Technique #1 – Single Port Robotic Perineal Prostatectomy
For this technique, the patient is positioned lithotomy, however the operation does not require any Trendelenburg, which makes it advantageous for patients that are obese and may be difficult to ventilate in steep Trendelenburg. A 3-cm incision is made in the perineum (1.5 cm on either side of midline) and dissection is carried down almost to the level of the urethra. A GelPort is then placed followed by the SP robot trocars and instruments. Dr. Kaouk notes that the view from the robotic perineal procedure may be comfortable for surgeons who have done the Retzius sparing robotic prostatectomy procedure, specifically because the apex is at the 12 ‘o clock position and the urethra is visualized from above. Unlike the standard robotic prostatectomy procedure where one worries about positive margins at the apex, in the perineal approach, the worry for positive margins is at the base of the prostate. The last part of the dissection is the bladder neck, which Dr. Kaouk notes is usually quite well preserved. He feels that this leads to almost immediate continence post-operatively for these patients. One of the biggest limitations of this approach according to Dr. Kaouk is the size of the prostate. If the prostate is large (~>80g), it significantly limits the procedure because of minimal space in the surgical field. For the urethrovesical anastomosis, he starts with the anterior wall of the urethra and finishes with the posterior wall. One limitation of the open perineal approach is being able to perform a pelvic lymph node dissection, which Dr. Kaouk states is very feasible with the robotic SP platform. If he needs to he can even do an extended lymph node dissection from the perineal approach. What you see first in the surgical field is not the external iliac vein, but rather the obturator vessels. He does not leave a drain post-operatively.
Technique #2 – Single Port Robotic Extra-peritoneal Prostatectomy
For this procedure, Dr. Kaouk makes an incision just below the umbilicus for ~3cm. He then opens the anterior rectus sheath for placement of the balloon dissector to develop a place behind the pubic bone. He keeps the patient completely flat, without stirrups, akin to the open approach. Once inside the space, the steps are essentially the same as an anterior transperitoneal robotic prostatectomy. Dr. Kaouk states that 90% of the time he does a robotic extra-peritoneal robotic prostatectomy, however he favors the perineal approach for patients that have had ulcerative colitis, a colostomy, multiple abdominal procedures, etc. The advantage is that the patient does not require narcotics post-operatively and 80% of the patients go home 3-4 hours after the procedure.
Technique #3 – Single Port Transvesical Robotic Simple Prostatectomy
Dr. Kaouk performs this operation also in the flat, non-Trendelenberg position akin to the robotic perineal prostatectomy. The bladder is identified with a needle, a low suprapubic, curvilinear incision is made, and the SP robotic system is placed right into the bladder. The bladder is insufflated with carbon dioxide – in Dr. Kaouk’s opinion the advantage of this approach is that you do not bivalve the bladder and the bladder is able to be closed with a simple external figure-of-8 suture. For the adenoma resection, he favors a flexible suction so that the surgeon can suction for him/herself. Another advantage to the robotic approach is that the mucosal flap that’s present after removing the adenoma is carefully sutured back around the urethra. Dr. Kaouk says that next steps for this operation are assessing how quickly post-operatively the Foley can be removed.
Presented by: Jihad Kaouk, Cleveland Clinic, Cleveland, Ohio
Written by: Zachary Klaassen, MD, MSc – Assistant Professor of Urology, Georgia Cancer Center, Augusta University - Medical College of Georgia, Twitter: @zklaassen_md at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois