Robotic Assisted Laparoscopic Prostatectomy (RALP) A technical description of 11 steps of the procedure

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1 Robotic Assisted Laparoscopic Prostatectomy (RALP) A technical description of 11 steps of the procedure Author: John W. Davis, MD Assistant Professor, Urology The University of Texas M.D Anderson Cancer Center Houston, Texas Document Inception: April, 2008 Editors: Surena Matin, MD, Louis Pisters, MD, Curtis Pettaway, MD, Ashish Kamat, MD Preparatory Steps: Anesthetic: general Monitoring line: peripheral venous x 2, arterial x 1 Arm position: padded/tucked at sides Legs: Allen Stirrups Additional precautions o : a padded chest strap to prevent sliding down the table Padding should also cover the upper arms to prevent pressure points o Pre-anesthetic compression/inflation stockings o Additional padding coverage of the hands Position: neutral to start, steep trendelenburg once the robot is docked Universal protocol: correct patient, correct consent, correct procedure, correct site Laparoscopic Access Virgin abdomen or minor prior abdominal surgery: Veress needle insufflation to 15 mmhg CO2 pneumoperitoneum o Prior surgery: consider direct vision entry with Hassan or balloon port entry 12 mm camera port position: peri-umbilical, shaded to the left o Acceptable range of distance to pubic bone: cm 8 mm robotic ports x 3 o Right and left dominant arm ports are symmetrically spaced as follows: Davis et al: Weblink on RALP technique page 1 of 9

2 o From the camera port headed to the anterior superior iliac spine, measure 9-10 cms Adjust this point to be cms from the pubic bone Additional arm (red arm for davinci standard, 3 rd arm for davinci S models) We prefer a left sided placement 2-3 finger-breadths superior/medial to the anterior superior iliac spine but keeping 3-4 fingerbreadths away from the left sided arm Option: this can be reversed for a left handed console surgeon or by preference Assistant ports: patient right preference (reverse for left handed console surgeon) o 5mm port 4-5 cm above the camera port forming a symmetric triangle with the right robot port o 12mm port 2-3 cm superior/medial to right anterior iliac spine Robot docking: per company recommendations for arm spacing and positioning Instrumentation Tissue dissection o Cautier grasper in the additional left arm o Maryland bipolar grasper in the left arm o Monopolar scissors in the right arm o Rationale for the 2 left arm grasper/right sided assistant model: the surgeon can keep the scissors in the right hand needed for tissue dissection, while alternating left had grasping according to need Bipolar active mode The bipolar is active for maneuvers needing bipolar coagulation The bipolar is active to use its pointed tip shape used in conjunction with the scissor tips to dissect out vascular structures that need clipping and avoidance of thermal vascular control (a.k.a. athermal dissection) The Cautier is inactive and placed in static positions to improve exposure Cautier active mode The Cautier is active to take advantage of its precise and gentle handling of tissues that will be divided by the monopolar scissors. The bipolar is placed in a static position useful for exposure Suturing o The right and left arms use the large needle drivers o The Cautier remains in place to provide static retraction Lens choices o The zero lens can be used for the entire procedure if desired Davis et al: Weblink on RALP technique page 2 of 9

3 o The 30 degree lens up may be useful for viewing the urachus and medial umbilical ligaments o The 30 degree lens down view may be useful for trainees learning the bladder neck dissection and for any surgeon negotiating the bladder neck of a patient with a large prostate. Initial Surgical Field Inspection Inspect for any access related bowel or vascular injury Inspect visible bowel If the sigmoid colon rides high on the left side of the peritoneum over the vessels, it may be useful to mobilize the sigmoid colon. The reasons are that it may reduce bowel tension on the anastomosis, and facilitates posterior approach dissection of the seminal vesicles, vas, and posterior Denonvilliers plane. 1) Seminal Vesicles/Vas: Posterior Approach (common) or Anterior (selected cases) The posterior approach requires mobilization of the peritoneum overlying the vast deferens as it transverses out of the inguinal ligament into the pouch of Douglas and inserts into the base of the prostate in the midline. Once the peritoneum is sharply divided the vas is grasped at the most convenient location and divided and then dissected free with monopolar current all the way to it s insertion in the base of the prostate. These two vasa can then be lifted upwards and this will place the laterally located seminal vesicles on tension and can be located. The seminal vesicles are a potential danger zone for injury to the neuro vascular bundle. Anatomic studies show that they are in very close proximity to the tips of the seminal vesicles and they are perforating arteries off the neurovascular bundles going into the seminal vesicles. Through this posterior approach the medial sheath of the seminal vesicles can be sharply divided and the surgeon can then isolate the perforating arteries at the tips of the seminal vesicles and allow an assistant to come in with a hemolock clip and occlude these vessels and sharply divided them with no use of power both bipolar or monopolar power whatsoever. Once the tips are free the remaining dissection is blunt and sharp and easy. Using the fourth arm of the robot and the assistant s grasper, the two seminal vesicles and vasa are lifted straight upwards to put the Denonvilliers fascia on tension. The Denonvilliers fascia can be sharply incised and a blunt plane developed underneath the Denonvilliers fascia. The Denonvilliers fascia should be left intact with the specimen to reduce positive margins. With the bladder still attached upwards the vast majority of the posterior dissection can be performed in the midline to drop the rectum downward going from base to apex and extending out laterally. Perforating small vessels can be bipolared and sharply divided. The assistant can use the suction device to pull down and provide adequate traction and counter traction. Davis et al: Weblink on RALP technique page 3 of 9

4 o Monopolar/bipolar acceptable along the pouch of Douglas peritoneum and vas dissection o No thermal energy during seminal vesical dissection clips/sharp division o Bipolar acceptable during Denonvilliers fascia dissection 2) Bladder Drop/Anterior Dissection of the Prostate With the posterior dissection completed we now turn attention to the anterior dissection. From the transperitoneal access the urachus and medial umbilical ligaments are grasped up high near the umbilicus and lifted downwards and cauterized and divided. Continual downward pressure will then show the surgeon the extra peritoneal space of Retzius familiar to most surgeons from open prostatectomy. The fourth arm of the robot can provide cephalic retraction to expedite this process. Lateral dissection should continue all the way to the vasa similar to a radical cystectomy set up and the peritoneal mobilized in continuity with the previous dissection line going into the pouch of Douglas. This will allow lateral mobility of the bladder walls and prostate. o Alternate Technique: Leave the Urachus intact and dissect in and around it, dividing medial umbilical ligaments. This technique is a little more work, but makes cephalic retraction of the bladder easier and may keep bowel from migrating into the field during pedicle division. Space of Retzius should be fully divided and fat swept off the endopelvic fascia. It is helpful to use bipolar cautery to occlude any surrounding pelvic vessels near the bone that may bleed later. o Thermal heat o Sharp dissection o Blunt dissection 3) Endopelvic Fascia dissection By rolling the bladder and prostate to the midline the endopelvic fascia will be placed on tension and then sharply divided starting at the mid gland and continuing back towards the base. Levator muscles are then swept off the lateral sidewalls. This is generally an avascular plane. Next the pubo-prostatic ligament should be sharply divided and just lateral to them the open plane developed to push levators off of the dorsal vein complex. There is generally a cluster of levator muscles firmly attached to the apical area of the prostate and often with perforating vessels. These need to be bipolared and sharply divided and swept off of the prostate. The lateral walls to the prostate should be visible and fairly mobile at least anteriorly. The superficial dorsal vein can then be isolated in the midline with the fat swept off of it and the vein bipolared and divided and remaining endopelvic fat removed off of the bladder neck to facilitate identification of the proper planes later. The prostate should be mobile enough to see around the edges of the Davis et al: Weblink on RALP technique page 4 of 9

5 dorsal and complex where a distal suture can be placed. Levator muscles are bluntly pushed off of this area with the bipolar forcep. o Sharp dissection of endopelvic fascia o Bipolar perforating vessels prefer to isolate and bipolar rather than avulse and chase. o Avoid monopolar below the level of the endopelvic fascia. 4) Dorsal Vein Ligation The dorsal vein is a major source of bleeding and must be properly occluded. One technique is to firmly over sew it with O-Vicryl CT1, three loops around the vein with a tight knot and anchored up to the pubic bone for additional tightness. Identify the groove between the DVC and urethra, aim needle distal/away from apex but exclude surrounding levator muscles. A figure of 8 mid prostate back bleeding stitch serves as a reliable grasping point for the base of the prostate and prevents back-bleeding during bladder neck division. Optional technique: DVC stapling. o This technique was tried and abandoned due to the extra cost, frequency of having to resuture the staple line, and time savings if suturing can be accomplished in 5 minutes, and the pathologist do not like staples on the specimen. It may occasionally play a role in a morbidly obese patient with a narrow pelvis where needle driver access is limited. o Suturing o Bipolar/monopolar usually does not control the DVC. 5) Anterior Bladder Neck Division The dorsal vein run-off bed can be squeezed with both instruments to the midline, identifying the plane between prostate and bladder. The run-off bed is divided with cautery and traction. The Foley balloon is moved to visually identify the plane. Although a small bladder neck looks nice for sewing, it may risk a positive margin, or may result in difficulty seeing the posterior inside of the bladder. A medium to larger neck will facilitate the posterior dissection and can be reconstructed. A median lobe may distort the movement of the Foley and any lateral motion of the Foley often indicates its presence. Once in the bladder, grasp the tip of the Foley and pull to the pubic bone. Outside tension with a clamp will elevate and retract the prostate up. o Monopolar/bipolar o Avoid going too lateral, as the bleeding increases and the nerves are near. Davis et al: Weblink on RALP technique page 5 of 9

6 6) Posterior Bladder Neck Division The surgeon then uses the monopolar scissors to carve out the lateral and posterior planes. In general there is a one to two centimeter plane of perivesical tissue just lateral to the midline on each side which there is a clear distinction between bladder and extra bladder space where is this plane is very tight at the exact six o clock position and any errors in this location too far forward will result in dissecting into the prostate, too far back will button hole back into the bladder, planes can be correctly oriented latterly and then brought back around to match at six o clock. Once the bladder is mobilized at six o clock it can be pulled towards the head and the plane behind the bladder dissected until one reaches the previously dissected vas and seminal vesicles. The endpoint of the step is meeting the vasa in the pre-dissected plane from the beginning. o Monopolar/bipolar 7) Division of the Prostate Pedicles and Nerve Bundles The seminal vesicles can be lifted upwards for exposure; in general there are three types of tissue that can be observed inserting into the lateral base of the prostate. o In the immediate posterior plane just off the midline there will still be soft Denonvilliers fascia and surrounding muscle looking tissue that are essentially the posterior aspect of Denonvilliers fascia wrapped around the dissected seminal vesicles. These can be isolated and either occluded with bipolar current or a small clip. o There will be remaining bladder pedicle inserting into the base of the prostate just lateral to the insertion of the seminal vesicle. These can be isolated with the Maryland bipolar occluded with five or 10 millimeter hemolock clips and sharply divided. o Next, there will be prostate pedicles emanating from the base are from the neurovascular bundles and these should be occluded high on the prostate and close to it with small hemolytic clips ensure up this section without cautery. o There is a series of motions that works well based on the set ups described. For a right side dissection the fourth arm of the robot can hold the seminal vesicle while the first and third arm do the dissecting and the assistant has a free port open to apply clips. On the left side in some cases the fourth arm can hold the seminal vesicle and other cases it will cause collisions and the assistant will need to hold the seminal vesicle but then drop it when it s time to insert a clip. Nerve Sparing Dissection. o The neurovascular bundle runs in a sheath covered anteriorly bilateral prostate fascia and posterior by Denonvilliers fascia, on the right side it runs on the clock face at approximately five o clock and on the left side at seven o clock. Davis et al: Weblink on RALP technique page 6 of 9

