Simple Prostatectomy

Robotic Simple Prostatectomy

Preop workup


  1. Positioning: supine split leg, arms tucked, trendelenberg 23deg
  2. Drape patient and place foley, consider gentamicin instillation (especially if bladder stone or chronic catheter)
  3. Gain access with veress via umbilicus, perform drop test
  4. 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
  5. Dock robot, place arms - bipolar in left, monopolar scissors in right, needle driver in 4th arm
  6. Take down adhesions for better access to bladder
  7. Have assistant fill bladder with 200-250mL, then make midline or transverse bladder incision
  8. 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
  9. Assess bladder, ensure no abnormallities
  10. Make transverse mucosal incision halfway between trigonal ridge and urethral opening
  11. Once prostatic capsular plane is identified, use L arm to retract upwards to continue the dissection distally, then track laterally as well
  12. Once adequate mobilization, place vicryl traction stitch into prostate (figure-of-8) and use 4th arm to grasp stitch for more traction on prostate
  13. Continue dissection circumferentially, can bipolar detrusor prior to cutting through to minimize bleeding
  14. Tip: use combination of bipolar and suction to retract in opposite directions so scissors can cut, alternate blunt dissection and spot cautery
  15. Cut through urethra (identify with catheter) and move specimen out of bladder, assess for residual adenoma
  16. Obtain hemostasis mainly with bipolar, can irrigate to assess for active bleeding
  17. 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)
  18. Place floseal into prostatic fossa and place new 3-way catheter and inflate balloon to 15mL, compress fossa for hemostasis
  19. Cut traction stitch, close bladder mucosa with running V-loc (run up to down if midline, or two stitches at opposite corners if transverse)
  20. Prior to closure, suction out floseal and inflate balloon to 30mL
  21. Test bladder after closing inner layer with 120mL, then start CBI
  22. Close second layer (detrusor + serosa) with running V-loc
  23. Place drain through 4th port, place into Pouch of Douglas
  24. Undock robot, remove ports under direct visualization
  25. 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