade is used as a spatula to free adjoining vessels. Caution should be made not to injure or coagulate the vas deferens as doing so may increase the risk of tearing when the assistant lifts it for exposure of the seminal vesicle. This is done approximately 5 cm from the level of the prostate.

Exposure of the Seminal Vesicles:

For this part of the procedure the assistant is asked to provide upper traction of the vas deferens and downward traction with the suction tip to expose the tip of the seminal vesicle. Blunt dissection of the fibrovascular tissue overlying the surface of the seminal vesicles exposes the postero-medial surface of the seminal vesicle. Then, the lateral surface of the organ is mobilized using, again, blunt dissection. The seminal vesicle is then grasped by the bipolar instrument to

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help liberate the posterior avascular plane. Meticulous blunt dissection is continued to allow complete liberation of the seminal vesicle. The same steps are done on the contralateral organ.

Deep posterior dissection is then continued to the level of Denonvillier’s fascia. This fascia layer will be incised later in the procedure. One of the most important aspects of posterior-first dissection is the anterior dissection to the level of the prostate of both vas deferens. This allows a safe entry into the retro-prostatic dissection during posterior bladder neck dissection. Prior to Retzius space dissection and dropping of the bladder assurance of hemostasis is made.

3) Retzius Space Dissection And Endopelvic Fascia Dissection

The umbilical ligaments and urachus are initially divided with the bipolar graspers. The forth arm Prograsp is used to provide traction. Care is made to achieve good hemostasis since occasionally these structures have patent vessels. The bladder is then liberated off the anterior surface of the abdominal wall. The avascular plane found is further blunt dissected to the pubic bone and the bladder is placed on stretch (See Figure 3). The lateral attachments to the vas deferens are liberated as well.

Figure 3: Retzius Space Dissection. After diving the umbilical ligaments and urachus the anterior surface of the bladder is liberated off the anterior surface of the abdominal wall. It is usually an avascular plane however patent vessels can be found and good hemostasis is to be achieved. This flimsy tissue is bluntly dissected to the pubic bone.

Anterior prostatic fat (AFP) dissection:

Resting on top of the anterior wall of the prostate a layer of fat is identified. Removing this layer of fat will allow better visualization of the puboprostatic ligaments, the dorsal venous complex as well as the junction between the bladder neck and the prostate (See Figure 4). Also, Alhering et al. showed that lymph nodes are found in this tissue in 11%

of patients. They found that the removal of the APF and its pathologic analysis can result in pathologic upstaging [19]. Consequently, this ‘flap’ of fat is dissected in a cephalad direction up to the junction of the bladder. It is then further dissected laterally towards the lateral pelvic sidewall.

At this point the anterior surface of the prostate is seen. Thereafter, all the tissues lying on top of the prostate are dissected to demonstrate the pubo-prostatic ligaments as well as the dorsal venous complex (DVC). Lateral dissection of the bladder is carried out down toward the crossing of the median umbilical ligament and vas deferens in order to ensure optimal mobility of the bladder and to minimize future tension at the vesicourethral anastomosis. Accessory pudendal arteries traveling longitudinally along the anteromedial aspect of the prostate are easily recognized during RARP. Attempt at preservation of these arteries is important for erectile function because in some men these arteries may be the dominant source of arterial blood supply to the corpora cavernosa.

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Figure 4: Anterior Prostatic Fat Dissection. A: Anterior Prostatic Fat (APF) overlying the dorsal venous complex, the anterior surface of the prostate and the prostato-vesical junction. B: En bloc dissection of the APF extended cephalad to the prostatovesical junction and laterally toward the lateral pelvic sidewall. C: Anterior prostatic surface exposed after APF dissection.

4) Dorsal Vein Complex (DVC) Ligation

The dorsal venous complex is usually responsible for significant blood loss during open surgery [20]. With the benefits of articulated instrumentation and the tamponade effect offered by the pneumoperitoneum control of important venous bleeding is achieved. The average blood loss in our institution is 200ml through RARP versus 800- 1000ml during open surgery.

A total of 2 suture ligations are made (one distal and another more proximal) (See Figure 5). The proximal suture will be used later for prostate traction whereas the first one provides the needed hemostasis. The suture used (Vicryl 1-0 polyglactin 910 with a CTX needle) is passed beneath the DVC and anterior to the urethra as close to the pubis and as far from the prostatic apex as possible. Securing the DVC as far away from the prostatic apex as possible can help minimize iatrogenic entry into the prostatic apex during later division of the DVC [21]. Using a square knot technique, sufficient tension of the suture is achieved to assure all the veins of the complex are controlled. A total of four knots are used. The assistant’s scissors are then introduced and used to cut the sutures. It is important to avoid damage to the anterior urethral sphincter muscle from placing the sutures. As such, a sufficient apical dissection is necessary to obtain visualization of the notch between rhabdosphincter, prostate and urethra.

Figure 5: Dorsal Venous Complex Ligation. A: Distal ligation of the Dorsal Venous Complex (DVC) using a Vicryl 1-0 suture. The suture is passed beneath the DVC and anterior to the urethra as far from the prostatic apex as possible. B: Proximal ligation of the DVC. This suture is placed to allow cephalad traction while transecting the DVC later in the procedure.

5) Bladder Neck Transection

Compared to conventional open surgery, robotic bladder neck transection is one of the most difficult aspects to acquire during a surgeon’s learning curve.

Prior to incision, the robotic instruments are use to define the junction between the prostate and the bladder. Different maneuvers have been described to determine the right plane of dissection:

• Visual identification of the point of transition of the pre-vesical fat to the anterior prostate can serve as a guide.

• Intermittent and repetitive caudal retraction of the urethral catheter balloon can help identify and confirm the transition between bladder neck and prostate.

• Using a forceps to grasp and retract the dome of the bladder in a cephalad direction results in “tenting” of the bladder neck at its attachment to the prostate.

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• Bimanual “palpation” or “pinch” of the bladder neck using the tips of two robotic or laparoscopic instruments.

Once the proper plane of dissection is identified, the bladder neck is divided horizontally with monopolar cauterization until the urethral catheter is identified. The anterior bladder neck incision should not be carried too laterally because branches of the dorsal vein fanning over the prostate are often encountered, resulting in unwanted bleeding. These will be controlled by Hemolock clips. The Foley catheter balloon is then deflated. With the help of the bedside assistant who is asked to create counter traction externally on the penile meatus Foley catheter, the prostate is suspended anteriorly towards the abdominal wall by grasping the tip of the catheter and lifting upwards. A visual plane is then carefully created to assure proper dissection in the correct space and not to dissect into the prostate or worse, towards the bladder trigone and ureteral orifices.

At this point, an inspection of the posterior bladder neck is made in order to identify the ureteral orifices and also to look for a large median lobe. In the case that a large median lobe is found, further exposure is required to visualize behind the protruding median lobe and identify the posterior bladder neck. This is achieved by lifting it anteriorly using the ‘Prograsp’ forceps or, in our experience, to avoid unnecessary mucosal oozing, the use of suture suspension. We usually use a single 15cm 3-0 VLoc suture with several passes through the median lobe. The Microfrance grasper by the assistant lifts upwards on the suture rather than the Foley catheter.

With upper traction with one hand by the assistant and downward traction at the level of the bladder neck with the suction tip, the posterior detrusor fibers as well as the mucosa are taken down from the left to right direction between the jaws of the bipolar, diamond-tipped graspers (See Figure 6). This way, the retrotrigonal fascia is exposed and it is then sharply popped through with the instruments. This will then expose the previously dissected vas deferens that lie in the midline. These structures, along with the seminal vesicles are collectively grasped, pulled through the open bladder neck and handed to the assistant for upper traction to initiate prostate pedicle control as well as neurovascular bundle dissection.

In case of a prior TURP, the bladder neck margin is less evident and often distorted as a result of prior resection and scarring. Careful inspection is made of the posterior bladder neck paying specific attention to the location of the ureteral orifices because they are often found close to the posterior bladder neck margin. If there is any doubt, the anesthesiology team is asked to administer intravenous indigo carmine to identify the orifices for their protection.

Figure 6: Bladder Neck Transection. A: The anterior bladder neck is incised and the prostate is suspended anteriorly toward the abdominal wall by the assistant’s grasper. At this point the bedside assistant also provides counter traction externally on the penile meatus Foley catheter. B: After having inspected the posterior bladder neck the assistant is asked to provide posterior traction with the suction tip at the level of the bladder neck. The posterior detrusor fibers and the bladder mucosa are then incised.

6) Athermal Sexual Nerve Sparing Technique and Vascular Pedicle Control

This aspect of RARP is of paramount importance to preserve sexual function. Other critical areas where attention is required is during the apical seminal vesical dissection as well as the urethral transection to avoid injury to the plexus and nerve fibres. It is important for the surgeon to use an athermal technique near the nerve bundles and limit the amount of stretch, which may cause traction nerve injury [2]. Dissection of the pedicle is performed using the diamond tipped bipolar instrument to isolate the pedicle of tissue to be clipped by the assistant. A medium 10mm Weck Hem-o-lok clip is introduced by the bedside assistant, which allows for proximal control. When presented with large veins, a back-lid clip can also be applied to limit amount

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of oozing during surgery. Once the clips have been placed, sharp scissor cutting between them helps liberate the tissue. Proper communication between the surgeon and assistant, experience and proper exposure and presentation of the tissue to be clipped is essential.

Alternatively, individual vessel titanium clip ligation can be performed however in our experience not recommended due to the high likelihood for clip migration and slippage. This technique requires meticulous dissection of specifically those vessels to be cut and only placing a clip on the stay side that will remain inside the body.

NVB Preservation:

In well selected patients with low volume and low risk disease for extracapsular extension, an interfascial nerve preservation technique is used. We have previously published on our tailored technique for ipsilateral nerve sparing to minimize the risk of positive surgical margins [22, 23]. Herein, we describe an interfascial dissection. Use of the Memorial Sloan-Kettering Cancer Center nomogram developed by Dr. Kattan et al (available online at ttp://nomograms.mskcc.org/Prostate/PreTreatment.aspx) is also helpful in patient counseling for nerve preservation.

After releasing the prostate from its vascular pedicles and completing the posterior plane dissection after dissecting through Denonvilliers fascia to the prostate apex, the avascular plane is followed laterally along the prostatic capsule. Meticulous care is made not to injure or violate this capsule. The back end of the monopolar scissor is used with small stroking motions to liberate the tissues. Any perforating vessel can be cut sharply and if needed, short use of the single blade of the open monopolar scissors can be used to achieve hemostasis. Aggressive hard use of the instruments could potentially lead to a positive surgical margin (PSM), which increases patient risk for disease recurrence. Gentle dissection can be carried along this plane from the base to the apex of the gland (anterograde). The apex of the gland is a challenging area to release due to the circular contour of the prostate. As such, surgical experience and technique are required for optimal and safe nerve release. Recently, a study by Patel et al, observed that a retrograde nerve sparing approach with early apical release facilitates early recovery of potency and continence compared with an antegrade approach without compromising the margin status in patients with normal preoperativ erectile function and full nerve preservation. Furthermore, they found that retrograde nerve sparing technique leads to less blood loss intraoperatively [24].

7) Non-nerve Sparing Technique

Occasionally, due to cancer related factors (Gleason score, PSA, digital rectal exam, clinical stage, number and

percentage of biopsy cores), the surgeon may perform a wider resection away from the prostate capsule due to a high likelihood of extracapsular disease. This is done in order to reduce the risk of positive surgical margins (PSM). As mentioned previously, we routinely use the Kattan Memorial Sloan Kettering prostate cancer nomogram to counsel our patient’s risk of extracapsular disease (http://www.mskcc.org/applications/nomograms/prostate/)

In order to efficiently seal tissue and vessels of the prostate pedicle, use of wider placed Hemolock clips or vesselsealing devices such as the EnSeal (Ethicon Endosurgery, Cincinatti, OH) is preferred to assure hemostasis and maintain tissue integrity. Initially in our experience bipolar cautery was used to coagulate the tissue prior to scissor division. The tremendous amount of black burnt tissue occurred with bipolar cautery. Many surgeons still use this technique for wide resection.

Care must always we made especially along the apex of the gland not to injure or enter into the rectum. Although few data are available in the literature regarding RARP for unilateral nerve-sparing techniques, a recent consensus panel believed that these techniques can be considered for patients with unilateral extraprostatic disease. In such cases, partial preservation of the neurovascular bundles limited to the side with organ-confined disease or no disease may be indicated [2].

8) Urethral Division and Specimen Liberation

One of the last remaining anchoring tissues that hold the prostate in place is via the urethra. At this time, the Foley catheter is replaced and the surgeon’s instruments are used to divide the apex of the prostate. Meticulous care must be made not to cut into the prostate and cause a positive margin. On the other hand, cutting the urethra too far away would injure the sphincter which and this will have an impact on urinary control. Care must also be made at this time to avoid injury to the neurovascular bundles that were preserved earlier. Additionally, care must be made to avoid cutting the DVC suture.

Initially, the 4th arm is used to grasp the backbleed Vicryl suture that was previously placed along with the DVC suture and place cephalad traction. The bipolar instrument is then placed beneath the DVC alongside the prostatic capsule. Monopolar scissors are used to divide through the tissue between the opened blades of the bipolar (See Figure 7). Once the DVC has been transected, attention is then drawn to urethral division. If the DVC suture looses tension or slips off, use of the 3-0 15cm VLOC suture is used to oversew the loose DVC stump. The urethra is then skeletonized to delineate the end of the prostate and the released neurovascular bundles. Sharp scissor cutting through the anterior urethral wall allows for visualization of the Foley

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catheter, which is then withdrawn to expose its tip. The remaining posterior wall including the rectourethralis fibres are then cut sharply to liberate the prostate (See Figure 8). At this point the apex of the free prostate is inspected. The prostate is placed in an endo-catch bag for later retrieval after the vesico-urethral anastamosis. The bag is closed and the specimen, including the anterior prostatic fat is placed in the upper abdominal space for later retrieval.

Figure 7: Dorsal Venous Complex (DVC) Transection. The fourth arm grasper provides cephalad traction on the backbleed Vicryl suture that was placed proximally while the monopolar scissors divide the DVC.

Figure 8: Urethral transection. Once the dorsal venous complex has been divided the urethra is skeletonized to delineate the end of the prostate and the released neurovascular bundles. The anterior urethral wall is then transected until visualization of the Foley catheter.

9) Continuous Vesico-Urethral Anastamosis (VUA) Using VLOC Sutures [25]:

With the removal of the prostate there is a fossa defect

between the bladder and the urethra. Hemostasis is first verified along with removal of all clots and blood in the field. The well-dissected bladder is free and mobile and can be easily descended into the pelvis. The anastamosis is done using a self-cinching unidirectional barbed suture (2 knotless, interlocked 6-inches 3-0 V-Loc-180 suture) as previously described [26]. The sutures could be easily interlocked via their tail loops by the scrub nurse which takes less than a minute to prepare. The bedside assistant then introduces the interlocked sutures to the surgeon’s robotic needle drivers.

Posterior Reconstruction

Posterior reconstruction helps create a posterior plate in which to buffer the anastamosis and reduce bleeding (See Figure 9). Several studies have shown that a proper posterior reconstruction could help promote earlier return to pad-free continence [27, 28] and most important, reduce urinary leaks. The bladder is brought down into the pelvis to allow for reconstruction. The left sided VLOC suture is anchored at the 5 o’clock position of the bladder neck. The cut Denonvillier’s fascia and the detrusor muscle are grasped and passed through with the needle without entering the bladder. This space is denominated as the retrotrigonal area. The suture slack is held and pulled upward using a ‘hand over hand’ technique until the part the sutures interlock are within the bladder muscle. The needle is then positioned towards the urethra and the assistant introduces the Foley catheter tip. This way the surgeon is sure to grab only the posterior cut Denonvilliers fascia. The needle is then passed through the posterior side of the urethra (the periurethral rectourethralis muscle) at the same 5 o’clock position. The suture is pulled through until the interlocked loops abut with the tissue providing resistance, as a knot would. Once the expected tension is achieved the suture can be released expecting no back cinching due to the properties of the sutures. A second bite is then taken from the midline retrotrigonal area behind the bladder followed by a 6 o’clock bite of the periurethral tissue. Special care is made to ensure there is no cephalad traction on the bladder prior to cinching. Finally, a final 7 o’clock suture is taken on the bladder-side retrotrigonal tissue again ensuring not to include any mucosa. The left arm of the interlocked V-Loc suture is then lifted cephalad and anteriorly with the left needle driver, while the open right needle driver sat on the bladder tissue to serve as a fulcrum point to avoid tissue tearing. The bladder is thus cinched down with repetitive, short pulls until the bladder neck mucosa is adjacent to the urethral stump with no gap. This provides for unprecedented hold of auto-tissue tension and allows the urethral stump to be retracted from the pelvic floor to provide increased length.

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Figure 9: Posterior Reconstruction. A: The VLOC suture is passed through the bladder-side retrotrigonal area at the 5, 6 and 7 o’clock position and through the periurethral rectourethralis muscle. B: Traction is used on the VLOC suture to cinch down the bladder until its mucosa is adjacent to the urethral stump and no gap is left.

Vesico-urethral Anastamosis (See Figure 10)

The same left arm of the interlocked suture is used to begin the vesico-urethral anastamosis. An initial transmural inside-out bite of the bladder is made at the 6 o’clock position, followed by a bite of the posterior urethra. Depending on the size of the bladder neck the surgeon may take larger tissue bites to parachute down for the bladder neck – urethral stump discrepancy. The urethra is usually the size of a pen and the bladder neck could be anywhere from the size of a pen to the size of a nickel or a quarter. Other techniques of tapering down the bladder neck include:

• Figure of eight sutures at 3 and 9 o’clock positions to taper the bladder neck using 3-0 Monocryl (Ethicon Endo Surgery, Cincinnati, OH).

• An anterior or posterior tennis racket suture. This depends on surgeon’s preference and experience.

The assistant reintroduces the tip of the Foley catheter to ensure the grasp of the correct tissues. The ‘outside-in’

bites along the bladder and the inside-out urethral bites are continued from 6- to 10-o’clock, each time cinching the tissue with the right needle driver straddling the suture to avoid urethral tearing. Rather than completing the left side of the VUA and obscuring the posterior anastamosis, the right arm of the V-LOC stitch is used to complete a synchronous process starting from an outside-in 5- o’clock bladder bite to a 5-o’clock ‘inside-out’ urethral throw. Care is made not to incorporate the neurovascular bundles or rhabdosphincter muscle with aggressive bites. Repetitious passes were continued for the entire right side 5- to 12-o’clock with final pass, each time, independently assuring adequate tension.

The right arm is finally brought through the anterior urethral side and cut with a 2 to 3 cm stump. The left wall is then completed in a running fashion from the 10- to 12-o’clock location again finishing on the anterior urethra. Prior to cutting the left arm V-Loc suture, the integrity of the VUA is verified with 300 cc normal saline instilled in the bladder (See Figure 11). If any leakage were seen, further cinching of the suture or placement of additional V-Loc bites would be required. The needles can be snapped out and removed from the body by the assistant. The two cutends are left untied thus allowing for a completely, knot-free reconstruction.

Figure 10: Overview of Posterior Reconstruction (PR) and Vesico-Urethral Anastamosis (VUA) using V-LOC sutures. A: Interlocked V-LOC configuration for PR and VUA. Note the use of two six-inch sutures in which the loops of both sutures are threaded by the opposite needles. B: The left-arm of the hybrid suture is passed initially at the 5-o’clock position of the retrotrigonal tissue. The suture is pulled through until the inter-twined loops oppose the tissue providing resistance. (red asterix) Using three consecutive bites, the PR helps approximate the edge of the bladder neck to the peri-urethral tissue. C: The left arm of the suture is then passed trans-murally through the 6-o’clock bladder neck and used to initiate a standard Van Velthoven anastamosis. The right arm is then used to close the right-sided VUA. D: A visual cystogram with 300 cc of normal saline is performed to ensure no leakage.

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Figure 11 : Vesico urethral Anastamosis (VUA). A: The left arm of the VLOC suture is used to start the Van Velthoven anastamosis. The right arm of the VLOC suture is then used to close the right-sided VUA. B: A visual cystogram with 300cc of saline is performed to ensure the integrity of the VUA and thus the absence of saline leakage.

10) Case Completion and Post-operative Considerations

Prior to undocking the robot and removal of the specimens, the pelvis and operative field are carefully reinspected for bleeding under low insufflation pressure (<10 mm Hg). The bowel is equally examined closely to make certain that there is no injury resulting from instrument exchanges. Then, the string for the laparoscopic entrapment sack is transferred to the camera port site at the umbilicus and the abdomen is completely deflated. The specimens within the laparoscopic entrapment sack are extracted intact through extension of the periumbilical trocar site (usually 2.5 to 3.5cm in lenght. The fascial defect is then immediately closed by a 0-Vicryl suture. The skin defects are then closed with a subcuticular absorbable suture (4-0 Monocryl) followed by the skin adhesive Dermabond (Ethicon, Cincinatti, OH). Closure of the fascial defect for the 5mm and 12mm trocar sites are not necessary.

Once extubated, the patient is then transferred to the recovery room where vital signs, in/outs are taken as usual for post-op patients. Regular diet is offered the evening of the surgery and patients are mobilized out of bed within hours of surgery. For pain control all patients are given NSAIDs (Toradol) 30mg IV q6h along with regular Acetaminophen (Tylenol) 650 mg PO q6h. Narcotics are only administered in the event of severe pain. Upon discharge, patients are provided with a script of Codeine if needed with instructions on the regular use of NSAIDs (Motrin) 400mg q12h along with Acetaminophen (Tylenol) 650 q12h for 5-7 days.

On the first post-operative day, the nursing team helps the patient out of bed and encourages mobilization. Early mobilization has been well documented to reduce risks of ileus, atelecetasis and thrombosis. Following surgery, patients are advised to avoid heavy lifting of anything over 20-30lbs for the next 3-4 weeks to reduce the risk of developing an incisional hernia. Thereafter, patients can resume all preoperative physical activities.

Patients are advised to make regular use of oral PDE5-inhibitors (Sildenafil) as it has been suggested that their administration soon after radical prostatectomy exerts an anti-fibrotic effect in the corpora cavernosa and it helps preserve erectile tissue integrity. Therefore, their use leads to an earlier recovery of erectile function [29].

Patients are also encouraged to continue the pelvic floor muscles (PFM) reinforcement exercise program (Kegel exercises) that they had been suggested to start before the surgery. In this exercise program, patients are asked to isolate and correctly contract the PFM to increase strength and endurance. Repeated contractions are thought to improve urinary control trough increased support for the detrusor muscle and urethral sphincter [30]. Studies suggest that doing such rehabilitation program exercises on a daily basis hastens the return to urinary continence after surgery thus improving the quality of life of patients [31].

Finally, over 95% of our patients are discharged within 24 h of surgery with planned removal of the Foley catheter on post-operative day 4.. Patients are educated on how to take care of the catheter and it is left in place to a leg-bag upon discharge. A trained nurse then removes the catheter during an outpatient appointment.

Upon discharge, patients are advised to avoid any aspirin-like medication for at least a week after surgery since an NSAID (Motrin) is being used regularly. They are also explained that light pink urine is typical for a week following the procedure and they are not be alarmed by it. They are told to expect a smaller bladder capacity for several weeks after surgery due to the dissection around the bladder and they may experience an increase in urinary frequency and some urinary urgency.

An initial follow-up visit is scheduled 4-6 weeks after surgery

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to review recovery and the final surgical pathology. Serum PSA is obtained at 3, 6 and 12 months following RARP with subsequent serum assessments depending on the pathological stage, grade and margin status.

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16. Blaya R, M.J., Penile Rehabilitation after Radical Prostatectomy. AUA Update Series, 2008. 27(Lesson 36): p. 346-351.

17. Park, E.Y., et al., The effect of pneumoperitoneum in the steep Trendelenburg position on cerebral oxygenation. Acta Anaesthesiol Scand, 2009. 53(7): p. 895-9.

18. Lukasewycz, S., et al., Does a perioperative belladonna and opium suppository improve postoperative pain following robotic assisted laparoscopic radical prostatectomy? Results of a single institution randomized study. Can J Urol, 2010. 17(5): p. 5377-82.

19. Finley, D.S., et al., Anatomic excision of anterior prostatic fat at radical prostatectomy: implications for pathologic upstaging. Urology, 2007. 70(5): p. 1000-3.

20. Tufek, I., et al., The Use of Laparoscopic Bulldog Clamp to Control the Dorsal Vein Complex during Robot Assisted Radical Prostatectomy: A Novel Technique. J Endourol, 2012.

21. Talug, C., et al., Controlling the dorsal venous complex during robotic prostatectomy. Can J Urol, 2012. 19(1): p. 6147- 54.

22. Zorn, K.C., et al., Planned nerve preservation to reduce positive surgical margins during robot-assisted laparoscopic radical prostatectomy. J Endourol, 2008. 22(6): p. 1303-9.

23. Schatloff, O., et al., Cavernosal nerve preservation during robot-assisted radical prostatectomy is a graded rather than an all-or-none phenomenon: objective demonstration by assessment of residual nerve tissue on surgical specimens. Urology, 2012. 79(3): p. 596-600.

24. Patel, V.R., et al., The role of the prostatic vasculature as a landmark for nerve sparing during robot-assisted radical prostatectomy. Eur Urol, 2012. 61(3): p. 571-6.

25. Zorn, K.C., et al., Novel method of knotless vesicourethral anastomosis during robot-assisted radical prostatectomy:

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feasibility study and early outcomes in 30 patients using the interlocked barbed unidirectional V-LOC180 suture. Can Urol Assoc J, 2011. 5(3): p. 188-94.

26. Zorn, K.C., et al., Prospective randomized trial of barbed polyglyconate suture to facilitate vesico-urethral anastomosis during robot-assisted radical prostatectomy: time reduction and cost benefit. BJU Int, 2012. 109(10): p. 1526-32.

27. Rocco, F., et al., Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy. J Urol, 2006. 175(6): p. 2201-6.

28. Gautam, G., et al., Posterior rhabdosphincter reconstruction during robot-assisted radical prostatectomy: critical analysis of techniques and outcomes. Urology, 2010. 76(3): p. 734-41.

29. Iacono, F., et al., Histopathologically proven prevention of post-prostatectomy cavernosal fibrosis with sildenafil. Urol Int, 2008. 80(3): p. 249-52.

30. Bo, K., Pelvic floor muscle training is effective in treatment of female stress urinary incontinence, but how does it work? Int Urogynecol J Pelvic Floor Dysfunct, 2004. 15(2): p. 76-84.

31. MacDonald, R., et al., Pelvic floor muscle training to improve urinary incontinence after radical prostatectomy: a systematic review of effectiveness. BJU Int, 2007. 100(1): p. 76-81.

FIGURES

Figure 1: Standard six-port placement for Robot Assisted Radical Prostatectomy. Two 12mm, three 8mm and one 5mm trocar are placed in the standard way providing sufficient distance between the camera and working ports to prevent internal or external collision of instruments.

Figure 2: Posterior Dissection. A: With the bedside assistant providing anterior upper traction on the peritoneum using the Xomed Microfrance graspers and posterior downward traction using the suction tip, access through the peritoneum is granted and the vas deferens and seminal vesicles are exposed. B: Both the seminal vesicles and transected vas deferens are liberated.

Figure 3: Retzius Space Dissection. After diving the umbilical ligaments and urachus the anterior surface of the bladder is liberated off the anterior surface of the abdominal wall. It is usually an avascular plane however patent vessels can be found and good hemostasis is to be achieved. This flimsy tissue is bluntly dissected to the pubic bone.

Figure 4: Anterior Prostatic Fat Dissection. A: Anterior

Prostatic Fat (APF) overlying the dorsal venous complex, the anterior surface of the prostate and the prostato-vesical junction. B: En bloc dissection of the APF extended cephalad to the prostatovesical junction and laterally toward the lateral pelvic sidewall. C: Anterior prostatic surface exposed after APF dissection.

Figure 5: Dorsal Venous Complex Ligation. A: Distal ligation of the Dorsal Venous Complex (DVC) using a Vicryl 1-0 suture. The suture is passed beneath the DVC and anterior to the urethra as far from the prostatic apex as possible. B: Proximal ligation of the DVC. This suture is placed to allow cephalad traction while transecting the DVC later in the procedure.

Figure 6: Bladder Neck Transection. A: The anterior bladder neck is incised and the prostate is suspended anteriorly toward the abdominal wall by the assistant’s grasper. At this point the bedside assistant also provides counter traction externally on the penile meatus Foley catheter. B: After having inspected the posterior bladder neck the assistant is asked to provide posterior traction with the suction tip at the level of the bladder neck. The posterior detrusor fibers and the bladder mucosa are then incised.

Figure 7: Dorsal Venous Complex (DVC) Transection. The fourth arm grasper provides cephalad traction on the backbleed Vicryl suture that was placed proximally while the monopolar scissors divide the DVC.

Figure 8: Urethral transection. Once the dorsal venous complex has been divided the urethra is skeletonized to delineate the end of the prostate and the released neurovascular bundles. The anterior urethral wall is then transected until visualization of the Foley catheter.

Figure 9: Posterior Reconstruction. A: The V-LOC suture is passed through the bladder-side retrotrigonal area at the 5, 6 and 7 o’clock position and through the periurethral rectourethralis muscle. B: Traction is used on the V-LOC suture to cinch down the bladder until its mucosa is adjacent to the urethral stump and no gap is left.

Figure 10: Overview of Posterior Reconstruction (PR) and Vesico-Urethral Anastamosis (VUA) using V-LOC sutures. A: Interlocked V-LOC configuration for PR and VUA. Note the use of two six-inch sutures in which the loops of both sutures are threaded by the opposite needles. B: The left-arm of the hybrid suture is passed initially at the 5-o’clock position of the retrotrigonal tissue. The suture is pulled through until the inter-twined loops oppose the tissue providing resistance. (red asterix) Using three consecutive bites, the PR helps approximate the edge of the bladder neck to the peri-urethral tissue. C: The left arm of the suture is then passed trans-murally through the 6-o’clock bladder neck and used to initiate a standard Van Velthoven anastamosis. The right arm is then used to close the right-sided VUA. D: A

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visual cystogram with 300 cc of normal saline is performed to ensure no leakage.

Figure 11: Vesico-Urethral Anastamosis (VUA) using V-LOC sutures. A: The left arm of the VLOC suture is used to start the Van Velthoven anastamosis. The right arm of the V-LOC suture is then used to close the right-sided VUA. B: A visual cystogram with 300cc of saline is performed to ensure the integrity of the VUA and thus, the absence of fluid leakage.

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Extraperitoneal Retrograde Robotic Radical Prostatectomy: The Heilbronn Technique

Correspondence:

Department of Urology, SLK Klinikum, Heilbronn, Germany

Dr. Ali Serdar Gözen Associated Professor of UrologyDepartment of Urology SLK Kliniken, Heilbronn, Heidelberg UniversityAm Gesundbrunnen 2074074 HeilbronnTel.: 07131-492401Fax: 07131-492429E-mail: [email protected]

Ali Serdar Gözen Jens Rasssweiler

INTRODUCTION

Radical prostatectomy is the standard of care for treatment of localized prostate cancer. Since the description of the prostate surgical anatomy and the nerve spearing technique, made by Walsh, radical retropubic prostatectomy (RRP) has been introduced as the mostly used surgical approach. The main goals of radical prostatectomy are cancer control accompanied by acceptable functional outcomes, like continence and potency, and low morbidity.

In 1999, at our institution, a different laparoscopic radical prostatectomy (LRP) technique that sheared many similarities with the classic open approach was developed. Its main steps included an ascending part, with an early urethral division, followed by a descending part that consists of the bladder neck incision and dissection of the cranial pedicles, seminal vesicles, and vasa deferentia. The first 3 years were marked by a continuous technical evolution, even though our earlier results did not really differ from the

ones of the open procedures. Three years ago, the Da Vinci Robotic Surgical System was introduced to our institution. Since then we have performed more than 400 Roboticaly Assisted Laparoscpic Radical Prostatectomies (RALP). The main principle of the Heilbronn technique (extraperitoneal retrograde LRP and RALP) is to apply the same steps and principles of the well known RRP in laparoscopy and robotic surgery respectively.

SURGICAL TECHNIQUE

Patient Positioning

The patient lies in the operating table in a lithotomy position and arms parallel with the trunk axis. (Fig. 1A/B). Preparation includes shaving from the costal margins to the pubic base of the penis. A rectal balloon catheter is placed. The operating table is adjusted in a Trendelenburg position which usually ranges from 15o to 20o. A 16-French transurethral foley catheter is inserted under sterile conditions and blocked with 15cc Saline solution.

Abstract: This technique is more closely related to the open Radical Retropubic Prostatectomy (RRP) than any other laparoscopic and robotic approach and combines the advantages of minimally invasive surgery with those of an extraperitoneal approach. In this chapter we describe the

different steps of extraperitoneal retrograde robotic radical prostatectomy. We also present our collected patient data, with oncological and functional results and postoperative complications, graded using the Clavien-Dindo Score.

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Fig 1A.

Fig 1B.

Team:

The surgeon ( JR) is experienced in laparoscopic and robotic surgery and has performed more than 3000 laparoscopic and 300 robotic cases. The technique acquires two assistants. The first assistant uses the suction device and applies the clips, and the second assistant mainly helps in retraction of the prostate according to directions of the operator. They are one experienced scrub nurse and a circulating nurse. The anesthetist is trained in laparoscopic surgery anesthesia and has an anesthesia technician as a helper.

Trocar Sites

For the extraperitoneal approach we use the open (Hasson) technique. The first incision for the optic trocar (13mm) is

usually infraumbilcal. The approach continues with blunt dissection of the extraperitoneal space using a balloon trocar (Fig. 2). After an adequate extraperitoneal space and pneumo-extraperitoneum is created (max. pressure 12-15mmHg) the trocars are arranged in W-shaped manner. The four working trocars include 2 x 8-mm ports for the robot arms and 2 x 11-mm assistant ports. An extra 5-mm suprapubic port is used for retraction and manipulation of the prostate during the procedure (Fig. 3). Thereafter the robot arms are docked to the robot ports (Fig. 4). The instruments used with the working robotic arms are the endowrist curved monopolar scissors for sharp incision and the endowrist needle-driver for the right arm, as well as an endowrist Maryland curved bipolar forceps for grasping, retracting and coagulating for the left arm.

The main landmarks that are exposed by blunt and sharp dissection are the pubic bone caudally and the external iliac vessels laterally and the bladder is released by its anterior attachments. A pelvic lymph node dissection may be the next step of the procedure, depending on the oncologic risk of the patient

Fig 2.

Fig 3.

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Fig 4.

Preservation of the Puboprostatic Collar and Early Continence

The endo-pelvic fascia, puboprostatic ligaments, and superficial branch of the dorsal vein and possible accessory pudendal arteries are being exposed by carefully dissecting the fatty tissue covering the prostate.

The rectal balloon is deflated and the endopelvic fascia is medially incised below the puboprostatic ligaments and the avascular plane between the levator and the prostatic fascia is developed (Fig. 5). In that way the intra-pelvic branch of the pudental nerve is preserved and covered by levator fascia, which remains intact. The puboprostatic collar is preserved by suturing the Dorsal Venous Complex (DVC) using a V-Loc barbed suture (3/0., 15 cm). The major branches of the dorsal vein of the penis and Santorini’s plexus (DVC) travel within the anterior prostatic fascia.

The DVC is divided after retracting the prostate cranially using a special 120o vascular endodissector in the prostato-vesical junction. The division is performed cranially to the ligation suture with the use of the monopolar scissors (Fig. 6). The vessels at the base of the prostate controlled via bipolar coagulation (backflow).

Fig 5.

Fig 6.

Dissection of the Prostatic Apex

Non-Nerve-Sparing Technique (NNS)

The anterior striated sphincteric urethral complex is demonstrated by transecting the DVC. Its fibers, at the level of the prostatic apex, are horseshoe-shaped and form a tubular, striated sphincter that surrounds the membranous urethra. The rectal balloon is inflated 50-60 ml at this level in order to facilitate the apex dissection. The sphincter is incised using endo-scissors and the prostatic apex is rotated anteriorly by gentle cranial traction of the prostate. The anterior urethral wall is sharply incised without the use of electro-coagulation. The urethral dissection is performed proximally of the verumontanum, in order to preserve the rectourethralis muscle. If the urethral transsection is performed at this level, the expected period of postoperative incontinence is much shorter than when the transsection would be at the level of the prostatic apex (Fig. 7).

Fig 7.

Nerve-Sparing Technique (NS)

The neurovascular bundles (NVB) are located in the posterolateral side of the prostate. The lateral pelvic fascia

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(laterally), the prostatic fascia (medially), and the anterior layer of the Denonvillier’s fascia (base) form the walls of the bundles in a triangular orientation. The anatomic location of the nerves can be estimated, by using the capsular vessels as a landmark, as they are microscopic in size. Near, the apex the NVB travel at the 5 and 7 o’clock positions. Incision of the pelvic fascia is performed prior to the urethral incision (Fig. 8).

Fig 8.

The lateral surface of the prostate is being exposed by displacing the gland on its side. By blunt dissection, beginning at the bladder neck and extending distally to the prostatic apex, the area of the NVB is detached from the posterolateral border of the prostate (early detachment). In that case we can safely and gently release the NVB off the prostatic apex. For controlling all the prostatic branches of the NVB we usually use 5-mm Titanium clips in a step-by-step procedure (Fig. 9). The use of monopoloar and bipolar coagulation is being avoided in the vicinity of the NVB. We can then continue with the urethral incision, as in the non-nerve-sparing technique, but with great caution not to divide the striate sphincter near the prostatic apex, as there is an inherent risk of damage of the NVB. We divide the lateral edges of the urethral sphincter down to the lateral edge of the urethral smooth muscle and not further posteriorly at the level of the prostatic apex. This step should be meticulously performed, because the NVB, as it approaches the prostatic apex, is usually attached medially beneath the striated sphincter by an apical vessel (Fig. 10)

Fig 9.

Fig 10.

Incision of the Bladder Neck

As soon as the detachment of the posterior surface of prostate from the rectum is completed, the second assistant gently retracts the foley catheter ventrally. The vesico-prostatic junction is identified with the help of the catheter balloon (Fig. 11). The balloon is being exposed by incision of the anterior wall of the bladder neck using monopolar scissors and bipolar forceps. The catheter is used as a loop-shaped retractor, in order to elevate the prostate (Fig. 12).

The ureteric orifices are identified, and the posterior bladder neck wall is dissected and transected to expose the retrovesical space (vesico-genital space) and identify the vasa deferentia and seminal vesicles (Fig. 13).

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Fig 11.

Fig 12.

Fig 13.

Division of Lateral Pedicles and Dissection of Seminal Vesicles

The division starts from the superficial portions and continues to the deep portions of the pedicles. It is gradually performed by applying two to three 10-mm Hem-o-lock clips. Then, the vasa deferentia are being transected and the

seminal vesicles are being dissected and divided by using 10-mm Titanium clips. In the NS technique, we clip the small seminal arterial branches in close proximity to the seminal vesicles. Finally, prostatectomy is completed, and the specimen is entrapped in a self-opening extraction bag and isolated away from the working field.

Posterior Reconstruction

The Rocco suture approximates the prostate-vesicle muscle to the rectourethralis muscle [1]. Although its importance for early continence remains debatable [2], it definitely relieves tension on the anastomosis and the NVB.

Urethrovesical Anastomosis

Urethrovesical Anastomosis can be accomplished by using the interrupted, continuous or single-knot technique [3,4].We prefer in robotic surgery Van Velthoven Running Single-Knot Suture technique with barbed suture. During the whole procedure the assistant applies a perineal push to help with approximation of the bladder neck with the urethra and relieve tension from the urethrovesical anastomosis.

Van Velthoven Running Single-Knot Suture

It is used for the urethrovesical anastomosis and consists of a double-armed suture (30 cm Quill 3/0). The sutures are initially placed at the 6 o’clock position of the bladder neck in an outward-inward direction and continue to the posterior urethra in an inward-outward direction. The two parts of the suture are progressing clockwise and counter-clockwise until the posterior part of the anastomosis is completed (Fig. 14, 15). It is then that the approximation of the bladder neck to the urethra by stepwise pulling taut the sutures (winch mechanism) takes place and the new F18-silicon catheter is inserted to help completing the anastomosis.

Fig 14.

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Fig 15.

Reconstruction of the Bladder Neck

When the ureteral orifices are close to the resection line (<5mm), for example in large middle lobes, a reconstruction of the posterior bladder neck is required. When bladder neck preservation is not possible or indicated, an anterior reconstruction may also become necessary.

Retrieval of the Specimen

Once the anastomosis is completed, a drainage tube is being inserted via the right 8-mm port. The prostate is, finally, extracted (Fig 16,17) via the periumbilical incision (site of the optic trocar). The length of the skin incision, as well as the longitudinal incision of the rectus fascia, depends on the size of the gland. The specimen is then sent for staging and grading by the pathologist.

Fig 16.

Fig 17.

Postoperative Care

The urethral catheter is removed at the 7th postoperative day after performing a retrograde cystography and proof a watertight anastomosis. In case of anastomosis leakage the catheter stays in situ for another 3-6 days. Postoperative antibiotic prophylaxis is usually provided with cotrimoxazol until catheter removal. Follow-up visits are programmed every 3 months for the first 3 years, and every 6 months for the following years.

Tips to reduce complication rates during RALP

There are some technical modifications that prove to be beneficial for reducing specific complication types. We believe that the induction of a rectal balloon reduces the rate of rectal injuries. Reducing the bipolar coagulation power to a maximum value of 50W and avoiding application of the Hem-o-lock clips in close proximity to the rectum eliminates the possibility of a rectal fistula creation. Additionally, by avoiding clipping near the urethra can reduce the bladder neck stricture rates due to clip migration. Retrograde stenting or percutaneous nephrostomy rates for treating extravasations can be greatly reduced by reconstruction of the bladder neck, in case of ureteral orifices are closely related to the resection line. Finally, antibiotic prophylaxis is recommended for reducing urinary tract infection rates. We use the urine loss ratio (ULR) to assess the early continence. It is based on a standard micturition protocol that helps quantifying urine loss after catheter removal and is defined as the weight of pad urine loss divided by the daily micturition volume [6]. If the ULR during the first day is below 0.05, the patient’s probability to become continent within 3 weeks postoperatively is 89%. Minimal urine loss (ULR<0.02) can be achieved in 92.3% after combining posterior reconstruction with preservation of the puboprostatic collar.

CONCLUSIONS

Laparoscopic and Robotic assisted radical prostatectomy

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are created to offer the same oncological and functional outcomes with their open counterparts, while decreasing morbidity. In contrast with other techniques, the Heilbronn technique provides an excellent approach of applying all steps and principles of the already well known open anatomical radical prostatectomy. Based on our own experience with more then 2500 radical prostatectomies LRP and RALP have undergone continuous evolution of equipment and technique, which is reflected by the improvement of our clinical and operative data. However, as mentioned before, functional results greatly depend on non-surgical factors (e.g. Age, BMI, concomitant disease). Future technological advancements in the field of video-endoscopy seem to offer new challenges for surgeons and investigators.

REFERENCES

1. Rocco F, Rocco B. Anatomical reconstruction of the rhabdosphincter after radical prostatectomy. BJU Int. 2009; 104(2): 274-81.

2. Menon M, Shrivastava A, Kaul S, Badani KK, Fumo M, Bhandari M, Peabody JO. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol. 2007; 51(3): 648-57.

3. Tewari AK, Bigelow K, Rao S, Takenaka A, El-Tabi N, Te A, Vaughan ED. Anatomic restoration technique of continence mechanism and preservation of puboprostatic collar: a novel modification to achieve early urinary continence in men undergoing robotic prostatectomy. Urology. 2007; 69(4): 726-31.

4. Teber D, Erdogru T, Cresswell J, Gözen AS, Frede T, Rassweiler JJ Analysis of three different vesicourethral anastomotic techniques in laparoscopic radical prostatectomy. World J Urol. 2008; 26(6): 617-22.

5. Hruza M, Weiss HO, Pini G, Goezen AS, Schulze M, Teber D, Rassweiler JJ. Complications in 2200 consecutive laparoscopic radical prostatectomies: standardised evaluation and analysis of learning curves. Eur Urol. 2010; 58(5): 733-4.

6. Hsu CY, Joniau S, Oyen R, Roskams T, Van Poppel H. Outcome of surgery for clinical unilateral T3a prostate cancer: a single-institution experience. Eur Urol. 2007; 51(1): 121-8.

2013


Surgical Technique:Robotic-assisted laparoscopic radical prostatectomy (RARP)

Patient positioning (Picture 1):

Patient is taken to 30o Trendelenburg position.

Picture 1. 30o Trendelenburg position.

Abdominal trocar placement (Picture 2):

Picture 2. Abdominal trocar placement for RARP procedure.R: robotic port (8 mm)C: camera port (12 mm)Assistant surgeon port: 12 mm

Overall, we use 5 trocars:One 12 mm sized trocar for the robotic 3D cameraThree 8 mm sized trocars for the robotic arms One 12 mm sized trocar for assistant surgeon

Correspondence:


A. Erdem Canda, MD Associate Professor of UrologyYildirim Beyazit Universtiy, School of MedicineAnkara Ataturk Training & Research HospitalDepartment of UrologyBilkent 06800, Ankara – Turkeywww.erdemcanda.comE-mail: [email protected]

A. Erdem Canda1 Ziya Akbulut1 Ali Fuat Atmaca1 Serkan Altinova1 M. Derya Balbay2

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We use the 4th arm of the Da Vinci-S surgical robot on the right side of the patient and we use Prograsp for the 4th-arm throughout the RARP procedure.

If no previous abdominal surgical history exists, we use the Veress needle that we insert approximately 2 cm above the umbilicus into the abdominal cavity following making a 12 mm sized skin and fascial incision (Picture 3). In the presence of an abdominal surgical history, we use open technique for abdominal trocar insertion.

Picture 3. Introduction of Veress needle into the abdominal cavity.

We set the CO2 pressure to 18 mmHg initially. We then insert the 12 mm port through this area into the abdomen (Picture 4). Thereafter, we insert the 3D robotic lens and make an intra-abdominal inspection. We mark the places for the remaining trocars on the abdominal skin and insert them under direct vision (Picture 4-5). Lastly robot is docked (Picture 6).

Picture 4. Localization of the port sites on the abdominal skin.

Picture 5. Insertion of the abdominal trocars.

Picture 6. Robot docking.

1st STEP: Exposing Douglas pouch, dissecting seminal vesicles & vas deferences (Pictures 7-10):

The 4th-arm with Prograsp forceps is used to retract the sigmoid colon posteriorly that creates a larger space and exposes the Douglas pouch for the surgeon (Picture 7).

Picture 7. Exposing the Douglas pouch.

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Procedure is started by making an incision on the anterior peritoneal covering of the Douglas pouch, approximately 1 cm proximal to its reflection on rectum (Picture 8).

Picture 8. Incision on the anterior peritoneum covering the Douglas pouch.

Both vas deferences and seminal vesicles are identified and dissected (Picture 9). In order to prevent thermal injury to the neurovascular bundles (NVB), cautery is not applied particularly on the lateral sides of the seminal vesicles. Both vas deferences are cut through their lateral sides.

Picture 9. Dissection of seminal vesicles and vas deferences.

Hem-o-Lock® clips are applied during lateral dissection of the seminal vesicles to control bleeding rather than using cautery in order not to cause thermal injury to the NVBs (Picture 10).

Picture 10. Application of Hem-o-Lock® clips during lateral dissection of the seminal vesicles.

2nd STEP: Identification of the Denonvillier’s fascia and its opening (Pictures 11 and 12):

Denonvillier’s fascia is identified below seminal vesicles and cut vas deferences (Pictures 11 and 22). Console surgeon cuts the Denonvillier’s fascia with monopolar curved scissors and pararectal fat tissue appears (Pictures 11 and 22). Thereafter, it might be possible to dissect the prostate from the rectum up to its apex.

Picture 11. Denonvillier’s fascia is identified below seminal vesicles and cut vas deferences.

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Picture 12. Denonvillier’s fascia is opened.

3rd STEP: Identification and exposure of lateral pelvic fascia, levator muscles and puboprostatic ligaments (Pictures 13-21):

Following completion of the posterior dissection, parietal peritoneum is incised and dissected off lateral to the medial umblical ligaments on both sides (Pictures 13 and 14). Anterior attachments between bladder and abdominal wall are taken down by Maryland monopolar curved scissors and Retzius space is entered. After defatting (Pictures 15 and 16), superficial dorsal vein is identified, cauterized and cut (Picture 17).

Picture 13. Identification of anterior abdominal wall and medial umblical ligament.

Picture 14. Parietal peritoneum is incised and dissected off lateral to the medial umblical ligaments on both sides.

Picture 15. Defatting (left side, endopelvic fascia).

Picture 16. Defatting (left side, endopelvic fascia).

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Picture 17. Superficial dorsal vein.

Endopelvic fascia is opened (Picture 18) and levator ani muscle fibers are dissected off all the way along the lateral prostatic fascia (Picture 19).

Picture 18. Opening of the endopelvic fascia.

Picture 19. Levator ani muscle fibers are dissected off all the way along the lateral prostatic fascia.

Accesory pudendal artery (if present) is preserved (Picture 20). Right and left pubo-prostatic ligaments are cut (Picture 21).

Picture 20. Appearance of the accessory pudendal artery (left side).

Picture 21. Pubo-prostatic ligament (left side).

4th STEP: Ligation of dorsal venous complex (Pictures 22-25):

Following identification of the prostatic apex, dorsal venous complex (DVC) is identified and suture tied distal to the apex of the prostate (40 mm needle, 0 Vicryl suture). A sliding stich is used in order to tie the dorsal venous complex.

Picture 22. Ligation of dorsal venous complex.

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Picture 24. A sliding stich is used in order to tie the dorsal venous complex.


5th STEP: Identification of the intersection of prostate and bladder (Pictures 26-28):

Detrusor apron overlying the prostate anteriorly is identified and dissected superiorly until the entrance of urethra into the prostate, at bladder base is observed where its anterior wall was incised. In order to find the coalescence point of the urinary bladder and prostate, the console surgeon holds

the anterior bladder wall with the 4th-arm and hooks it up. This forms a triangle shape between the bladder and the prostate that exactly shows the coalescence line of these two organs. Then, the console surgeon opens the bladder starting from this coalescence point while the 4th-arm hooks up the bladder and enters the bladder easily. This manoeuvre facilitates preservation of the bladder neck.

Picture 26. 4th-arm hooks up the anterior bladder wall forming a triangle shape that exactly shows the coalescence line of these two organs.

Picture 27. The junction between the prostate and the bladder is cut anteriorly with monopolar curved scissors.

Picture 28. Appearance of the urethra following entering the bladder.

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6th STEP: Dissection of the median lobe and posterior prostatic dissection (Pictures 29-32):

Posterior neck area was checked for the presence of median lobe and incision of the urethra at this level is completed. If a median lobe is detected, it is important to find the intersection point of the median lobe and bladder neck. In order to better expose this area, the console surgeon grasps the tip of the median lobe with the 4th-arm and holds it up that exposes the line between the bladder neck and the median lobe. In the presence of larger median lobes, a stitch could be passed through the median lobe and is hooked up with the 4th-arm. Thereafter, incision through the plane between the bladder neck and median lobe is performed. This manoeuvre with the 4th-arm is important in order to enter the correct space. The detrusor muscle connection between the bladder and the prostate is cut posteriorly and the predissected space at the very beginning of the RARP procedure through the Douglas pouch is entered.

Picture 29. Dissection of the median lobe.

Picture 30. Dissection of detrusor fibres between the prostate and bladder.

Picture 31. Identification of seminal vesicles and vas deferences.

Picture 32. Prostatic pedicle dissection and clip application.

7th STEP: Neurovascular bundle preservation (Pictures 33 and 34)

Starting from the prostatic base, periprostatic fascia is released by anterior release technique for NVB preservation. Intrafascial versus interfascial dissection is performed due to the patient and tumor characteristics.

Picture 33. High anterior release of the periprostatic fascia.

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Picture 34. Preserved NVBs.

8th STEP: Division of dorsal venous complex and membranous urethra (Pictures 35 and 36)

Following prostate is completely released from the surrounding structures, dorsal venous complex is cut by monopolar curved scissors (Picture 35).

Urethra is cut as close as to the prostatic apex in order to preserve maximal urethral length without using any cautery (Picture 36).

Picture 35. Division of deep venous complex.

Picture 36. Division of the membranous urethra.

