NARUS 2018: Troubleshooting in Robotic Radical Prostatectomy

Las Vegas, NV (UroToday.com) Dr. Davis gave a practical presentation on some of the various problems that could potentially occur during robotic radical prostatectomy. The first topic discussed was a scenario where patients referred for radical prostatectomy have a history of prior laparotomies. This situation leads us to wonder whether in these patients, their surgical position should be changed? And whether port placement should be different. Some of he recommendations that were discussed included the use of optical trocar, which has a blunt tip that dilates tissues radially instead of cutting it. When using the optical trocar, it is critical that the layers of the abdominal wall be recognized as the trocar is advanced. After the skin incision is made, the optical trocar, with an inserted 0 degree laparoscope, is advanced into the wound. It is extremely important to identify the peritoneal layer just beneath the posterior fascia. Additionally, it is important to not place trocars at the site of previous scars and have a low threshold for open Hassan technique.

Another potential problematic issue presented was the correct identification of the space behind the bladder neck, that enables you to and directly in the seminal vesicle/vas deferens area. Some of the principles that can help guide you in finding the correct plane include: achieving good control of the bladder neck, remembering that the are area you are looking for is always right behind the bladder wall – following the detrusor plane down, it is important not to let BPH fool you, and utilize wider entry planes.

A large distance between the bladder neck and urethra was another issue that was debated. This could be especially problematic if there is bone in the way, causing the instruments to clash and making if difficult to reach the posterior urethra. Several possible solutions include decreasing pneumoperitoneum, using a barbed suture, using a Rocco stitch, application of the Van Velthoven anastomosis, and pulley technique. If the urethra is not visible, the camera should be dropped to improve visualization, and to remember that perineal pressure can also significantly help in visualization. Another helpful tip is to use stay sutures on the urethra, or to use a urethral catheter with balloon slightly inflated, or sound with tynes.

The next topic discussed was ureteral injuries. More than 70% of ureteral injuries are diagnosed postoperatively. Its incidence is 0.8% during urologic laparoscopy and 0.3% during laparoscopic/robotic prostatectomy. It is important to diagnose it intraoperatively and perform reconstruction/reimplantation as needed.

Another topic discussed is potential injuries to the rectum. If there is doubt with regards to rectum injury, perform an air leak test. If an injury to the rectum has occurred and it is a simple relatively small injury, it is possible to perform a simple primary closure. If the injury is large or complex, especially if it is in a previously radiated patient, a diversion may be needed.

Lastly, the topic of apical dissection was discussed. It is important to properly dissect this plane in order to avoid positive surgical margins. The surgeon must be in the correct plane when freeing prostate at bladder neck and along nerve bundle. When performing anterior dissection, it is preferable to use the 30 degree down camera, and when performing posterior dissection, it is better to use the 30 degree up camera. When cutting the dorsal vein complex, a sharp incision should be made. Before incising the urethra, careful retraction and lateral dissection is required. It is important to remember that the prostate extends posteriorly behind the urethra.

Presented By: John Davis, MD Anderson, Texas, USA

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre @GoldbergHanan at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV

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