Tricks of the trade: robotic assisted laparoscopic prostatectomy

15 June 2011

A well-known consequence of early diagnosis of prostate cancer is the downward stage migration of the disease, with younger and healthier men being diagnosed with clinically localised cancer. Particularly in these cases, it is essential to provide excellent functional outcomes beyond a mandatory oncological outcome. In this regard, the introduction of robotic surgery to the field of urology has added new perspectives.

The data from mature series of RARP seem to show encouraging results both in the recovery of urinary control and sexual activity; additionally, in a selected case study of a single expert surgeon, up to 86% of patients were free from cancer and had regained complete urinary continence and erectile efficiency sufficient for sexual intercourse one year after robot assisted radical prostatectomy.

We believe that these excellent results can be, at least in part, explained by the increasing surgical experience and the consequent development of technical refinements during RARP. We present here some of these technical modifications.

Athermal early retrograde release of NVB
The conventional approach to nerve sparing during laparoscopic and robotic prostatectomy has been from the prostate base to apex (antegrade). However, the NVB is closely and complexly related to the base of the prostate, which might be at risk of inadvertent trauma during an antegrade approach to nerve sparing. Based on this philosophy, Patel et al. have reported a unique technique whereby the NVBs are approached in a retrograde fashion (from apex to base).

Full, incremental and non nerve sparing RARP
The use of the technique described above allows for a very precise control of the prostatic pedicle and preservation of the neurovascular bundle along its entire length. However, in patients with high-risk disease the likelihood of positive surgical margins after a full nerve-sparing approach can be increased. On the other hand, the complete excision of the bundles may compromise the functional outcomes; in such cases a partial or incremental nerve-sparing approach can be adopted, dissecting the NVB 3 to 5 mm apart from the prostatic capsule while avoiding complete excision of the bundle.

Urinary continence
Urinary incontinence after radical prostatectomy is one of the main points of concern for the patient and the physician. However, objective evaluation of continence outcomes after RP remains stalled by the lack of standardisation among series. Most studies used no validated institutional questionnaires and the outcomes were assessed by an open interview. According to data from the European Association of Urology urinary incontinence after radical prostatectomy can be estimated around 7.7%.

In recent years, several technical modifications aiming to improve recovery of urinary continence after RP have been described. While some authors focused their attention on the so-called proximal zone (such as bladder neck preservation techniques and bladder neck intussusception) many other authors have proposed technical modifications in the dissection and reconstruction of the urethral sphincter complex, such as the preservation of the puboprostatic ligaments, the anterior suspension of the urethral sphincter complex and the posterior reconstruction of the rhabdosphincter. These two latter techniques have been initially proposed by Walsh and Rocco respectively, and subsequently adapted by Patel for the robotic setting.

The anterior suspension stitch
In 1998 Walsh described a manoeuvre consisting of passing a suture through the DVC, then through the perichondrium of the pubic symphysis in a reverse direction. The suture is tied, suspending the DVC. According to the author, this manoeuvre can help control the venous bleeding and can provide a recapitulation of the puboprostatic ligaments, supporting the striated sphincter.

Patel et al, have recently described a similar technique of periurethral suspension stitch during RARP. The stitch is passed from right to left between the urethra and DVC, and then through the periostium on the pubic bone.

The posterior reconstruction of the rhabdosphincter
The technique of posterior reconstruction of the rhabdosphincter was originally described by Rocco and colleagues. These authors illustrated the asymmetrical conformation the rhabdosphincter, showing that the anterolateral walls are thicker compared to the posterior wall, which is composed mainly by connective tissue. The contraction of the sphincter occurs primarily in the anterolateral walls which move towards the less muscular and more rigid posterior wall; this posterior segment acts, therefore, as a fulcrum for an effective sphincteric contration. The effects of RP on the sphincteric complex include: retraction and shortening of the sphincter, loss of the posterior support and distal sliding of the rhabdosphincter. Based on these principles, Rocco et al described a two-layered reconstruction of the posterior segment of the rabdosphincter during open and laparoscopic RP aiming to restore the urethral length and reposition the sphincteric complex in the anatomical position in the pelvic floor.

Coelho et al recently proposed a further modification of the second layer of the posterior reconstruction, consisting of a direct approximation of the posterior bladder neck to the initial reconstructed layer of posterior rhabdosphincter and posterior urethra.

Conclusions

The introduction of any innovative surgical procedure is associated with a time period when the surgeons develop the knowledge and skills required to perform the procedure with safety and efficiency. Therefore, the development of technical modifications and surgical refinements are inevitable with increasing RARP experience, explaining the role of surgical volume in ultimately improving the outcomes. During our ongoing learning experience, we have developed several technical modifications which currently allow us to perform the procedure with improved functional outcomes without compromising cancer control.

Full report, illustrations and references were published in the May 2011 issue of EUT.

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