9th STEP: Urethro-vesical anastomosis (Pictures 37 and 38):

We use absorbable 3/0 polydiaxanone (PDO), 36 cm violet, double armed, round 16 mm, ½ running sutures for urethra-vesical anastomosis by using the van Velthoven technique. The same suture is used for posterior Rocco reconstruciton. An 18 Fr foley urinary catheter is used for this anastomosis. Following completion of the anastomosis, bladder is distended with 100 cc sterile saline in order too see if the anastomosis is watertight. A pelvic drain in inserted after the surgery through the robotic trocar located on the right abdomen used for the 4th-arm. On the postoperative 1st-week, we perform a cystography and if no leakage is present, urethral catheter is withdrawn.

Picture 37. Urethro-vesical anastomosis.

Picture 38. Urethro-vesical anastomosis.

Bilateral extended pelvic lymphadenectomy is performed in patients who have an intermediate- or high-risk for pelvic lymph node (LN) metastasis according to Partin’s tables with an at least 6% risk of LN involvement by prostate cancer.

Prostate is extracted from the abdomen after the enlargement of the supra-umbilical 12 mm sized camera port site following inclusion into the endobag. Thereafter, we grossly examined the prostate for any suspicious areas.


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How to use the 4th arm of the Da Vinci surgical robot efficiently during robotic-assisted radical prostatectomy (RARP)

Robotic-assisted radical prostatectomy (RARP) is frequently being performed for the surgical treatment of localized prostate cancer. The Da-Vinci-S and Si surgical robots have 4 arms that are all used during RARP. Three of the robotic arms are used for robotic instruments and one arm is used for the 3D camera. Using the 4th robotic arm efficiently might significantly facilitate the RARP procedure for the operating console surgeon.

Abdominal trocar placement for RARP procedure.R: robotic port (8 mm)C: camera port (12 mm)Assistant surgeon port: 12 mm

Overall, we use 5 trocars:One 12 mm sized trocar for the robotic 3D cameraThree 8 mm sized trocars for the robotic arms One 12 mm sized trocar for assistant surgeon

We use the 4th arm of the Da Vinci-S surgical robot on the right side of the patient and we use Prograsp for the 4th-arm throughout the RARP procedure.

EXPOSING THE DOUGLAS POUCH BY THE 4TH-ARM (Pictures 1-4):

The 4th-arm with Prograsp forceps is used to retract the sigmoid colon posteriorly that creates a larger space and exposes the Douglas pouch for the surgeon. When enough space is created, the 4th-arm is immobilized retracting the sigmoid colon posteriorly. This manoeuvre keeps the sigmoid colon and bowel segments away from the Douglas pouch enabling a better vision of this narrow area for the console surgeon that gives the opportunity of working in a more confortable way.

Picture 1. Picture showing bladder, Douglas pouch and sigmoid colon.

Correspondence:

A. Erdem Canda1

1Yildirim Beyazit University, School of Medicine, Ankara Ataturk Training & Research Hospital, Department of Urology, Ankara, Turkey 2Memorial Sisli Hospital, Department of Urology, Istanbul, Turkey

A. Erdem Canda, MD Associate Professor of UrologyYildirim Beyazit Universtiy, School of Medicine Ankara Ataturk Training & Research Hospital Department of UrologyBilkent 06800, Ankara – Turkey www.erdemcanda.comE-mail: [email protected]

M. Derya Balbay2

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Picture 2. Picture showing bladder, Douglas pouch and sigmoid colon after retracting the sigmoid colon with the 4th-arm.



HOLDING THE BOTH VAS DEFERENS AND SEMINAL VESICLES UP WITH THE 4TH-ARM IN ORDER TO EXPOSE THE DENONVILLIER’S FASCIA (Picture 5):

After freeing and dissecting the both vas deferens and seminal vesicles, the console surgeon cuts the both vas deferens at their lateral sides. Particularly if the sizes of the seminal vesicles are large and distended with seminal fluid, they might prolapse or fall down inferiorly with the cut vas deferences obstructing the area where the Denonvillier’s fascia is present. At this stage, 4th-arm with Prograsp forceps is placed underneath seminal vesicles and cut vas deferences retracting them posteriorly and superiorly in order to expose the Denonvilliers’ fascia located at the bottom of the Douglas pouch.

Picture 5. The 4th-arm with Prograsp forceps is placed underneath the seminal vesicles and cut vas deferences retracting them posteriorly and superiorly in order to prevent their prolapsus and better expose the Denonvilliers’ fascia.

4TH-ARM IS USED TO GRAB AND RETRACT THE MEDIAL UMBLICAL LIGAMENTS (FOLDS) DURING DROPPING DOWN THE BLADDER FROM ANTERIOR ABDOMINAL WALL (Pictures 6 and 7):

The console surgeon grasps the tip of the medial umblical ligaments (folds) with the 4th-arm and retracts inferiorly that facilitates to find the correct plane of dissection during dropping down the bladder from anterior wall. During this step, the console surgeon could change the position of the 4th-arm and increase its retraction force on the medial umblical ligaments (folds) in order to create a better exposure of the operated area.

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Picture 6. Medial umblical ligaments ( folds) (arrows).

Picture 7. The 4th-arm grasps the tip of the right medial umblical ligament ( folds) and retracts it that creates a better exposure of the operated area.

4TH-ARM IS USED TO RETRACT THE URINARY BLADDER TO BOTH SIDES IN TURN THAT EXPOSES THE ENDOPELVIC FASCIA (Pictures 8 and 9):

After the bladder is dropped down from the anterior abdominal wall, 4th-arm is used to retract the urinary bladder to both sides in turn that exposes the endopelvic fascia nicely. This manoeuvre creates more space at the area of the endopelvic fascia thus facilitates its opening. Following opening the endopelvic fascia, the 4th-arm could also be used to retract the prostate to both sides in turn to better dissect the levator muscles away from the prostate and if present to preserve the accessory pudendal artery.

Picture 8. The console surgeon is positioning the 4th-arm to retract the prostate to the right side (before retraction).

Picture 9. The console surgeon is retracting the prostate to the right side with the 4th-arm (after retraction). Endopelvic fascia is stretched and visualized better.

4th-ARM IS USED TO GRAB AND RETRACT THE URINARY BLADDER SUPERIORLY THAT SHOWS THE COALESCENCE POINT OF THE PROSTATE AND BLADDER (Picture 10):

In order to find the coalescence point of the urinary bladder and prostate, the console surgeon holds the anterior bladder wall with the 4th-arm and hooks it up. This forms a triangle shape between the bladder and the prostate that exactly shows the coalescence line of these two organs. Then, the console surgeon opens the bladder starting from this coalescence point while the 4th-arm hooks up the bladder and enters the bladder easily. This manoeuvre facilitates preservation of the bladder neck.

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Picture 10. The 4th-arm hooks up the bladder forming a triangle shape between the bladder and the prostate that exactly shows the coalescence point of these two organs.

FOLLOWING OPENING THE BLADDER, THE 4TH-ARM GRASPS THE URETHRAL CATHETER AND RETRACTS IT SUPERIORLY (Picture 11):

Following opening the bladder, the urethra catheter is seen. Thereafter, the console surgeon grasps the urethral catheter close to its tip and hooks it up close to the pubic bone.

Picture 11. The 4th-arm grasps the urethral catheter and hooks it up.

4TH-ARM HOLDS THE MEDIAN LOBE UP IN ORDER TO SHOW THE INTERSECTION OF THE MEDIAN LOBE AND BLADDER NECK (Pictures 12-14):

If a median lobe is detected, it is important to find the intersection point of the median lobe and bladder neck. In order to better expose this area, the console surgeon grasps the tip of the median lobe with the 4th-arm and holds it up that exposes the line between the bladder neck and the

median lobe. In the presence of larger median lobes, a stitch could be passed through the median lobe and is hooked up with the 4th-arm. Thereafter, incision through the plane between the bladder neck and median lobe is performed. This manoeuvre with the 4th-arm is important in order to enter the correct space.

Picture 12. The 4th-arm grasping and hooking up the median lobe.

Picture 13. The 4th-arm grasping and hooking up the median lobe.

Picture 14. The 4th-arm hooking up the median lobe via a suture passed though it.

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IN ORDER TO BETTER EXPOSE THE AREA BETWEEN THE BLADDER NECK AND THE PROSTATE, 4TH-ARM IS USED TO HOLD FROM THE LOWER BORDER OF THE PROSTATIC URETHRA AND HOOK IT UP THAT RAISES UP THE PROSTATE (Pictures 15-17):

In order to better expose the area between the bladder neck and the prostate, the console surgeon grasps the lower border of the cut prostatic urethra by the 4th-arm and hooks it up. This manoeuvre raises the prostate up and shows the detrusor muscle connections between the bladder and the prostate nicely that facilitates cutting detrusor muscle fibers in order to enter the space that is dissected at the very beginning of the RARP procedure through the Douglas pouch.

Picture 15. The 4th-arm grasps the lower border of the cut prostatic urethra and hooks it up.

Picture 16. This manoeuvre raises the prostate up and shows the detrusor muscle connections between the bladder and the prostate nicely.

Picture 17. Following cutting the detrusor muscle fibers, the dissected space at the very beginning of the RARP procedure through the Douglas pouch is entered.

THE 4TH-ARM GRASPS THE PREDISSECTED SEMINAL VESICLES AND VAS DEFERENCES AND RETRACTS THEM SUPERIORLY (Pictures 18 and 19):

Following cutting the detrusor muscle fibers, the dissected space at the very beginning of the RARP procedure through the Douglas pouch is entered. After entering this space, the seminal vesicles and vas deferences are seen. The console surgeon grasps these structures with the 4th-arm and retracts superiorly. Thereafter, lateral edge of the seminal vesicles are grasped with the 4th-arm and retracted medially and superiorly that exposes the cut edge of the incised prostatic fascia.

Picture 18. The 4th-arm grasps the predissected seminal vesicles and vas deferences and retracts them superiorly.

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Picture 19. 4th-arm grasps from the cut edge of the incised prostatic fascia and retracts the prostate.

THE 4TH ARM HOLDS AND RETRACTS THE PROSTATE TO EXPOSE THE PROSTATIC PEDICLES (Pictures 20 and 21):

In order to have a good exposure of the prostatic pedicles, the console surgeon grasps from the prostatic base by the 4th-arm and retracts superiorly.

Picture 20. Prostatic base is grasped by the 4th-arm and retracted superiorly.

Picture 21. Prostatic base is grasped by the 4th-arm and retracted superiorly exposing the prostatic pedicle.

THE 4TH-ARM GRASPS THE PROSTATIC BASE AND RETRACTS CRANIALLY (Pictures 22 and 23):For the better visualization of the prostatic apex, 4th-arm grasps the prostatic base and pulls the prostate gland cranially. This manoeuvre exposes the apex.

Picture 22. The 4th-arm is grasping the prostatic base and pulling the prostate cranially.

Picture 23. Appearance of the prostatic apex.

THE 4TH ARM RETRACTS THE PROSTATE CRANIALLY TO EXPOSE THE MEMBROANOUS URETHRA (Pictures 24 and 25):

The console surgeon retracts the prostate cranially with the 4th-arm in order to expose the membranous urethra that facilitates its dissection. This manoeuvre is important to preserve a longer urethral length.

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Picture 24. The 4th-arm retracting the prostate cranially.

Picture 25. The 4th-arm retracting the prostate cranially and leading to a better urethral exposure.

THE 4TH ARM DEPRESSES THE BLADDER IN ORDER TO EXPOSE THE CUT BLADDER NECK (Pictures 26 and 27):

The console surgeon places anteriorly the 4th-arm over the bladder and slightly depresses it that leads to better exposure of the cut surface of the bladder neck.

Picture 26. The 4th-arm depressing the bladder.

Picture 27. Appearance of the cut surface of the bladder neck.


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Robotic-assisted laparoscopic radical cystoprostatectomy and intracorporeal urinary diversion (Studer pouch or ileal conduit) for bladder cancer

1. Introduction

Bladder cancer is the fourth most common malignancy in American men and almost 25% is muscle invasive at the time of diagnosis (Cancer Facts and Figures, 2009; Nieder et al., 2008).

Currently, most effective local treatment of muscle invasive bladder cancer and non-invasive, high-grade bladder tumors that recur or progress despite intravesical therapies is open radical cystoprostatectomy with urinary diversion (Clinical Practice Guidelines in Oncology, 2010; Huang et al., 2007).

With the advancement of technology, minimally invasive surgical approaches including laparoscopic (Huang et al., 2010; Guazzoni et al., 2003) or robotic-assisted laparoscopic (Akbulut et al., 2011; Rehman et al., 2011; Kauffman et al., 2011; Hellenthal et al., 2010; Kasraeian et al., 2010; Pruthi et al., 2010; Schumacher et al., 2009) cystectomies are increasingly being performed.

This chapter summarizes the current state of the use of the surgical robot in performing radical cystoprostatectomy with urinary diversion in patients with bladder cancer.

2. Why to use a surgical robot?

Radical cystoprostatectomy with bilateral extended lymph node dissection and urinary diversion (Studer pouch reconstruction or ileal conduit formation) are complex and time consuming surgical procedures. Performing these complex procedures in an open surgical approach is well established. To perform these complex procedures pure laparoscopically is extremely difficult. However, the use of a surgical robot enables the operating surgeon to perform these procedures much more easily because it has the advantages of the 3-dimensional and magnified image capability, higher grades of wristed hand movements, decreased hand tremor leading to a shorter learning curve. Besides, having the 4th-robotic arm gives the advantage of additional assistance and tissue retraction and letting the console surgeon to operate in a comfortable sitting position rather than standing position for long hours. Menon et al suggested that robotic approach combines the oncological principles of open surgery with technical advantages of the surgical robot which allows a precise, gentle, quick and safe surgery during performing radical cystectomy for bladder cancer (Menon et al., 2003).

Therefore, following the introduction of da Vinci-S 4-arm surgical robot (Intuitive Surgical, Sunnyvale, California)


This document was published in:Canda AE, Atmaca AF, Balbay MD. Robotic-assisted laparoscopic radical

cystoprostatectomy and intracorporeal urinary diversion (Studer pouch or ileal conduit)

for bladder cancer. Bladder Cancer: From Basic Science to Robotic Surgery, Canda AE

(Editor), InTech, Croatia, 2012;321-344.

M. Derya Balbay2A. Erdem Canda1 Ali Fuat Atmaca1

Correspondence:A. Erdem Canda, MD Associate Professor of UrologyYildirim Beyazit Universtiy, School of MedicineAnkara Ataturk Training & Research HospitalDepartment of UrologyBilkent 06800, Ankara – Turkeywww.erdemcanda.comE-mail: [email protected]

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many centers have started to publish their experiences with the use of a surgical robot in performing these complex surgical procedures (Akbulut et al., 2011; Rehman et al., 2011; Kauffman et al., 2011; Hellenthal et al., 2010; Kasraeian et al., 2010; Pruthi et al., 2010; Schumacher et al., 2009).

3. Open versus robotic approach

3.1 Comparison of complications

A prospective study from Weill Cornell Medical College, Department of Urology, New York, NY, USA has recently evaluated prospective complications of open (n=104) versus robotic (n=83) cystectomy procedures (Ng wt al., 2010). Complications were classified due to modified Clavien system. Significantly lower major complications were detected in the robotic group compared to the open surgical approach (17% versus 31%, p=0.03). Robotic cystectomy was found to be an independent predictor of fewer overall and major complications at 0-30 day (perioperative) and 31-90 day periods. Another well known study from The University of North Carolina at Chapel Hill, Division of Urologic Surgery, Chapel Hill, North Carolina, USA randomized 21 patients to robotic approach and 20 to the open technique. No significant difference in regard to overall complication rate or hospital stay was detected between the two groups of patients (Nix et al., 2010). In our initial experience of 12 cases whom we performed robot assisted laparoscopic nerve sparing radical cystoprostatectomy with bilateral extended lymph node dissection and intracorporeal Studer pouch construction, we had 6 minor complications (Grade 1 and 2) 2 major complications (Grade 3-5) in the perioperative period (0-30 day) and 3 minor and 2 major complications in the 31-90 day period due to modified Clavien system (Akbulut et al., 2011). Although the number of prospective and randomized studies comparing these two approaches is limited currently in the literature, robotic approach does not seem to add an additional complication risk when compared to open surgery.

3.2 Comparison of oncologic parameters

Lymph node yield, surgical margins, recurrence-free survival and overall survival are important parameters in evaluating surgical oncologic efficacy. The University of North Carolina study which randomized 21 patients to robotic approach and 20 to the open technique did not find any significant difference in the number of lymph nodes removed between two groups (19 versus 18, p>0.05). Likewise, surgical margins were negative in all patients in both approaches (Nix et al., 2010). The Weill Cornell Medical College study, having larger numbers of patients similarly did not find significant differences concerning these two parameters between the two approaches (15). Mean lymph node yield

was 15.7 in the open surgical approach and was 17.9 in the robotic approach (p>0.05). Positive surgical margins were detected 8.7% of the patients in open approach and 7.2% of the patients in robotic approach (p>0.05). In our initial series of 12 patients, mean lymph node yield was 21.3±.8.8 (Akbulut et al., 2011).

A recent review from the Memorial Sloan-Kettering Cancer Center has recently evaluated the oncological outcomes after radical cystectomy for bladder cancer comparing open versus minimally invasive approaches (Chade et al., 2010). Although the follow-up is limited in robotic series compared to open surgical approach, robotic assisted studies reported recurrence-free survival rates of 86% to 91% at 1 to 2 years and 90% to 96% overall survival in 1 to 2 years of follow-up. On the other hand, large open surgery studies showed 62% to 68% recurrence-free survival at 5 years and 50% to 60% at 10 years, with overall survival of 59% to 66% at 5 years and 37% to 43% at 10 years.

With these limited current data, robotic approach seems to provide sufficient short-term surgical oncologic efficacy in patients with bladder cancer.

3.3 Comparison of cost

Controversial reports exist regarding the cost analysis of open versus robotic approaches. One study revealed that robotic assisted laparoscopic radical cystectomy is associated with a higher financial cost than the open approach in the perioperative setting (Smith et al., 2010). Whereas, another study suggested that although robotic approach is more expensive in terms of operative costs and robotic supplies, due to decreased hospital stay in robotic approach and higher complication rates with open surgical approach make total actual costs much higher than robotic approach (Martin et al., 2011).

4. Surgical oncologic safety of robotic approach (lymph node yield and surgical margins)

Regarding open radical cystectomy, lymph node yield and positive surgical margin rates are considered as the significant factors related to surgical quality (Herr et al., 2004; Skinner et al., 2007; Stein et al., 2003). Herr et al and Skinner et al suggested a lymph node yield of greater than 10 and a positive surgical margin rate of less than 10% in surgical oncologic adequacy (Herr et al., 2004; Skinner et al., 2007). Stein et al suggested a lymph node yield of greater than 15 obtained during open radical cystectomy in order to be oncologically acceptable and sufficient (Stein et al., 2003).

Guru et al evaluated whether robot assistance allows adequate pelvic lymph node dissection particularly during the initial experience (Guru et al., 2008). In a series of 67 patients, mean number of lymph nodes retrieved was 18 (6-

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43) (Guru et al., 2008). Mean lymph node yield was 41.8 (18-67) in another series of 15 consecutive patients who underwent robotic radical cystectomy for bladder cancer (Lavery et al., 2010). Recently, International Robotic Cystectomy Consortium (IRCC) evaluated 527 patients who underwent robotic cystectomy for bladder cancer and mean lymph node yield was 17.8 (range 0-68) (Hellenthal et al., 2011). Mean lymph node yield was 21.3 (range, 8-38) and 24.8±.9.2 in our initial series of 12 (Akbulut et al., 2011) and 27 cases (unpublihsed data), respectively.

Positive surgical margin rates were reported as 6.8%, 0%, 7.2% and 2% in 513, 83, 100 and 50 robotic cystectomy patients (Hellenthal et al., 2010; Pruthi et al., 2010; Ng et al., 2010; Shamim Khan et al., 2010). In our initial series of 12 patients, positive surgical margin rate was 0% (Akbulut et al., 2011). We had only one patient with positive surgical margin (3.7%) who had pT4b disease in the total of 27 patients underwent totally intracorporeal robotic cystectomy (unpublihsed data).

5. Learning curve of robotic approach

Robotic-assisted laparoscopic radical cystectomy with bilateral extended lymph node dissection and particularly intracorporeal urinary diversion (Studer or ileal conduit) are complex procedures. Therefore, a learning curve is required in order to perform these procedures successfully.

Regarding the completion of the learning curve of robotic cystectomy, some authors have suggested to perform a certain number of cases in the literature. International Robotic Cystectomy Consortium (IRCC) suggested that 21 cases were needed to be performed for operative time to reach 6.5 hours and 8, 20 and 30 patients were required to reach a lymph node yield of 12, 16 and 20, respectively (Hayn et al., 2010). On the other hand, others reported that after the first 20 cases of robotic cystectomy, no further significant improvement was detected in terms of intraoperative parameters, pathologic outcomes and complication rates (Pruthi et al., 2008). Following evaluation of 100 cases of robotic cystectomy, Guru et al stated that operative results and oncologic outcomes for robotic-assisted radical cystectomy constantly improve as the technique evolves (Guru et al., 2009).

We have started performing robotic urological procedures at our institution in February 2009, following initially performing more than 50 cases of robot assisted laparoscopic radical prostatectomy cases some of which also included pelvic lymph node dissection. We recommend to start performing robotic cystectomy cases after a certain experience gained particularly on robotic radical prostatectomy. Additionally, a good knowledge of the pelvic anatomy and adequate open surgical experience are essential.

6. Surgical technique

6.1 Patient position

Patient is placed in deep (30°) Trendelenburg position at the beginning of the procedure until the completion of robotic cystectomy, bilateral extended lymph node dissection and transposition of the left ureter under the mobilized sigmoid colon. During performing intracorporeal Studer pouch reconstruction or ileal conduit formation, patient position is adjusted to mild (5°) Trendelenburg position.

A Veress needle is introduced into the abdominal cavity about 2 cm above the umbilicus. Intra-abdominal pressure is set to 10-12 mmHg during performing bilateral extended lymph node dissection. Regarding rest of the surgery, intra-abdominal pressure is set to 16-18 mmHg.

6.2 Abdominal port locations

Overall, we use 6 trocars with the 4th-arm of the surgical robot placed on the patient’s right which provides easy control to the right-handed console surgeon (Figure 1).

Figure 1. Abdominal port locations (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Camera port (12-mm) is placed 2 cm above the umblicus. Two robotic trocars (8-mm) are placed 8 cm apart from the camera port at the level of the umblicus. A 8-mm sized

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robotic trocar is placed 3 cm vertically above from the right iliac crest for the 4th-arm. We use 2 assistant trocars on the left abdomen for the assistant surgeon: A 15-mm trocar for introducing for tissue staplers for bowels and endobags for specimens is placed 3 cm vertically above from the left iliac crest and a 12-mm trocar is placed between the camera port and the 2nd-robotic arm.

6.3 Robotic-assisted laparoscopic bilateral neurovascular bundle sparing radical cystoprostatectomy in male patients (Akbulut et al., 2011; Canda et al., 2011; Canda et al., 2011; Akbulut et al., 2010)

Surgery starts with dissection of the ureters. They are double clipped and cut where they enter the bladder. Most distal parts are sent for frozen section analysis (Figure 2).

Figure 2. Ureters are dissected, double clipped and cut where they enter the bladder (left side). Arrow: left ureter, arrowhead: incised and opened peritoneum on the left side. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Peritoneum on the anterior wall of the Douglas’ pouch is incised and posterior dissection of the prostate is carried out (Figure 3).

Figure 3. Incision of the peritoneum on the anterior Douglas’ pouch wall (arrows). (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Following the identification of seminal vesicles, Denonvilliers’ fascia is opened (Figure 4). Tissue lateral to the tip of the seminal vesicles corresponding to the mid point of the pararectal plexus is marked with a Hem-o-lok® clips on both sides (Figure 5). Prostate is dissected off of the rectum. Lateral bladder pedicles are severed with vessel sealing system (Ligasure®) until the Hem-o-lok® clips placed at the tips of the seminal vesicles to mark pararectal plexus of which the neurovascular bundles originate (Figure 6). Then, endopelvic fascia is opened on both sides. Dorsal venous complex is ligated by 0/0 vicryl (40 mm ½ RB needle). High anterior release (intra-fascial) neurovascular bundle preservation is performed on both sides by dissecting the periprostatic fascia over the prostatic capsule alongside the prostate down until the dorsal venous complex suture and bilateral neurovascular bundle dissections are completed (Figure 7).

Figure 4. Opening Denonvilliers’ fascia (arrow). (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Figure 5. Tip of the seminal vesicle is marked with a Hem-o-lok® clip and cut (arrow). (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

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Figure 6. Severence of lateral bladder pedicles with vessel sealing system (arrow). (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Figure 7. High anterior release of the periprostatic fascia (arrow) over the prostatic capsule alongside the prostate in preserving neurovascular bundles on the left side. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Starting from the umblical level, urachus is dissected by incising lateral to the medial umblical ligaments on the anterior abdominal wall. Puboprostatic ligaments are cut. Ligated dorsal venous complex (Figure 8) and ligated membraneous urethra (Figure 9) with 0/0 vicryl (40 mm ½ RB needle) to prevent tumor spillage are cut. Cystoprostatectomy is completed (Figure 10) and specimen is put into the endobag. Urethral stump is sampled for frozen section analysis.

Figure 8. Dorsal venous complex is ligated and cut (arrow). (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Figure 9. Membraneous urethra is cut. Arrow: appearance of the urethral catheter. DVC: dorsal venous complex (ligated and cut) (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Figure 10. Bilaterally preserved neurovascular bundles following the removal of the cystoprostatectomy specimen into the endobag (arrows). (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

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6.4 Robot assisted laparoscopic bilateral extended lymph node dissection (Akbulut et al., 2010; Akbulut et al., 2011)

We use the landmarks below during performing robot assisted laparoscopic bilateral extended lymph node dissection:

Superior border: inferior mesenteric artery and accompanying vena cava superior

Inferior border: node of Cloquet and circumflex iliac vein

Medial border: cut edge of the endopelvic fascia over the neurovascular bundles and internal iliac vessels

Lateral border: genitofemoral nerves, psoas muscles and ureters

Initially, starting from the genitofemoral nerve lymphatic tissue around external iliac artery & vein are removed until the obturator nerve is seen (Figure 11).

Figure 11. Arrowhead: Genitofemoral nerve (left). Arrow: External iliac artery (left). LNs: Lymph node tissue. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Then, bifurcation of common iliac artery are identified and lymphatic tissues located below the obturator nerve and surrounding the internal iliac artery are removed. Later, lymphatic tissues medial to the genitofemoral nerve and around the common iliac artery are dissected until the aortic bifurcation. Same lymphatic dissection is performed on the other side. Then, lymphatic tissues which are located distal to the aortic bifurcation, overlying and distally located to the vena caval bifurcation and common iliac arteries and veins are removed followed by presacral lymph nodes anterior to the sacrum. Lastly, preaortic and paracaval lymphatic dissections are performed. Inferior mesenteric artery on the aorta makes the most proximal end of the extended lymphatic dissection (Figure 12). Hem-o-lok® clips are used in order to tie off the most distal parts of the lymphatic

vessels draining the limbs to prevent or reduce lymphatic leakage and lymphocele formation.

Figure 12. Completed bilateral extended lymph node dissection and appearance of the major abdominal vasculature that are skeletonized. A: abdominal aorta, VCI: vena cava inferior, Arrows: right and left common iliac arteries, Arrowhead: right external iliac artery. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Having completed the extended lymph node dissection, sigmoid colon is mobilized and left ureter is transposed to the right gutter underneath the sigmoid colon above the vasculature.

6.5 Robot assisted laparoscopic intracorporeal Studer pouch reconstruction (Akbulut Z et al., 2010; Akbulut Z. et al; 2011)

Using a double armed 3/0 monocryl (17 mm ½c RB needle) urethral remnant is anostomosed to the assigned 1 cm opening on the antimesenteric wall of the most dependent part of the segregated ileum, initially (Figures 13,14). A 10 cm ileal segment on the right and a 40 cm ileal segment on the left side of urethroileal anastomosis are assigned for the pouch sparing the distal 20 cm ileal segment adjacent to the ceacum. Laparoscopic intestinal staplers are introduced through the 15 mm assistant port on the left side and placed perpendicular across the ileum and adjacent mesointestinum of approximately 2 cm (Figure 15). Side-to-side ileoileostomy is performed using two additional laparoscopic intestinal staplers between proximal and distal ends of the ileum (Figure 16).

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Figure 13. Segregated antimesenteric ileal wall. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Figure 14. Urethral remnant is sutured to the assigned antimesenteric ileal wall which is segregated. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Figure 15. Laparoscopic intestinal stapler introduced through the 15 mm assistant port on the left side and placed perpendicular across the ileum with adjacent 2 cm of mesointestinum included. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Figure 16. Formation of side-to-side ileoileostomy by using laparoscopic intestinal staplers between proximal and distal ends of the ileum. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Proximal 10 cm segment of the segregated ileum is spared as afferent loop. Then, a 60 cm feeding tube is inserted through the urethra and advanced within the lumen of the ileal segment until the proximal end of the afferent loop. Next, sparing the afferent loop, anti-mesenteric border of the remaining ileal segment is incised. Asymmetric closure of the posterior wall is accomplished with interrupted 2/0 vicryl (30 mm ½c RB needle) sutures followed by a running suture of 3/0 monocryl (26 mm ½c RB needle). Anterior wall anastomosis is accomplished using a running 3/0 monocryl (26 mm ½c RB needle) (Figure 17).

Figure 17. Anterior wall closure. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Distal ureteric ends are spatulated and anastomosed to each other at their medial edges in order to develop a common ureteral duct (Figure 18).

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Figure 18. Distal ureteric ends are spatulated and anastomosed to each other at their medial edges in order to develop a common ureteral duct before reconstruciton of a Wallace type uretero-ureteral and intestinal anastomosis. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Double J stents with long strings at their distal ends are passed through inside the feeding tube over a guide wire to the uretero-intestinal anostomosis site and fed up to the ureters and renal pelves (Figure 19). Distal tips of the stents are tied to the tip of a 22F urethral catheter outside the body, which will then be passed through the urethra into the completed Studer pouch over a guide-wire.

Figure 19. Use of a feeding tube for inserting the double J catheters through the urethra, within the lumen of the ileum and into the ureters up to the renal pelves. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

A Wallace type uretero-intestinal anostomosis is performed between common ureteral duct and proximal end of the afferent loop. To do this anostomosis, medial edge of the ureteral duct is sutured to the medial edge of the ileal wall with a double armed 4/0 monocryl (22 mm ½c RB needle)

running suture. After internalization of the double-J stents, rest of the ureteroileal anastomosis is completed (Figure 20). Ureteroileal anastomosis is retroperitonealized by using several interrupted sutures in the right gutter laterally.

Figure 20. Stapler line is excised at the proximal end of the afferent loop and posterior wall is anastomosed halfway between the ileal wall and medial edge of the uretero-ureteric anastomosis with a double armed 4/0 monocryl (22 mm ½c RB needle) running suture. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Watertightness of the created Studer pouch is tested filling it with 150 cc of saline (Figure 21).

Figure 21. Completed intracorporeal Studer pouch. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Robotic-assisted laparoscopic radical cystoprostatectomy with intracorporeal Studer urinary diversion leads to better wound healing with excellent cosmetic result (Figure 22).

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Figure 22. Postoperative 6th-month abdominal appearance of a male patient who underwent robotic-assisted laparoscopic bilateral neurovascular bundle sparing radical cystoprostatectomy with bilateral extended lymph node dissection and intracorporeal Studer pouch formation for bladder cancer. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

Patients are discharged after tolerating an oral diet and sufficient ambulation following removal of the lodge drain. A cystography is done by filling the bladder with 200 cc of diluted contrast material on the postoperative 21st-day. When no leakage is seen, urethral catheter is removed. If leakage is detected, urethral catheter is kept for one more week and removed after another cystography.

6.6 Robotic-assisted laparoscopic intracorporeal ileal conduit formation

Initially, sigmoid colon is mobilized and left ureter is transposed to the right gutter underneath the sigmoid colon above the vasculature. 20 cm ileal segment including the terminal ileum adjacent to the ceacum is spared and a 15-20 cm of ileal segment is segregated by using tissue staplers.

A Wallace type uretero-ureteric anastomosis is performed as explained above. For inserting the JJ stents into the renal pelves, a feeding tube is passed through the urethra and advanced within the lumen of the ileal segment. Its tip is held close to anastomozed ureteral lumens and JJ stents are passed over a guide wire up to the renal pelves. Then, uretero-ileal anostomosis is performed by using a double armed running 3/0 monocryl suture (Figure 23). Ureteroileal anastomosis is retroperitonealized by using several interrupted sutures in the right gutter laterally.

Figure 23. Uretero-ileal anostomosis with JJ stents and intracorporeal ileal conduit. Arrowhead: ileal conduit, Arrow: Wallace type uretero-ureteric anastomosis. (Archive of Ankara Atatürk Training and Research Hospital, 1st Urology Clinic, Ankara, Turkey)

The 8-mm robotic trocar site opening located next to the supraumblical camera port on right is used for ileal conduit stoma following its enlargement. Interrupted 2/0 vicryl sutures are used in order to fix the ileal loop serosa to the anterior rectus sheet. Ileal opening is everted by interrupted 2/0 vicryl sutures to create a nipple type stoma.

Patients are discharged after tolerating an oral diet and sufficient ambulation following removal of the lodge drains.

ReferencesAkbulut Z, Canda AE, Atmaca AF, Ozdemir AT, Asil E & Balbay MD. (2010) Robot assisted laparoscopic bilateral nerve-sparing radical cystoprostatectomy: Initial Ankara experience. J Endourol 24(Supplement 1):A360:VS8-14.

Akbulut Z, Canda AE, Atmaca AF, Ozdemir AT, Asil E & Balbay MD. (2010) Robot assisted laparoscopic extended pelvic lymph node dissection during radical cystoprostatectomy: Initial Ankara experience. Eur Urol Suppl 9(5):521.

Akbulut Z, Canda AE, Atmaca AF, Ozdemir AT, Asil E & Balbay MD. (2010) Robot assisted laparoscopic intracorporeal Studer pouch formation: Initial Ankara experience. J Endourol 24(Supplement 1):A359:VS8-12.

Akbulut Z, Canda AE, Ozcan MF, Atmaca AF, Ozdemir AT & Balbay MD. (2011) Robot assisted laparoscopic nerve sparing radical cystoprostatectomy with bilateral extended lymph node dissection and intracorporeal Studer pouch construction: Outcomes of first 12 cases. J Endourol In Press.

Canda AE, Asil E & Balbay MD. (2011) An unexpected resident in the ileum detected during robot assisted laparoscopic radical cystoprostatectomy and intracorporeal Studer pouch formation: Taenia saginata parasite. J Endourol 25(2):1-3.

Canda AE, Dogan B, Atmaca AF, Akbulut Z & Balbay MD. (2011) Ureteric duplication is not a contrandication for robot assisted

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laparoscopic radical cystoprostatectomy and intracorporeal Studer pouch formation. JSLS In Press.

Cancer Facts and Figures 2009. Atlanta: American Cancer Society 2009.

Chade DC, Laudone VP, Bochner BH & Parra RO. (2010) Oncological outcomes after radical cystectomy for bladder cancer: open versus minimally invasive approaches. J Urol 183(3):862-69.