7 o By pinching on the outer border of the prostate laterally one can appreciate a loose fascial covering that can be individually, sharply divided. Once a small rent is created in the fascia the Maryland bipolar tips can be inserted and spread to guide careful sharp dissection to divide the lateral prostatic fascia from the base to the apex without making an incision into the capsular prostate itself and exposing any prostate glands or a tumor. o There are relatively fewer perforating vessels in the mid prostate plane and therefore the bundle is loosely adherent to the lateral wall of the prostate in a semi-circular shape and requires sharp and blunt dissection. o As there are fewer perforating vessels in the mid prostate plane this is a good point to start developing the grove between the prostate order and the neurovascular bundle. Fourth arm or assistant retraction should be easiest to pull backward retraction on the prostate as well as roll it off to the side to really expose the lateral surface. o The grove is established bluntly and sharply and then the scissor tips aimed back toward the base to further develop the bundle group, as one approaches back to the base it s the occluded that there are perforating arteries coming from the bundle into the base of the prostate and these can be isolated with the bipolar tips occluded with hemolock clips and sharply divided. o An optional move is to divide the DVC earlier in the dissection to allow the prostate to roll on the side more freely and help visualize the nerve bundle dissection. o Bipolar only in the most medial plane o Bipolar briefly on a specific vessel o Clips/sharp dissection as much as possible o Residual bleeders arterial should be oversewn (4-0 Vicryl/RB1), venous can be left alone if minor 8) Apex/Urethra Division Traction is provided by using the 4 th are to pull back on the mid prostate bunching stitch. The monopolar scissors are used to divide the dorsal vein complex, using cautery through at least the top half of the complex. Division should be near the stitch without pulling it out. The dorsal vein stitch may be loose, and tightened further by pulling up at using a clip at the pubic bone to hold tension. Sharp dissection with point bipolar for bleeders is used to divide the remaining dorsal vein. There is a distinct plan under the DVC. Once divided, the scissors are used to mobilize the sides of the urethra. Loose areolar tissue is present over the urethra that is swept back over the specimen, and sampled anteriorly to represent the apical/anterior tip of the Davis et al: Weblink on RALP technique page 7 of 9

8 transition zone tissue. There is no clear prostatic capsule at this junction. Frozen section experience demonstrates the possibilities of skeletal muscle, muscle with benign glands, and muscle with cancerous glands. Additional frozen section should be taken if possible to ensure to malignant and hopefully no benign glands. The lateral pillars of the urethral sphincter that enter the lateral sides of the apices are sharply cut, possible bipolar use. The urethra is cut close with the specimen Usually there will be remaining apical lateral fascia that is still in contact with the nerve bundles. With the DVC cut, the prostate is more mobile and can be rolled to either side to allow final release of the nerve bundles. No cautery or bipolar this close. The posterior fascia planes are cut, and there will possibly be remaining posterior Denonvilliers fascia to release. Avoid over mobilizing under the urethra. The prostate is free and placed in an endobag for later retrieval. o Monopolar to divide anterior DVC, then switch to sharp/bipolar o Sharp dissection posterior/lateral to urethra. Over sew bleeders later if needed o Avoid clips in this zone Post-Prostatectomy Hemostasis After the prostate is removed, the bladder is pulled cephalic to place the bundles on tension and view bleeding. Slow venous bleeding can be left alone Arterial bleeding should be controlled o Prefer oversewing with 4-0 Vicryl. Avoid bipolar/monopolar to the nerve bundles o It is unknown for sure the efficacy of floseal/surgiceal to the bundles and any inflammatory response detrimental to nerve bundle response. 9) Pelvic Lymph Node Dissection Standard lymph node dissections o Medial edge of external iliac vein near bifurcation, distal to node of cloquet, posterior to obturator nerve, lateral to pelvic side wall Extended: add tissue over the external iliac artery, and medial tissue along the hypogastric artery to posterior to the obturator nerve Use clips for larger divided lymphatics, otherwise cautery Newer technique: early split/roll of the hypogastric artery, sparing its branches. This facilitates the lower regions of the PLND. 10) Posterior Anastomosis Sutures: 2-0 Monocryl/SH (or Biosyn equivalent), tan 8 inches, blue 6 inches, tied together with small piece of vas as a pledget Evert mucosa at 12 o clock on bladder with 3-0 Vicryl Davis et al: Weblink on RALP technique page 8 of 9

9 Reconstruct anterior tennis racquet to match urethra with 2-0 Vicryl UR6 Avoid deep bites on urethra so as to maximize urethral stump length Place tan bladder to urethra at o clock, then the blue at 5-4 o clock. Parachute these 5 throws down to approximate bladder to urethra. The catheter should flow into the bladder freely. 11) Anterior Anastomosis Continue suturing around to 12 o clock. Transition on bladder side. Water tight test to 100 cc Anterior pexy stitch from bladder neck to dorsal vein x 2. New 20F/5cc catheter Re check hemostasis. Exiting Place prostate in an endocatch bag Redirect bag suture through suction port Extract through camera port incision Close 12mm assistant port with Carter Thompson device and 1 Vicryl Drain optional Repair extraction incision with figure 8 1 Vicryl interrupted. Davis et al: Weblink on RALP technique page 9 of 9