Prostate Cancer Surgeries

Pre/Post-Op RALP prep

Specific surgical risks for counseling

Postop catheterization

Robotic Radical Prostatectomy Steps

Preparation

  1. Position patient supine split leg (allows for perineal pressure)
  2. Ensure patient can tolerate 23-30deg trendelenberg
  3. Shave entire abdomen
  4. Place foley catheter on field

Access

  1. Place veress needle through umbilicus, drop test, attach insufflation
  2. Place camera port to R of midline superior to umbilicus under direct visualization
  3. Place ports: robot x2 on R of midline, x1 on L of midline, large assist port superolateral to camera on L side, and 2nd assist port on L side (mirror image of 4th arm)
  4. Dock robot, place scissors in R, bipolar in L, grasper in 4th arm
  5. Take down any physiologic attachments preventing the bowel from moving superiorly

Posterior dissection

  1. Make transverse incision in bladder peritoneum just anterior to rectovesical fold
  2. Dissect distally to find vas and seminal vesicles
  3. Dissect out vas (transect after bipolar) and seminal vesicles
  4. Dissect more superior/inferior to make it easier to identify during anterior dissection

Pelvic lymph node dissection

  1. Identify ureter at iliac vessel bifurcations
  2. Remove tissue with borders being external iliacs laterally, obturator fossa medially, iliac bifurcation proximally, and inguinal ligament distally
  3. During dissection, will likely make anterior wall incision in peritoneum

Anterior dissection

  1. Extend the started paramedian dissection on either side of bladder to drop the sides from the anterior wall
  2. Bipolar then cut medial umbilical ligaments and drop proximal attachments completely
  3. Mostly bluntly dissect bladder from anterior abdominal wall, all the way to pubic symphysis
  4. Dissect off anterior prostatic fat and retract it proximally onto bladder (can send as specimen, sometimes contains nodes)
  5. Use catheter traction to identify bladder neck and prostatic junction, then cut through to divide prostate from bladder (can bleed a lot)
  6. Clip and divide posterolateral pedicle attachments to come around prostate from behind
  7. Once distal prostate identified, can cut through to transect from urethra entirely
  8. If careful dissection performed, can avoid disrupting DVC
  9. Place specimen and lymph nodes into bag
  10. Obtain hemostasis in resection bed

Vesicourethral anastomosis

  1. Use double arm V-loc suture, place both stitches at posterior midline of bladder going out/in, then place into urethra going in/out (may require perineal pressure
  2. Starting on one side, continue running stitch, make sure to get mucosa with each stitch to avoid strictures
  3. Intermittently insert catheter to ensure catheter has not been tagged and is able to pass through
  4. Once anastomosis completed, perform leak test with 120mL saline, then place catheter and inflate balloon
  5. Can place stitches through pubic periosteum before cutting to help reapproximate urethral angle
  6. Place drain through 4th arm port down into pelvis if desired

Closure

  1. Remove ports under direct visualization
  2. Extract specimen by extending camera port site
  3. Close large incision with PDS running
  4. Close incisions with monocryl and dermabond