Clinical Practice Guidelines in Oncology, version 1.2010. Bladder Cancer. National Comprehensive Cancer Network. Available at http://www.nccn.org. Accessed March 15, 2010.

Guru KA, Perlmutter AE, Butt ZM, Piacente P, Wilding GE, Tan W, Kim HL & Mohler JL. (2009) The learning curve for robot-assisted radical cystectomy. JSLS 13(4):509-14.

Guru KA, Sternberg K, Wilding GE, Tan W, Butt ZM, Mohler JL, et al. (2008) The lymph node yield during robot-assisted radical cystectomy. BJU Int. 102(2):231-4.

Hayn MH, Hussain A, Mansour AM, Andrews PE, Carpentier P, Castle E, Dasgupta P, Rimington P, Thomas R, Khan S, Kibel A, Kim H, Manoharan M, Menon M, Mottrie A, Ornstein D, Peabody J, Pruthi R, Palou Redorta J, Richstone L, Schanne F, Stricker H, Wiklund P, Chandrasekhar R, Wilding GE & Guru KA. (2010) The learning curve of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. Eur Urol. 58(2):197-202.

Hellenthal NJ, Hussain A, Andrews PE, Carpentier P, Castle E, Dasgupta P, Kaouk J, Khan S, Kibel A, Kim H, Manoharan M, Menon M, Mottrie A, Ornstein D, Palou J, Peabody J, Pruthi R, Richstone L, Schanne F, Stricker H, Thomas R, Wiklund P, Wilding G & Guru KA. (2010) Surgical margin status after robot assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. J Urol. 184(1):87-91.

Hellenthal NJ, Hussain A, Andrews PE, Carpentier P, Castle E, Dasgupta P, Kaouk J, Khan S, Kibel A, Kim H, Manoharan M, Menon M, Mottrie A, Ornstein D, Palou J, Peabody J, Pruthi R, Richstone L, Schanne F, Stricker H, Thomas R, Wiklund P, Wilding G & Guru KA. (2011) Lymphadenectomy at the time of robot-assisted radical cystectomy: results from the International Robotic Cystectomy Consortium. BJU Int. 107(4):642-6.

Herr H, Lee C, Chang S & Lerner S; Bladder Cancer Collaborative Group. (2004) Standardization of radical cystectomy and pelvic lymph node dissection for bladder cancer: a collaborative group report. J Urol. 171(5):1823-8.

Huang GJ & Stein JP. (2007) Open radical cystectomy with lymphadenectomy remains the treatment of choice for invasive bladder cancer. Curr Opin Urol 17:369-8.

Huang J, Lin T, Liu H, Xu K, Zhang C, Jiang C, Huang H, Yao Y, Guo Z & Xie W. (2010) Laparoscopic radical cystectomy with orthotopic ileal neobladder for bladder cancer: oncologic results of 171 cases with a median 3-year follow-up. Eur Urol. 58(3):442-9.

Kasraeian A, Barret E, Cathelineau X, Rozet F, Galiano M, Sanchez-Salas R & Vallancien G. (2010) Robot-assisted laparoscopic cystoprostatectomy with extended pelvic lymphadenectomy, extracorporeal enterocystoplasty, and intracorporeal enterourethral anastomosis: initial Montsouris experience. J Endourol. 24(3):409-13.

Kauffman EC, Ng CK, Lee MM, Otto BJ, Wang GJ & Scherr DS. (2011) Early oncological outcomes for bladder urothelial carcinoma patients treated with robotic-assisted radical

cystectomy. BJU Int. 107(4):628-35.

Lavery HJ, Martinez-Suarez HJ & Abaza R. (2010) Robotic extended pelvic lymphadenectomy for bladder cancer with increased nodal yield. BJU Int. 11. doi: 10.1111/j.1464-410X.2010.09789.x. [Epub ahead of print]

Martin AD, Nunez RN, Castle EP. (2011) Robot-assisted Radical Cystectomy Versus Open Radical Cystectomy: A Complete Cost Analysis. Urology. 77(3):621-5.

Menon M, Hemal AK, Tewari A, Shrivastava A, Shoma AM, El-Tabey NA, Shaaban A, Abol-Enein H & Ghoneim MA. (2003) Nerve-sparing robot-assisted radical cystoprostatectomy and urinary diversion. BJU Int. 92(3):232-6.

Ng CK, Kauffman EC, Lee MM, Otto BJ, Portnoff A, Ehrlich JR, Schwartz MJ, Wang GJ & Scherr DS. (2010) A comparison of postoperative complications in open versus robotic cystectomy. Eur Urol. 57(2):274-81.

Nieder AM, Mackinnon JA, Huang Y, Fleming LE, Koniaris LG & Lee DJ. (2008) Florida bladder cancer trends 1981 to 2004: minimal progress in decreasing advanced disease. J Urol. 179(2):491-5

Nix J, Smith A, Kurpad R, Nielsen ME, Wallen EM & Pruthi RS. (2010) Prospective randomized controlled trial of robotic versus open radical cystectomy for bladder cancer: perioperative and pathologic results. Eur Urol. 57(2):196-201.

Pruthi RS, Smith A & Wallen EM. (2008) Evaluating the learning curve for robot-assisted laparoscopic radical cystectomy. J Endourol. 22(11):2469-74.

Pruthi RS, Nielsen ME, Nix J, Smith A, Schultz H & Wallen EM. (2010) Robotic radical cystectomy for bladder cancer: surgical and pathological outcomes in 100 consecutive cases. J Urol. 183(2):510-4.

Rehman J, Sangalli MN, Guru K, de Naeyer G, Schatteman P, Carpentier P & Mottrie A. (2011) Total intracorporeal robot-assisted laparoscopic ileal conduit (Bricker) urinary diversion: technique and outcomes. Can J Urol. 18(1):5548-56.

Schumacher MC, Jonsson MN & Wiklund NP. (2009) Robotic cystectomy. Scand J Surg. 98(2):89-95

Skinner EC, Stein JP & Skinner DG. (2007) Surgical benchmarks for the treatment of invasive bladder cancer. Urol Oncol. 25(1):66-71.

Shamim Khan M, Elhage O, Challacombe B et al: (2010) Analysis of early complications of robotic-assisted radical cystectomy using a standardized reporting system. Urology. Sep 7. [Epub ahead of print]

Smith A, Kurpad R, Lal A, Nielsen M, Wallen EM & Pruthi RS. (2010) Cost analysis of robotic versus open radical cystectomy for bladder cancer. J Urol. 183(2):505-9.

Stein JP, Cai J, Groshen S & Skinner DG. (2003) Risk factors for patients with pelvic lymph node metastases following radical cystectomy with en bloc pelvic lymphadenectomy: concept of lymph node density. J Urol. 170(1):35-41.

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Robotic Bilateral Extended Pelvic Lymph Node Dissection Following Robotic Radical Cystectomy in Bladder Cancer

Introduction

Bladder cancer is the 9th most common cancer diagnosis worldwide with an estimated male:female ratio of 3.8:1.0 (1). Approximately, 70% of cases are diagnosed as non-muscle-invasive bladder cancer (NMIBC) and 30% as muscle-invasive bladder cancer (MIBC) (2). Among patients who had MIBC at the time of diagnosis and treated with radical cystectomy, 57% had muscle invasion, and 43% had been initially diagnosed with NMIBC (2).

Radical cystectomy is the standard treatment in most countries for patients with localized MIBC, high-risk, recurrent, and BCG-resistant superficial tumours, carcinma in situ (CIS) as well as extensive papillary disease that cannot be controlled with trans-urethral resection (TUR) and intravesical therapy alone (3).

Radical cystectomy includes the removal of the bladder and adjacent organs, that is prostate and seminal vesicles in men, and uterus and adnexa in women (4). Radical cystectomy also includes the dissection of regional lymph nodes. An extended lymphadenectomy includes all lymph nodes in the region of the aortic bifurcation and common iliac vessels medially to the crossing ureters (5):• Lateral border: Genitofemoral nerve

• Medial border: Cut edge of the endopelvic fascia over the neurovascular bundles and internal iliac vessels

• Superior border: Inferior mesenteric artery• Inferior border: The circumflex iliac vein, the

ligamentum lacunare, and the lymph node of Cloquet

Step by step surgical technique of robotic bilateral extended pelvic lymph node dissection (6-8):

Patient position: Deep (30°) Trendelenburg position

Correspondence:


A. Erdem Canda, MD Associate Professor of UrologyYildirim Beyazit Universtiy, School of MedicineAnkara Ataturk Training & Research HospitalDepartment of UrologyBilkent 06800, Ankara – Turkeywww.erdemcanda.comE-mail: [email protected]

A. Erdem Canda A. Egemen Isgoren Erem Asil

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Intra-abdominal CO2 pressure: 10-12 mmHg.

During robotic radical cystectomy intra-abdominal pressure is set to 15 mmHg. Following completion of robotic cystectomy, pressure is decreased to 10-12 mmHg in order to visualize the major vascular structures particularly the venous system. Following decreasing the pressure, the venous system fills with blood and the operating console surgeon could recognize them easily that is important in the prevention of accidental vascular injury.

Abdominal trocar sites:

Overall, 6 trocars are used: Camera port (12-mm) is placed 2 cm above the umbilicus, 2 robotic trocars (8-mm) are placed 8 cm apart from the camera port at the umblical level, trocar for the 4th-arm (8-mm) is placed 3 cm vertically above the iliac crest on the right. Two assistant trocars are placed on the left abdomen: A 15-mm trocar is placed 3 cm vertically above the left iliac crest used for tissue staplers and endobags and a 12-mm trocar is placed between the camera and the 2nd-robotic arm.

Robotic instruments used:• Monopolar Curved Scissors, 8mm (1st robotic arm)• Maryland Bipolar Forceps, 8mm (2nd robotic arm)• Prograsp Forceps, 8mm (3rd robotic arm)• 3D robotic camera (robotic camera arm)

• Initially, lymphatic tissues around external iliac vessels are removed and the genitofemoral nerve is visualized lateral to the iliac artery.

• After that, lymphatic tissues that are located below the obturator nerve and surrounding the internal iliac artery are removed until the common iliac artery bifurcation.

• Later, lymphatic tissues medial to the genitofemoral nerve and around the common iliac artery are dissected up to the aortic bifurcation. Same lymphatic dissection is performed on the other side.

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• Subsequently, lymphatic tissues which are located distal to the aortic bifurcation, overlying and distally located to the vena caval bifurcation and common iliac arteries and veins are removed followed by presacral lymph nodes.

• Lastly, preaortic and paracaval lymphatic dissections are performed.

• Inferior mesenteric artery on the aorta makes the most proximal end of the extended lymphatic dissection.

• We use 10 mm sized Hem-o-lok® clips or 5 mm sized metal/titanium clips in order to tie off the most distal parts of the lymphatic vessels draining the limbs to prevent or reduce lymphatic leakage and lymphocele formation. Additionally, monopolar and bipolar cautery

might be used very cautiously for minor lymphatic vessels. It is important not to use the cautery too much particularly on the major vessels that might damage vessel wall and might lead to pseudo-aneurism formation.

Tasks of the assistant surgeon:• The bedside assistant is located on the left hand side of

the patient. • During the console surgeon operates, the beside

surgeon assists with the tip of the aspirator by irrigating and aspirating around the major vascular structures.

• Additionally, the bedside assistant surgeon applies clips carefully to the points that the console surgeon requests.

• Assistant surgeon also checks the intra-abdominal pressure frequently.

• Above the level of the common iliac artery during extended pelvic lymph node dissection, the assistant surgeon might retract the bowel segments superiorly and clear the area of major abdominal vessels for console surgeon in order to facilitate lymph node dissection.

References:1. Ploeg M, Aben KK, Kiemeney LA. The present and future burden of

urinary bladder cancer in the world. World J Urol 2009; 27: 289-293.

2. Vaidya A, Soloway MS, Hawke C, et al. De novo muscle invasive bladder cancer: is there a change in trend? J Urol 2001 Jan;165(1): 47-50.

3. World Health Organization (WHO) Consensus Conference in Bladder Cancer, Hautmann RE, Abol-Enein H, Hafez K, Haro I, Mansson W, Mills RD, Montie JD, Sagalowsky AI, Stein JP, Stenzl A, Studer UE, Volkmer BG. Urinary diversion. Urology 2007 Jan; 69: 17-49.

4. Stenzl A, Nagele U, Kuczyk M, et al. Cystectomy - Technical Considerations in Male and Female Patients. EAU Update Series 2005; 3: 138-46.

5. Abol-Enein H, El-Baz M, Abd El-Hameed MA, et al. Lymph node involvement in patients with bladder cancer treated with radical cystectomy: a patho-anatomical study--a single center experience. J Urol 2004; 172: 1818-21.

6. Canda AE, Atmaca AF, Altinova S, Akbulut Z, Balbay MD. Robot assisted laparoscopic nerve sparing radical cystectomy with bilateral extended lymph node dissection and intracorporeal urinary diversion for bladder cancer: Initial experience in 27 cases. BJU Int. 2012 Aug;(110-3):434-44.

7. Akbulut Z, Canda AE, Ozcan MF, Atmaca AF, Ozdemir AT, Balbay MD. Robot assisted laparoscopic nerve sparing radical cystoprostatectomy with bilateral extended lymph node dissection and intracorporeal Studer pouch construction: Outcomes of first 12 cases. J Endourology 2011 Sep;25(9):1469-79.

8. Canda AE, Atmaca AF, Balbay MD. Robotic-assisted laparoscopic radical cystoprostatectomy and intracorporeal urinary diversion (Studer pouch or ileal conduit) for bladder cancer Bladder Cancer: From Basic Science to Robotic Surgery, Canda AE (Editor), InTech, Croatia, 2012;321-344.

9. Akbulut Z, Canda AE, Atmaca AF, Ozdemir AT, Asil E, Balbay MD. Robot assisted laparoscopic bilateral nerve sparing radical cystoprostatectomy for bladder cancer. Journal of Endourology, Part B, Videourology 2011. December 2011 - VOLUME 25 - ISSUE 6, doi: 10.1089/vid.2011.0035.

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Robotic Intracorporeal Studer Pouch Construction

Identifying the ileo-caecal junction, stay sutures are placed on the antimesenteric border of the ileum 20 cm apart (Picture 1).

Picture 1.

Most dependent region of the ileal segment to be used for the pouch approximately 40 cm from the ileaceal junction is determined by bringing the ileal wall down to the membraneous urethra (Picture 2).

Picture 2.

A 2 cm opening at this site is made and membraneous urethra is sutured to the ileum at this opening (Pictures 3 and 4).

Picture 3.

Memorial Sisli Hospital, Department of Urology, Istanbul, Turkey

M. Derya Balbay

Correspondence:M. Derya Balbay, MD Professor of UrologyMemorial Sisli HospitalDepartment of UrologyIstanbul, TurkeyE-mail: [email protected]

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Picture 4.

Intestinal staplers are applied at 20 cm and 50-55 cm from the ileo-caecal junction across ileal wall including adjacent meso (Pictures 5 and 6).

Picture 5.

Picture 6.

Sparing the most proximal 10-15 cm of ileum as afferent loop, remaining segregated ileal segment is opened at its antimesenteric border without disturbing the urethral anastomosis (Picture 7).

Picture 7.

Posterior wall of the pouch is brought together with interrupted sutures placed 5 cm apart and a running suture between the edges of the ileal segment. Running suturing is performed by passing 4-5 throws from the adjacent intestinal walls forming loose loops before pulling it up and tightening the suture line (Picture 8).

Picture 8.

A 30 cm long silk tie is threaded through the opening of the Foley catheter for future handling of the nelaton tube and maneuvers. Anterior wall of the pouch is folded downwards from its mid and a transvers anastomosis is accomplished using a running 3/0 monocryl suture (Pictures 9 and 10).

Picture 9.

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Picture 10.

A Wallace type uretero-ureterostomy is done between the spatulated ends of the ureters. Silk tie is pulled up bringing the nelatone tube through the opening at the level of uretero-intestinal anastomosis. Two double J stents (DJS) are introduced into the nelaton tube outside the body and guided to both ureters. Additionally another guidewire is sent and the nelatone tube is removed. Finally a 20 Fr Foley catheter with a slit at its tip is inserted into the pouch over this guide wire after distal ends of the DJS are tied together and to the Foley catheter outside.

Picture 11.

Picture 12.

Tightening the suture line after passing 4-5 throws so that string makes big loops prevents using laparoscopic hooks and shortens the procedure. Internalizing DJS prevents briding of the intestinal elements around them intraabdominally outside the pouch. It may also reduce

infectious complications and decrease the amount of mucus clogs due to the diversion of produced urine into the pouch that result in low pressure continuous irrigation with patients own urine. Our suturing and stenting techniques are useful adjuncts to a complicated robotic surgical procedure which we believe decrease peri and postoperative complication rates.

For further surgical and technical details about robotic intracorporeal Studer urinary reconstruction, please refer to our publications (please see below):

1. Canda AE, Atmaca AF, Altinova S, Akbulut Z, Balbay MD. Robot assisted laparoscopic nerve sparing radical cystectomy with bilateral extended lymph node dissection and intracorporeal urinary diversion for bladder cancer: Initial experience in 27 cases. BJU Int. 2012 Aug;(110-3):434-44.

2. Akbulut Z, Canda AE, Ozcan MF, Atmaca AF, Ozdemir AT, Balbay MD. Robot assisted laparoscopic nerve sparing radical cystoprostatectomy with bilateral extended lymph node dissection and intracorporeal Studer pouch construction: Outcomes of first 12 cases J Endourology 2011 Sep;25(9):1469-79.

3. Canda AE, Dogan B, Atmaca AF, Akbulut Z, Balbay MD. Ureteric duplication is not a contrandication for robot assisted laparoscopic radical cystoprostatectomy and intracorporeal Studer pouch formation. JSLS 2011 Oct-Dec;15(4):575-9.

