AUA 2019: Setbacks and Operative Solutions: Robotic Radical Prostatectomy
The first issue related to initial access and intra-peritoneal adhesions. These are a common finding effect 30-40% of RARPs according to Dr. Hemal. Dr. Hemal discussed potential approaches including an offset laparoscope with laparoscopic division including the use of ligasure, the potential for robotic docking (if feasible) with robotic lysis of adhesions, and mini-laparotomy to manage these adhesions. He highlighted that the use of mesh to repair hernias was associated with significant rates of intraperitoneal adhesion. Further, he suggested that clips should be avoided in as much as this is feasible, with the use of ligasure, cautery or vessel sealing technologies instead.
Second, the panel considered the issue of a “stuck” dissection in the process of dropping the bladder. Dr. Tewari highlighted that, where feasible, the operating surgeon should attempt to identify a more favorable dissection plane to develop before approaching the region which is “stuck”. A more thorough history may illicit otherwise unapparent causes for such abnormal anatomy as Dr. Davis highlighted.
A number of speakers then addressed the issues encountered in performed RARP in the obese patient, including bone interference, instrument reach, obscured anatomy, and anesthetic issues relating to positioning and ventilation. Dr. Shalhay first heightened the value of defatting the prostate and the pelvis to better define the surgical anatomy. However, he highlighted that the primary issue may relate to operative access, a concern echoed by Dr. Taylor. Together, they highlighted the value of determining port placement following insufflation with a tendency to bias the ports medially and cranially. Further, Dr. Shalhay felt that these issues were less significant following the introduction of the Xi robotic system. From an anesthetic perspective, Dr. Shalhay pointed out that reducing the degree of Trendelenburg may assist with ventilation and, in rare cases, ventilatory concerns may necessitate aborting the RARP with an open conversion.
Related, but not restricted, to the issue of RARP in the obese patient is the issue of difficulty visualizing the urethra. The panelists offered numerous approaches to this clinical issue. Dr. Davis first offered approaches that Dr. Peter Carroll had advocated including dropping the camera angle to improve visualization, the use of stay sutures to retract the urethra stump, inflation, and retraction of a urethral catheter to intraperitonealize the urethral stump, and to sound the urethra with tynes. Dr. Tewari suggested the use of a large suture (CT-1) to retract the urethra into the peritoneal cavity to facilitate anastomosis. Dr. Davis suggests that perineal pressure using a sponge stick could facilitate visualization of the urethral stump in most cases.
The group then considered the issue of ureteric orifices in close proximity to the bladder neck. This may arise as a result of anatomic abnormalities including the presence of a median lobe, distal ureteric insertion, or prior TURP or as a result of a proximal dissection plane. Dr. Tewari recommended the use of indigo carmine to visualize the ureteric orifices, lateral “fish-mouth” reconstruction, and liberal use of ureteral stents.
Dr. Davis then presented the case of a ureteral duplication. In this case, the patient had preoperative imaging which allowed a high index of suspicion prior to surgery. Dr Taylor highlighted the importance of pre-operative cystoscopy to delineate the anatomy of the ureteric orifices preoperatively. While considering the potential role for ureteric reimplantation, the panel highlighted that a careful resection with preservation of the native anatomy was much preferable.
The panel then considered the issue of a patient with an inflatable penile prosthesis. The group highlighted that the location of the reservoir is highly variable so an attentive dissection must be performed. Dr. Hemal suggested that sparing of the ipsilateral median umbilical ligament may allow for protection of the reservoir. Regardless, inflation of the IPP allows for the reservoir to deflate. Where possible, the reservoir should be padded and the pseudo-capsule preserved. Care should be taken with the angle and position of the robotic arms as well as the passage of sutures and clips to avoid inadvertent injury to the reservoir. The suggestion was also may to consider a retzius sparing approach or perineal prostatectomy in these patients.
Next, the panel considered the issue of a “stuck” posterior bladder neck. Dr. Tewari discussed approaches to this issue. First, he recommended a paramedical or lateral dissection in more normal tissues. In very severe cases, he stated that he had performed apical dissection with subsequent retrograde dissection prior to bladder neck division. Dr. Shalhav suggested that a posterior approach to dissection may facilitate the dissection in these patients.
The panel then considered the “holes and unfortunate cuts” of a bladder neck buttonhole. They considered options including repair of the section bladder incision or excision of the bladder bridge. Where repair was considered, care to place sutures in a caudal-cranial direction, avoiding the ureteric orifices was highlighted by Dr. Taylor.
Rectal injuries were then discussed. Dr. Shalhav highlighted the importance of early identification of these injuries and of primary 2-layer closure. Dr. Hemal pointed out that, for medicolegal reasons, it is important to involve general surgeons in the identification and repair of these injuries.
Finally, the group considered the issue of prostate capsular incision at the time of neurovascular bundle dissection. The group highlighted the importance of ex vivo re-approximation of the capsular incision to allow for more appropriate pathologic analysis of the surgical specimen. Further, Dr. Taylor emphasized that these issues often occur as a result of inadequate retraction during neurovascular bundle dissection.
Speakers: John Davis, MD, MD Anderson Cancer Center, Ashok Hemal, MD, Wake Forest School of Medicine, Ashutosh Tewari, MD, Icahn School of Medicine at Mount Sinai, Arieh Shalhav, MD, the University of Chicago and Jennifer Taylor, MD, Baylor College of Medicine.
Written by: Christopher J.D. Wallis, Urology Resident, University of Toronto @WallisCJD at American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois