Robotic Simple Prostatectomy
Preop workup
Technique
- Positioning: supine split leg, arms tucked, trendelenberg 23deg
- Drape patient and place foley, consider gentamicin instillation (especially if bladder stone or chronic catheter)
- Gain access with veress via umbilicus, perform drop test
- Ports: camera superior to umbilicus to right of midline, robot ports to left of midline, right of midline x2, assist port on left side superior to camera port
- Dock robot, place arms - bipolar in left, monopolar scissors in right, needle driver in 4th arm
- Take down adhesions for better access to bladder
- Have assistant fill bladder with 200-250mL, then make midline or transverse bladder incision
- Place keith needle at midline if transverse bladder flap, or laterally for midline bladder flaps, place through bladder flap then through abdominal wall for retraction
- Assess bladder, ensure no abnormallities
- Make transverse mucosal incision halfway between trigonal ridge and urethral opening
- Once prostatic capsular plane is identified, use L arm to retract upwards to continue the dissection distally, then track laterally as well
- Once adequate mobilization, place vicryl traction stitch into prostate (figure-of-8) and use 4th arm to grasp stitch for more traction on prostate
- Continue dissection circumferentially, can bipolar detrusor prior to cutting through to minimize bleeding
- Tip: use combination of bipolar and suction to retract in opposite directions so scissors can cut, alternate blunt dissection and spot cautery
- Cut through urethra (identify with catheter) and move specimen out of bladder, assess for residual adenoma
- Obtain hemostasis mainly with bipolar, can irrigate to assess for active bleeding
- Use 3-0 V-loc suture to bring mucosa into prostatic fossa (usually start at 3/9 o'clock), place deep capsular bite then take bite through detrusor to edge of mucosa (pulls mucosa down into fossa)
- Place floseal into prostatic fossa and place new 3-way catheter and inflate balloon to 15mL, compress fossa for hemostasis
- Cut traction stitch, close bladder mucosa with running V-loc (run up to down if midline, or two stitches at opposite corners if transverse)
- Prior to closure, suction out floseal and inflate balloon to 30mL
- Test bladder after closing inner layer with 120mL, then start CBI
- Close second layer (detrusor + serosa) with running V-loc
- Place drain through 4th port, place into Pouch of Douglas
- Undock robot, remove ports under direct visualization
- Enlarge camera or assist port to extract specimen then close with #1 non-looped PDS, then close all ports (4-0 monocryl) and suture in drain (2-0 nylon)
Postop plan
- Leave foley for 3-7d, no need for cystogram prior to removal
References
- Helo, S., C. Welliver, and K. McVary. "Minimally Invasive and Endoscope Management of Benign Prostatic Hyperplasia." Campbell-Walsh Urology 12 (2020).