4. Akbulut Z, Canda AE, Atmaca AF, Ozdemir AT, Asil E, Balbay MD. Robot assisted laparoscopic intracorporeal Studer pouch formation following radical cystoprostatectomy for bladder cancer. Journal of Endourology, Part B, Videourology; August 2012 - VOLUME 26 - ISSUE 4. doi: 10.1089/vid.2011.0036

2013


Fascia Sparing Intrafascial Nerve Sparing Robot-Assisted Radical Prostatectomy and Anatomic Vesicourethral Anastomosis:Point of Technique

Bakırköy Dr.Sadi Konuk Training & Research Hospital, Department of Urology, Istanbul, Turkey

Ali Ihsan Taşçı

Correspondence:Ali Ihsan TAŞÇI, MD Professor of UrologyChief, Department of UrologyBakırköy Dr.Sadi Konuk Training & Research HospitalIstanbul, TurkeyE-mail: [email protected]

Introduction

Prostate cancer is one of the most common cancers in Europe (1). Radical prostatectomy has been established as the most durable treatment option for long term survival in men with clinically localized prostate cancer (2). Despite the excellent oncologic results achieved by means of this procedure, some patients choose alternative treatments because they fear the side effects of radical surgery, such as erectile dysfunction and incontinence. In an effort to decrease the morbidity of radical prostatectomy, a minimal invasive surgery approach to managing prostate cancer was first described by Schuessler and colleagues (3). Subsequently, the introduction of the da Vinci Robotic Surgery System has been a key step toward a minimal invasive approach to radical prostatectomy. The first cases were performed by Binder et al and by Abbou et al (4, 5). Three-dimensional magnification provided by robotic systems make it possible to duplicate hand movements with high accuracy. Despite the absence of tactile feedback, the

application of robotic radical prostatectomy might offer real advantages, not only in terms of shorter learning curves, but also in terms of better functional results without impairment of early oncologic outcomes (6).

Surgical Technique

Da Vinci Robotic Surgical System (Intuivite Surgical Inc, Sunnyvale, CA) has been used in the operation of all the patients.

A)Preparation and Docking

After general anesthesia, the operation site was cleaned and draped, a veres needle was inserted into the abdomen at the midline 2 cm above the umbilicus; and pneumoperitonium up to 12 cm H2O pressure was created. The abdomen was visualized by a camera after the placement of a 12 mm port. Under direct vision, special trochars for the 8 mm robotic arm were placed at 8 cm from the right lateral and 10-12 cm

Nerve sparing radical prostatectomy provides excellent control of cancer, even though the recovery of continence and sexual function is changeable. We present our robot-assisted radical prostatectomy (RARP) surgical techniques employed to preserve the endopelvic fascia, which may lead to an improvement in the quality of life.

Our techniques included bladder neck preservation,

preservation of the endopelvic fascia and puboprostatic ligaments, nerve sparing intrafascial approach, selective suturing of the dorsal venous complex, anterior and posterior reconstruction. In this tecnique, within one month after surgery 74.2 % of patients recovered continence. At the follow-up period, the continence and potency rates were 95.6% and 75.0 %, respectively.

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from the left lateral of the camera port. For the fourth arm of the robot, an 8 mm trochar was placed to the lateral of the right trochar and 3-4 cm above and medial to the crista iliaca. A 10 mm trochar was placed as the assistant port on the left side between the telescope port and robotic port, 2 cm above the line of robotic trochars. The operation table was fixed in trendelenburg position at about 30 degree with the legs are abducted and positioned at semi-flection.

B) Posterior dissection

Operation was started by using 0 telescope, scissors at right arm, bipolar Maryland forceps at left arm and prograsp forceps at fourth arm. Initially, dustus deferens and vesicula seminalis were dissected by entering the douglas cavity.(Picture:1) An intrafascial plane was created between fascia and prostate after the exposure of Denonvillier fascia.

Picture 1: Posterior dissection

C) Anterior dissection

Following posterior dissection, lateral of the medial umbilical ligament was incised down to the ductus deferens and iliac vessels junction site. Urachal ligament was excised and retzius space was formed by dissecting the bladder from anterolateral bonds. (Picture:2) All fat was carefully cleaned off the prostate and prostate-vesiculo junction.

Picture 2: Anterior dissection

D) Dissection of bladder neck

Bladder neck-prostate junction was dissected without incising the endopelvic fascia. After the excision of bladder neck, longitudinal fibers that link detrusor fibers to the base of prostate were exposed and these fibers were cut transversely near the prostate. (Picture:3 a,b,c) The previously dissected background involving vesiculo-seminalis and ductus deferens was exposed by the excision of these fibers. Vesiculo-seminalis and ductus deferens were taken to the forefront. Traction was applied by holding the fourth arm of the robot.

Picture 3a,b,c: Dissection of bladder neck

Picture: 3a

Picture: 3b

Picture: 3c

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E) Dissection of lateral pedicules

The plane which was previously created at posterior between Denonvillier fascia and prostate was enlarged in all dimensions, and lateral prostate pedicules were exposed. Pedicules were sutured with 4/0 vicryl sutures or clipped with hem-o-lock clips at both sides. (Picture:4 a,b) Dissection was started by cutting the left pedicule and continued at intrafascial plane from lateral to anterior. The same procedure was repeated at the right side.

Picture 4 a,b: Dissection of lateral pedicules

F) Anterior dissection of the prostate

By taking care not to excise dorsal veins, a superficial incision was performed at the 1-2 mm prostatic side where puboprostatic ligaments were held on prostate. These incisions on the both sides was joined at midline at the tranverse plane. This line was combined with the former dissection site by proceeding towards the basal part of the prostate in clock 11 and 13 positions in the anterior surface of the prostate at laterals. (Picture:5)

Picture 5: Anterior dissection of the prostate

G) Deep dorsal vein control and apical dissection

Deep dorsal vein and its branches were sutured with running 4/0 vicryl suture, and cut.

The apex of the prostate was dissected at intrafascial plane. Urethra and rectourethral tissue were then excised. (Picture:6)

Picture 6: Apical dissection

H) Urethrovesical anastomosis

3/0 v-lock suture was used for anastomosis. Two sutures were tied together and each needle was brought out of the longitudinal detrussor fibers behind the bladder neck at first and then at the bladder neck in clock 4 and 6 positions. These sutures were then passed across the urethra and the recto-urethral muscles and tissues behind the urathra. I was approximated to the bladder neck to the urethra. Approximation was done by passing the sutures from detrusor fibers and bladder neck at the prostatic side and 0.5-1 cm away from the neck. Thus, posterior reconstruction was carried out. After the anastomosis of bladder neck and urethra, sutures were placed on the anterior excised edge of the endopelvic fascia, and the edges of endopelvic fascia and the initially excised healthy tissue of the bladder were approximated anterolaterally. Thus, anterior reconstruction was achieved. (Picture:7 a,b,c,d)

Picture: 4a

Picture: 4b

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Picture 7 a,b,c,d: Urethrovesical anastomosis

I) Operation site control and specimen removal

After the completion of anastomosis, bladder was checked

by filling of saline. A silicone drain was inserted into the operation site. The specimen was put into the organ bag and taken out of the area in which the camera port was located.

Discussion

RARP has been effectively employed in radical prostatectomy over the past ten years. Even though there is no strong evidence to support its efficiency over open radical prostatectomy, RARP is a procedure that allows lower rates of morbidity in potency, continence, and PSM, the rates of which have been reported to be 70-80%, 90-95%, and 9.3-20.9, respectively (8-11). Urinary incontinence and erectile dysfunction are considered to be the most irritating problems after radical prostatectomy. In order to minimize the rate of these two conditions, many urologists have tried several surgical techniques during radical prostatectomy.

The aetiology of urinary incontinence following radical prostatectomy has been attributed to various factors such as age, detrusor dysfunction, insufficiency of the sphincter mechanism, and decreased urethral sensitivity (12). Yet, the physiologic mechanism of male urinary incontinence after radical prostatectomy is poorly understood.

Bladder neck preservation (BNP) has been considered to have a relation with earlier recovery of urinary continence. Klein was the first to suggest that bladder neck resection and reconstruction at the time of radical prostatectomy may influence urinary control (13). Braslis et al. reported that bladder neck preservation may aid in an earlier return of continence and reduced anastomotic strictures (14). However, BNP does not improve the long term results of urinary continence but does contribute substantially to its earlier recovery (15). In the present study, BNP was performed in all patients.

The innervations of the proximal urethra through the pudendal nerve and pelvic hypogastric plexus appear to have a critical role for proper external urethral sphincter function (16, 17). It has been postulated that urethral sphincter innervation is closely related to the prostate apex, and some of the nerve branches modulating passive urethral closure enter the urethra from the anterolateral aspects of the lateral fascia (18). Menon et al. have reported that they preserved the lateral prostatic fascia during RARP, in which the bladder neck was transected without incising the endopelvic fascia. The dorsal vein complex was ligated only after dissection of the prostatic apex. In their series of 2625 patients, complete continence was obtained from 1142 patients at a minimum follow-up of 12 months, and continence rates at 3 and 12 months were 90% and 95.2%, respectively (19). The positive surgical margin rate was 13% and the 5-year biochemical recurrence rate was 8.4%.

Posterior reconstruction of the rhabdosphincter has been previously described by Rocco and colleagues (20). They reported that the Denonvilliers fascia and the posterior

Picture: 7a

Picture: 7b

Picture: 7c

Picture: 7d

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median raphe with the connected dorsal wall of the rhabdosphincter from a unique musculofascial plate that constitutes an important support structure within the pelvis. They concluded that careful reconstruction of the posterior aspect of the rhabdosphincter markedly shorter time to continence. Another technique was described by Patel and colleagues (21). They analyzed 331 consecutive patients who underwent RARP, 237 with the periurethral retropubic suspension stitch and 94 without the placement of suspension stitch. They concluded that suspension stitch during RARP resulted in a statistically significantly shorter interval to recovery of continence and higher continence rates at 3 mo after the surgery. The notion of peri-urethral suspension is based on an observation that in the normal pelvic anatomy the urethra is fixated to the posterior pubis via the pubo-prostatic ligaments (22). It has been proposed that anterior urethral fixation with peri-urethral suspension stitches reduces urethral hypermobility and aids in external sphincteric function after radical prostatectomy (23). Noguchi et al. analyzed the continence outcomes of peri-urethral suspension. The suspension technique involved preservation of the pubo-prostatic ligaments as well as the anterior urethral ligamentous attachment and anchoring of the anterior vesico-urethral anastomosis to the pubo-prostatic ligaments. After RP, these 3 techniques were reported to result in greater continence rates of 53%, 73% and 100% at 1, 3, and 6 months, respectively (24). We consider that sustained puboprostatic ligaments is one of the important parameters that contributes to early continence.

Improved understanding of the pelvic anatomy and urinary sphincter complex has led to some surgical modifications, such as bladder neck preservation and reconstruction, ligament and fascia sparing, and anatomic vesico-urethral anastomosis. This may result in improved continence after RARP.

Many studies have shown that the most common detractor of quality of life following radical prostatectomy is a decrease in erectile ability. In most series potency rates with the ability to achieve intercourse are 20%-40%. However, Walsh et al. reported a 73% intercourse rate with or without PDE5 inhibitors (25, 26). With bilateral extended nerve sparing, the so-called Veil of Aphrodite, 80-90% of patients can achieve intercourse (27). The outcomes of intrafascial versus interfascial bilateral NVB preservation in patients having undergone RARP have been compared in some studies. Potdevin et al. reported that erectile function recovery rates at 3, 6, and 9 months in the intrafascial group were 24%, 82%, and 91%, respectively, whereas in the interfascial group, the rates at the same months were 17%, 44%, and 67%, respectively (28). Parsons et al. reported a potency rate of 71% at 12 months in young men with a mean age of 50.1. These patients had undergone bilateral nerve sparing surgery with preoperative IIEF-5 scores greater than 20 (29).

Continence rates achieved by means of the technique explained in this study seem to be better than those achieved by other authors. We conclude that the fascia preserving technique appears to be effective and provide earlier recovery of continence.

References1. Orvieto MA, Patel VR. Evolution of robot-assisted radical

prostatectomy. Scand J Surg. 2009;98(2):76-88.

2. Han M, Partin AW, Pound CR, Epstein JI, Walsh PC. Long-term biochemical disease-free and cancer-specific survival following anatomic radical retropubic prostatectomy. The 15-year Johns Hopkins experience. Urol Clin North Am. 2001;28(3):555-565.

3. Schuessler WW, Schulam PG, Clayman RV, Kavoussi LR. Laparoscopic radical prostatectomy: initial short-term experience. Urology. 1997 Dec;50(6):854-7.

4. Binder J, Kramer W. Robotically-assisted laparoscopic radical prostatectomy. BJU Int. 2001;87(4):408-410.

5. Abbou CC, Hoznek A, Salomon L, et. al. Remote laparoscopic radical prostatectomy carried out with a robot. Report of a case. Prog Urol. 2000;10(4):520-3

6. Menon M, Shrivastava A, Tewari A, Sarle R, Hemal A, Peabody JO, Vallancien G. Laparoscopic and robot assisted radical prostatectomy: establishment of a structured program and preliminary analysis of outcomes. J Urol. 2002;168(3):945-9.

7. Ou YC, Yang CR, Wang J, et al. The learning curve for reducing complications of robotic-assisted radical prostatectomy by a single surgeon. BJU Int 2011;108(3):420–5.

8. Patel VR, Palmer KJ, Coughlin G, Samavedi S. Robotic- Assisted Laparoscopic Radical Prostatectomy: Perioperative Outcomes of 1500 Cases. J Endourol 2008;22:2299–306.

9. Badani KK, Kaul S, Menon M. Evolution of robotic radical prostatectomy: assessment after 2766 procedures. Cancer 2007;110:1951–8.

10. Mottrie A, Van Migem P, De Naeyer G, Schattenman P, Carpentier P, Fonteyne E. Robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of 184 cases. Eur Urol 2007;52:746–51.

11. Zorn KC, Gofrit ON, Orvieto MA, Mikhail AA, Zagaja GP, Shalhav AL. Robotic-assisted laparoscopic prostatectomy: functional and pathologic outcomes with interfascial nerve preservation. Eur Urol 2007;51:755–63.

12. Burkhard FC, Kessler TM, Fleischmann A, Thalmann GN, Schumacher M, Studer UE. Nerve sparing open radical retropubic prostatectomy--does it have an impact on urinary continence? J Urol 2006 Jul;176(1):189-95.

13. Klein EA. Early continence after radical prostatectomy. J Urol. 1992 Jul;148(1):92-5.

14. Braslis KG, Petsch M, Lim A, Civantos F, Soloway MS. Bladder neck preservation following radical prostatectomy: continence and margins. Eur Urol. 1995;28(3):202-8.

15. Selli C, De Antoni P, Moro U, Macchiarella A, Giannarini G, Crisci A. Role of bladder neck preservation in urinary continence following radical retropubic prostatectomy. Scand J Urol Nephrol. 2004;38(1):32-7.

16. Elbadawi A, Schenk EA. A new theory of the innervation of bladder musculature. 2.Innervation of the vesicourethralction and external urethral sphincter. J Urol 1974;111:613-5.

17. Narayan P, Konety B, Aslam K, Aboseif S, Blumenfeld W, Tanagho E. Neuroanatomy of the external urethral sphincter: implications for urinary continence preservation during radical prostate surgery. J Urol 1995;153:337-41.

18. Karam I, Droupy S, Abd-Alsamad I, Korbage A, Uhl JF, Benoit G, et al. The precise location and nature of the nerves to the male human urethra: histological and immunohistochemical studies with three-dimensional reconstruction. Eur Urol 2005;48: 858-64.

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19. Menon M, Shrivastava A, Kaul S, Badani KK, Fumo M, Bhandari M, et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol 2007;51:648-57.

20. Rocco F, Carmignani L, Acquati P, Gadda F, Dell’Orto P, Rocco B, Bozzini G, Gazzano G, Morabito A. Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy. J Urol. 2006 Jun;175(6):2201-6.

21. Patel VR, Coelho RF, Palmer KJ, Rocco B. Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes. Eur Urol. 2009;56(3):472-8

22. Steiner MS. The puboprostatic ligament and the male urethral suspensory mechanism: an anatomic study. Urology 1994;44:530-4.

23. Lowe BA. Preservation of the anterior urethral ligamentous attachments in maintaining post-prostatectomy urinary continence: a comparative study. J Urol 1997;158:2137-41.

24. Noguchi M, Kakuma T, Suekane S, Nakashima O, Mohamed ER, Matsuoka K. A randomized clinical trial of suspension technique for improving early recovery of urinary continence after radical retropubic prostatectomy. BJU Int 2008;102:958-63.

25. Walsh PC, Marschke P, Ricker D, Burnett AL. Patient-reported urinary continence and sexual function after anatomic radical prostatectomy. Urology 2000;55(1):58-61

26. Schover LR, Fouladi RT, Warneke CL, Neese L, Klein EA, Zippe C, Kupelian PA.Defining sexual outcomes after treatment for localized prostate carcinoma.Cancer 2002:15;95(8):1773-85.

27. Kaul S, Savera A, Badani K, Fumo M, Bhandari A, Menon M. Functional outcomes and oncological efficacy of Vattikuti Institute prostatectomy with Veil of Aphrodite nerve sparing: an analysis of 154 consecutive patients. BJU Int 2006;97(3):467-72.

28. L. Potdevin, M. Ercolani, J. Jeong, I.Y. Kim. Functional and oncologic outcomes comparing interfascial and intrafascial nerve sparing in robot-assisted laparoscopic radical prostatectomies. J Endourol 23 (2009) (1479 - 1484)

29. Parsons JK, Marschke P, Maples P, Walsh PC. Effect of methylprednisolone on return of sexual function after nerve-sparing radical retropubic prostatectomy. Urology 2004 Nov;64(5):987-90.

