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Pre-Operative preparation

Specific surgical risks for counseling

• Post-op pain
• Bleeding - need for transfusion rare
• Infection - check preop UCx
• Bowel/intraabdominal organ injury - rare
• Cancer recurrence - depends on path results
• Incontinence - most (~90-95%) regain function by 1yr, pre-op Kegels shown to help
• Erectile dysfunction - best case scenario will be at pre-surgical baseline, can take up to 2yrs to return, 50-95% regain some function with nerve-sparing approach
• Anastomotic leak
• Lymphocele - occur in up to 60% after PLND (usually asymptomatic), may require intervention in 0-16% w/ sclerosis, unroofing
• Anejaculation - expected side effect of surgery, unrelated to orgasm potential
• Climacturia - occurs in 30%

RALP Technique #1: complete anterior technique

Preparation

1. Position patient supine split leg (allows for perineal pressure)
2. Ensure patient can tolerate 23-30deg trendelenberg
3. Give cefazolin or culture-specific antibiotics
4. Prep abdomen/genitals and drape, 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

Initial anterior dissection

1. Bipolar medial umbilical ligaments, then cut through on anterior abdominal wall
2. Once window created through peritoneum, bluntly enlarge prevesical space to drop bladder
3. Continue enlarging window with blunt dissection until pubic bone visualized down to perivesical gutters

Pelvic lymph node dissection

1. Place bladder on superior traction with 4th arm, then open peritoneum lateral to medial umbilical ligament
2. Bluntly separate bladder fat from pelvic sidewall fat
3. Continue incising peritoneum toward iliac bifurcation (be conscious of vessels and ureter)
4. When vas identified, transect proximally so it falls out of field
5. Identify ureter at iliac vessel bifurcations
6. LND borders: external iliac artery laterally, obturator fossa medially, iliac bifurcation proximally, and inguinal ligament distally
7. Split/roll tissue off iliac artery, then continue to grasp tissue and bluntly push it off the iliac artery and vein, retracting it medially
8. Bluntly dissect down into obturator fossa, bipolar small perforating vessels when found, continue until all tissue freed from fossa (easiest time to remove this tissue), identify obturator nerve at this time for future dissection
9. Bipolar or place clips close to pubic bone to free off distal aspect of LN packet
10. Carefully scrape LN packet off obturator nerve
11. Place clips proximally to remove packet entirely

Anterior dissection continued

1. Dissect off anterior prostatic fat and retract it proximally onto bladder (can send as specimen, sometimes contains nodes)
2. Use catheter traction to identify bladder neck and prostatic junction, then cut through to divide prostate from bladder (can bleed a lot)
3. Once urethra entered sharply, grab catheter and have assistant grab through eyehole for anterior prostatic retraction
4. Use left hand to expose bladder neck to continue cutting through, then use left hand to grab lip of posterior bladder neck and continue dividing in semicircle following curve of bladder neck, making sure not to buttonhole bladder neck or leave prostate tissue behind
5. Sharply cut through remaining tissue to identify vas deferens

Vas + SV + posterior dissection

1. Grab vas, isolate completely from surrounding tissue by cautery and blunt dissection
2. Cut vas in the middle, if cut too long/short will dangle in front of camera
3. Grasp portion of SV, gently retract (will tear easily) in direction of opposite side, peel off overlying tissue with blunt dissection and cautery until SV completely exposed (can clip apical vessels to prevent nerve injury)
4. Twist SVs and hand to assist for anterior retraction
5. Turn scissor tips up, pull tissue posterior to prostate and incise sharply (without cautery)
6. Once window created posterior to prostate (should develop easily), push down on rectum (keep scissor tips up) while pushing upwards on back of prostate with left hand until only pedicles remain

Nerve-sparing

1. Bluntly dissect prostate posteriorly to identify plane along capsule
2. Push neurovascular bundle off side of prostate, clip/cut remaining attachments
3. No need to incise endopelvic fascia

Non-nerve-sparing

1. Can incise endopelvic fascia and push levators away from prostate
2. Bipolar neurovascular bundle, place clip, then cut distal to clip (avoid clips close to bladder neck)

Apical dissection

Once distal prostate identified, can cut through DVC sharply, expose urethra, and cut through completely to divide prostate from urethra

Tip: ensure space between urethra and rectum to prevent rectal injury during urethral division

Can consider careful dissection to minimize disrupting DVC and puboprostatic ligaments

Use V-loc to oversew DVC (place each stitch entering posteriorly and exiting anteriorly), use perineal pressure to avoid suturing urethra

Obtain hemostasis in resection bed - set pressure down to 5, use careful bipolar to avoid injuring nerves or rectum, can place vicryl stitch for hemostasis

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. Use needle driver in R arm and bipolar in L arm, switch to needle driver in L arm after 2nd stitch on L side
3. Avoid rubbing instruments on pubic bone or side wall, take care not to torque on urethra to avoid tearing
4. Starting on one side, continue running stitch, make sure to get mucosa with each stitch to avoid strictures
5. Intermittently insert catheter to ensure catheter has not been tagged and is able to pass through
6. Once anastomosis completed, perform leak test with 120mL saline, then place catheter and inflate balloon
7. Can place stitches through pubic periosteum before cutting to help reapproximate urethral angle
8. 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

Postop management, complications, expectations

Normal postoperative course

• Antibiotic prophylaxis for catheter removal: theoretical risk for UTI, but no strong evidence for peri-catheter removal antibiotics, if giving antibiotics consider 1 day only vs 3 days (per Ehdaie 2021)
• Suprapubic catheters: no clear benefit to decreasing postoperative pain, no increased risk of anastomotic stricture (from Xia 2020)

Pelvic lymph node dissection complications

• Iliac vessel injury
• Lymphocele: often asymptomatic, place IR drain if symptomatic/infected, drain creatinine rules out urinoma, can use sclerosing agent (doxycycline/iodine) if persistent output, can create open/lap peritoneal window
• Lower extremity lymphedema: check US for DVT, if negative check CT pelvis for lymphocele
• Obturator nerve injury: impairs legg adduction

Vesicourethral anastomotic stricture (info from Britton 2023)

• Prevalence: approximately 5%, higher with open technique, postoperative urine leak, early postoperative UTI
• Management: gentle balloon dilation, aggressive endoscopic resection more likely to cause incontinence, consider robotic reconstruction of bladder neck (Y-V plasty), endoscopic failure rate 40% at 5yr