Robotic Simple Prostatectomy
Preop workup
- Prior BPH surgery: no reported difference in outcomes (per Garbens 2022)
Technique
- Positioning: supine, 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 at midline, assist port lateral and superior to camera, robot ports in horizontal line across abdomen with one port on the assist side and two ports on the contralateral side
- 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 transverse arch-shaped bladder incision
- Keith needles can be placed through abdominal wall then through bladder wall to aid in retraction, but not required
- 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, consider placing 0 vicryl 6in traction stitch into prostate (figure-of-8) and use 4th arm to grasp stitch for more traction on prostate (more helpful for median lobes)
- 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 (double-armed) to "re-trigonalize" - start at trigone, bring bladder mucosa to urethra and run both sides to meet anteriorly, take bites only of urethral tissue/capsule and bladder mucosa (more mobile)
- Place floseal into prostatic fossa and place new 3-way catheter and inflate balloon to 30mL, compress fossa for hemostasis
- Close bladder mucosa with running V-loc (run up to down if midline, or two stitches at opposite corners if transverse)
- Test bladder after closing inner layer with 120-150mL, then start CBI
- Close second layer (detrusor + serosa) with running V-loc
- 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)
Postop plan
- Labs: can check PACU/AM labs to monitor for bleeding and electrolyte abnormalities
- Diet: consider clear liquids POD#0, otherwise regular diet starting POD#0-1
- Activity: encourage ambulation from POD#0, no strenuous lifting (> 15-20lbs) for 6wk postop
- Leave foley for 3-7d, no need for cystogram prior to removal
References
- Garbens, Alaina, et al. "Evaluating surgical outcomes of robot assisted simple prostatectomy in the retreatment setting." Urology 170 (2022): 111-116.
- Helo, S., C. Welliver, and K. McVary. "Minimally Invasive and Endoscope Management of Benign Prostatic Hyperplasia." Campbell-Walsh Urology 12 (2020).