2013


Clinical Importance of Apical Anatomy and Various Approaches to Control The Dorsal Vein Complex During Robot Assisted Radical Prostatectomy

Radical Prostatectomy is the choice of treatment for localized prostatic carcinoma. Walsh and Donker described the vascular and neural anatomy of the prostate and described the nerve sparing radical prostatectomy technique many years ago.1 The result was decraesed blood loss and proper preservation of neurovascular bundle during the procedure. Anatomic studies done by Walsh and Donker showed that cavernous nerves were branching from the pelvic plexus and running as a plexus within a prominent NVB on the posterolateral border of the prostate, before entering into the urogenital diaphragm. They are intimately associated with capsular vessels of the prostate and course outside the prostatic capsule.1

Minimal invasive techniques were developed to overcome the morbidities of the procedure such as bleeding, long hospital stay, longer catheher time, bladder neck stenosis etc. Mostly the bleeding occurs during the deep dorsal vein control and a certain number of the patients needs blood transfusion during open prostatectomy . First laparoscopic radical prostatectomy was performed in the late 90s. The advantage was to have magnified vision which allows to see the anatomy better. Next robot assisted radical prostatectomy became popular with the advantage of 3-D magnified vision on the console and 6 degree free movement of the instruments which facilitates intracorporeal suturing and knotting. Both techniques resulted with less blood loss, less

blood transfusion, shorter hospital stay and shorter catheter time.2

After introduction of the laparoscopic and robotic surgery, many anatomic studies were performed which made great contribution to understanding the pelvic anatomy much better. Cadaveric studies done by Costello and Takenaka showed that there are cavernous nerves not only located on the posterolateral border but also anterolaterally and posteriorly as well.3,4 Ash Tewari described Hammock shape distribution of the nerves around the prostate which correlates with the previous studies. He showed that there are nerve fibers even located posteriorly.5 Mani Menon described “Veil of Aphrodite” technique which a large amount of tissue is left behind at the apical region containing cavernosal neural fibers.6

There are several structures at the apex which are very important during radical prostatectomy operation. External sphincteric mechanism (striated muscle), deep dorsal vein complex (DVC), cavernosal nerve fibers entering into the urogenital diaphragm, the urethra and apical portion of the prostate. The goal is not to have positive surgical margin at the apex, better continence by preserving external sphincteric mechanism and longer urethral stump, and finally better potency by preserving cavernosal nerves around the prostate during the apical dissection. Two excellent cadaveric studies published by Alsaid recently showed that there are

Correspondence:

Acıbadem University1, Acıbadem Maslak Hospital2, Departments of Urology, Istanbul, Turkey

Ali Rıza Kural, MD Professor of UrologyAcıbadem UniversitySchool of MedicineDepartment of UrologyIstanbul, Turkey

Ali Rıza Kural1 İlter Tüfek1 Selçuk Keskin1 Burak Argun2

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more cavernosal nerves then expected located anteriorly at the level of urethra next to the apex. The bottom line is preservation of these structures is very important to have better potency.7,8

The control of dorsal vein complex is one of the crucial step of radical prostatectomy operation. Suturing of DVC may be difficult especially in patients with very deep and narrow pelvis during open RP and mostly the bleeding occurs during this part of the surgery. Usually, the suture is placed earlier just after the incision of endopelvic fascia during laparoscopic or robot assisted radical prostatectomy. But the disadvantages are bleeding if the suture become loose during the dissection and the possibility of injury to the external sphincteric mechanism if it is placed so deeply. Thomas Ahlering described the control of DVC with vascular EndoGIA placed by the bedside surgeon during RARP. They were able to reduce the positive surgical margin rate from 27.3% to 4.7% for pT2 disease since they divided the urethra under clear bloodless vision.9 Lei and Guru described athermal division of DVC and selective suturing technique. They did not put any suture earlier but increased the pneumoperitoneum up to 20 mm/Hg during DVC transection just before urethral divison.10,11 Once DVC is divided a suture is placed for hemostasis over the vein complex. The advantages with this technique are not to injure the external sphincteric mechanism with any blindly placed suture, not to use energy around the apex and to have longer urethral stump. But EBL was higher and even blood transfusion may be needed in few patients.

We developed a new technique for control of DVC during RARP recently. After completing the bladder neck dissection, seminal vesical dissection and release of neurovascular bundles, a laparoscopic bulldog is placed over the dorsal vein complex by bedside assistant under the guidance of console surgeon. Then DVC is transected and the urethra visualized under clear vision. Once the urethra is divided and the specimen is released, a continuous suture is placed over DVC under direct vision. The same suture is used for periurethral suspension. We use 30o down camera during this part of the procedure. If the pelvis is narrow and the prostate is deep, we change the camera position to up position to see the apical anatomy better during the control of DVC.The advantages with this technique are minimizing the trauma to the external sphincteric mechanism, complete control of DVC and decreasing the risk of apical surgigal margin positivity.12,13

Figure 1: The control of DVC with bulldog clamps.

Figure 2: The control of DVC with bulldog clamps (Division of DVC started).

Figure 3: Division of the urethra under clear vision (Bulldog clamps are still in place).

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Figure 4: Urethra is divided and the DVC is ready to be sutured.

Figure 5: The camera is changed to 30 up position to see the apex better in patients with deeper pelvis.

Figure 6: DVC and urethra is divided and the specimen is released. DVC is ready to be sutured.

Figure 7: DVC is sutured and periurethral suspension suture is placed under the guidance of camera 30 up position.

30 DOWN

30 UP

Figure 8: DVC is ready to for selective suturing after the release of the specimen using different camera position: 30 down and 30 up.

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References:1. Walsh PC, Donker PJ. Impotence following radical prostatectomy;

insight into aetiology and prevention. J Urol, 128: 492–7, 1982.

2. Menon M, Shrisvastava A, Tewari A, Sarle R, Hemal A, Peabody JO, Vallancien G. Laparoscopic and robot assisted radical prostatectomy: establisehment of a structured program and prelimnary analysis of outcomes. J Urol, 168:945-949, 2002.

3. Costello AJ, Brroks M, Cole OJ. Anatomical studies of the neurovascular bundle and cavernosal nerves. BJU int, 94:1071-76, 2004.

4. Takenaka A, Leung RA, Fujisawa M, Tewari AK. Anatomy of autonomic component in the male pelvis: the new concept from a perspective for robotic nerve sparing radical prostatectomy. World J Urol, 24: 136-43, 2006.

5. Srivastava A, Grover S, Sooriakumaran P, Tan G, Takenaka A, Tewari AK. Neuroanatomic basis for traction-free preservation of the neural hammock during athermal robotic radical prostatectomy. Curr Opin Urol, 21: 49-59, 2011.

6. Savera At, Kaul S, Badani K, Stark AT, Shah NL, Menon M. Robotic radical prostatectomy with the “Veil of Aphrodite” technique: histological evidence of enhanced nerve sparing. Eur Urol, 49: 1065-73, 2006.

7. Alsaid B, Karam I, Bessede T, Abdlsamad I, Uhl JF, Delmas V, Benoit G, Droupy S. Tridimensional computer-assisted anatomic dissection of posterolateral prostatic neurovascular bundles. Eur Urol, 58:281-7, 2010.

8. Alsaid B, Bessede T, Diallo D, Moszkowicz D, Karam I, Benoit G, Droupy S. Division of autonomic nerves within the neurovascular bundles distally into corpora cavernosa and corpus spongiosum components: immunohistochemical confirmation with three-dimensional reconstruction. Eur Urol, 59:902-9, 2011.

9. Ahlering TE, Eichel L, Edwards RA, Lee DI, Skarecky SW. Robotic radical prostatectomy: a technique to reduce pT2 positive surgical margins. Urology, 64: 1224-8, 2004.

10. Guru KA, Perlmutter AE, Sheldon MJ, Butt ZM, Zhang S, Tan W, Wilding G, Kim HL, Mohler JL Apical margins after robot-assisted radical prostatectomy: does technique matter ? J Endourol, 23: 123-7, 2009.

11. Lei Y, Alemozaffar M, Williams SB, Hevelone N, Lipsitz SR, Plaster BA, Amarasekera CA, Ulmer WD, Huang AC, Kowalczyk KJ, Hu JC. Athermal division and selective suture ligation of the dorsal vein complex during robot-assisted laparoscopic radical prostatectomy: description of technique and outcomes. Eur Urol, 59: 235-43, 2011.

12. Tüfek I, Atuğ F, Argun B, Keskin S, Obek C, Coşkuner E, Kural AR. The use of a bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy. J Endourol, 26: 1605-8, 2012.

13. Tüfek I, Atuğ F, Argun B, Keskin S, Obek C, Coşkuner E, Kural AR. The use of a laparoscopic bulldog clamp to control the dorsal vein complex during robot-assisted radical prostatectomy. J Endourol, 27: 29-33, 2013.

SCIENTIFIC PROGRAM

2013


Scientific Program 7. June. 2013 Friday

08:00 - 08:30 Welcome and Registration08:30 - 08:45 Opening SpeechesMorning Session:

Chairman: I. Bozkirli (Ankara, Turkey)08:45 - 09:00 Robotic Urology at Ankara Ataturk Training and Research Hospital:

5th-year in Robotic Urology (2009-2013)M. D. Balbay (Istanbul, Turkey), Z. Akbulut (Ankara, Turkey), A. F. Atmaca (Ankara, Turkey)

09:00 - 09:10 About the 1st Ankara Robotic Urology Symposium: 28 April 2012A. E. Canda (Ankara, Turkey)

09:10 - 10:30 Live Surgery - I: Robotic partial nephrectomySurgeon: K. Zorn (Montréal, Canada)Operating room moderator: A. T. Ozdemir (Istanbul, Turkey)Auditorium moderator: F. Atug (Istanbul, Turkey)

10:30 - 11:00 Coffee Break09:10 - 10:30 Live Surgery - II: GreenLight photoselective vaporization prostatectomy for BPH

Surgeon: K. Zorn (Montréal, Canada)Operating room moderator: A. E. Canda (Ankara, Turkey)Auditorium moderator: A. S. Gözen (Ankara, Turkey)

12:00 – 13:00 Lunch BreakAfternoon Session:

Chairman: Y. Ozgök (Ankara, Turkey) 13:00 - 15:00 Live Surgery - III: Robotic pyeloplasty

Surgeon: Z. Akbulut (Ankara, Turkey)Operating room moderator: S. Altinova (Ankara, Turkey)

15:00 - 15:30 Coffee Break

15:30 - 17:00

Lectures: Robotic radical cystectomy, robotic partial nephrectomy and GreenLight prostatectomyChairman: M. D. Balbay (Istanbul, Turkey)

15:30 - 15:45 XPS GreenLight photoselective vaporization prostatectomy for BPH: Personal and published results / K. Zorn (Montréal, Canada)

15:45 - 16:00 Surgical techniques to improve outcomes and reduce warm ischemia time for robotic partial nephrectomy / K. Zorn (Montréal, Canada)

16:00 - 16:15 Robot-Assisted Radical Cystectomy: The technique is ready but what about the evidence? / J. W. Davis (Texas, USA)

16:15 - 16:30 Video Lecture: Surgical techniqueRobotic nerve sparing radical cyctectomy for bladder cancerA. F. Atmaca (Ankara, Turkey)

16:30 - 16:45 Video Lecture: Surgical techniqueBilateral extended pelvic lymph node dissection following radical cystectomy in bladder cancerA. E. Canda (Ankara, Turkey)

16:45 - 17:00 Video Lecture: Surgical techniqueRobotic intracorporeal Studer urinary reconstructionM. D. Balbay (Istanbul, Turkey)

Ankara Atatürk Training and Research Hospital

2013



Scientific Program 8. June. 2013 Saturday

Morning Session:Chairman: A. R. Kural (Istanbul, Turkey) 08:30 - 11:30 Live Surgery - IV: Robotic nerve sparing transperitoneal radical prostatectomy

Surgeon: J. W. Davis (Texas, USA)

Operating room moderators: A F. Atmaca (Ankara, Turkey), A. E. Canda (Ankara, Turkey)

11:30 - 12:15Lectures: Robotic radical prostatectomyChairman: A. Ihsan Tasci (Istanbul, Turkey)

11:30 - 11:40 Complications of robotic radical prostatectomy / S. Altinova (Ankara, Turkey)11:40 - 11:50 Posterior reconstruction during robotic radical prostatectomy

A. T. Ozdemir (Istanbul, Turkey)11:50 - 12:15 Video Lecture: Surgical technique

Nerve sparing robotic radical prostatectomyL. Tunc (Ankara, Turkey)

12:15 – 13:00 Lunch BreakAfternoon Session:Chairman: E. Gumus (İstanbul, Turkey) 12:45 – 13:15 Video Lecture: Surgical technique

Nerve sparing robotic radical prostatectomyA. Ihsan Tasci (Istanbul, Turkey)

13:15 – 15:15 Live Surgery - V: Extraperitoneal retrograde robotic radical prostatectomy: The Heilbronn TechniqueSurgeon: A. S. Gözen (Heilbronn, Germany)Operating room moderator: A. F. Atmaca (Ankara, Turkey)

15:15 – 15:30 Coffee Break

15:30 - 17:15Lectures: Robotic radical prostatectomyChairman: A. R. Kural (Istanbul, Turkey)

15:30 - 15:45 Analysis of the outcomes of robotic radical prostatectomy: literature review of oncologic and functional results / F. Atug (Istanbul, Turkey)

15:45 - 16:00 Clinical Importance of apical anatomy and various approaches to the apex during robotic radical prostatectomy / A. R. Kural (Istanbul, Turkey)

16:00 - 16:15 Anatomic approaches to optimal nerve preservation and techniques to improve urinary continence for robotic radical prostatectomy / K. Zorn (Montréal, Canada)

16:15 - 16:45 Video-based review of creative reconstruction and hemostatic techniques during robotic radical prostatectomy--mostly unplanned! / J. W. Davis (Texas, USA)

16:45 - 17:00 Integrating new information from imaging and markers with robotic radical prostatectomy planning: nerve sparing and lymph node dissection templates J. W. Davis (Texas, USA)

17:00 - 17:15 Extraperitoneal robotic radical prostatectomy: The Heilbronn Technique A. S. Gözen (Heilbronn, Germany)


2013


Scientific Program 9. June. 2013 Sunday

Morning Session:Chairman: A. Unsal (Ankara, Turkey)09:00 - 10:00 Live Surgery - VI: Robotic flexible ureteroscopy

Surgeon: R. Saglam (Ankara, Turkey)Operating room moderators: M. F. Ozcan (Ankara, Turkey)

10:00 - 10:50Lectures: Chairman: Z. Akbulut (Ankara, Turkey)For Residents, Fellows & Operating Room Nurses:Assisting in Robotic Urology Procedures

10:00 - 10:10 Robotic urology operating room nursing and robotic instruments used in robotic urology procedures / G. Yildirim (Ankara, Turkey)

10:10 - 10:15 Assisting in robotic radical prostatectomy / M. F. Özcan (Ankara, Turkey)10:15 - 10:20 Assisting in robotic radical cystectomy / B. Dogan (Ankara, Turkey)10:20 - 10:25 Assisting in extended pelvic lymph node dissection (prostate and bladder cancer)

B. Gök (Ankara, Turkey)10:25 - 10:30 Assisting in robotic intracorporeal Studer urinary reconstruction

H. I. Cimen (Ankara, Turkey)10:30 - 10:35 Assisting in robotic partial nephrectomy / A. E. Isgoren (Ankara, Turkey)10:35 - 10:40 Assisting in robotic pyeloplasty / M. Kilic (Ankara, Turkey)

10:40 - 10:50 Clinical & surgical anatomy with robotic urology surgical pictures:Bladder, Prostate, Upper urinary tract, Pelvis, Major abdominal and pelvic vasculaturesA. E. Canda (Ankara, Turkey)

11:15 - 12:30Lectures: Chairman: A. F. Atmaca (Ankara, Turkey)

11:15 - 11:40 Robotic flexible ureteroscopy by using ‘’Avicenna (İbn-i Sina)’’ robot R. Saglam (Ankara, Turkey)

11:40 - 12:30 Video presentations with interactive discussion:Challenging cases in robotic urology

12: 30 - 12:45 Closing Remarks



THE FOLLOWING ORGANIZATIONS HAVE ANNOUNCED THIS MEETING:

Clinical Robotic Surgery Association (CRSA)

SOCIETY OF ROBOTIC SURGERY (SRS)

European Association of Urology (EAU)

Endourology Society

Société International D’Urologie (SIU)

The British Association of Urological Surgeons (BAUS)

Turkish Association of Urology

Turkish Endourology Society

UroToday

Emirates Urological Society

Polish Urological Association

Urological Association of Asia

Turkish Surgery Association

European Society of Residents in Urology (ESRU)

European Society of Residents in Urology (ESRU) - Türkiye

Arab Association of Urology

YILDIRIM BEYAZIT UNIVERSITY, SCHOOL OF MEDICINEANKARA ATATÜRK TRAINING AND RESEARCH HOSPITAL

Meeting Hall, Bilkent, Ankara - Turkey

7-9. June. 2013

2ND ANKARA ROBOTIC UROLOGY SYMPOSIUM AND COURSE

CONTACT DETAILS:

A.Erdem Canda, MDAssociate Professor of Urology

YiLDiRiM BEYAziT UnivERSiTY, SCHooL of MEDiCinEAnKARA ATATURK TRAininG AnD RESEARCH HoSPiTAL

Department of UrologyBilkent, Ankara - Turkey

E-mail: [email protected]


SCIENTIFIC RESEARCH PROJECTS DEPARTMENT OF YILDIRIM BEYAZIT UNIVERSITY

funded printing of this book.(www.ybu.edu.tr)




ISBN: 978-605-85925-0-6

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