AUA2023: REFLECTIONS Surgical Techniques: Robotic Single-port Extraperitoneal Radical Prostatectomy
By: Ahmed Ghazi, MD, FEBU, MHPE, Brady Urological Institute, Johns Hopkins University, Baltimore, Maryland | Posted on: 03 Aug 2023
Robotics in urological surgery has increasingly been adopted due to the advantages over standard laparoscopy. Similarly, a shift toward robotic single-site surgery was observed to further decrease the operative morbidity.1 The da Vinci SP is a robotic platform purpose-built for robotic SP surgery that shares multiple features with prior multiport da Vinci platforms. However, the SP robot includes a redesigned single 25-mm multichannel port accommodating an 8-mm articulating robotic camera and three 6-mm double-jointed articulating robotic instruments, a guidance system that allows the surgeon to know the location and movement of each instrument, 360° anatomical access from a single pivot point, and an extra clutch that gives the option to control the camera and the robotic arms as a single unit or independently.
Additional features and tips will be discussed in the context of an extraperitoneal robotic radical prostatectomy.2 Following anesthesia, the patient is positioned completely supine with only 5-10° Trendelenburg (Video). A single 3-cm longitudinal midline incision is made midway between the umbilicus and pubic symphysis. The abdominal planes are carefully dissected to the anterior rectus fascia, where a 4- to 5-cm staggered fascial incision is made caudal to the skin incision (see Figure). An index finger is introduced under the anterior rectus fascia toward the pubic symphysis to create a space in the preperitoneal cavity using gentle sweeping motions. The balloon dilator is not required for SP extraperitoneal access due to the caudal incision and only a single midline port with smaller working radius. The inner ring of an access port is inserted in the created space, and the “fishbowl” component housing a 25-mm SP short entry guide multichannel cannula is attached to the external ring. An AirSeal tubing is attached to the access port for insufflation (optimal but not mandatory) to a pressure of 12 mm Hg. An additional (plus-1) 8-mm AirSeal assistant port can be placed in a ‘‘sidecar’’ fashion, where the port is inserted into the same skin incision but into a separate fascial incision. The multichannel cannula allows the built-in floating docking to gain the 10-cm clearance, deploying the instruments with the triangulation required. Instruments are introduced in the following orientation: hot monopolar scissors (3 o’clock), hot Maryland bipolar grasper (9 o’clock), articulating camera (12 o’clock), and hot fenestrated bipolar grasper (6 o’clock). Personally, my preference is to have the fenestrated bipolar vs the Cadiere grasper for retracting as it allows interchange of cautery instruments during the procedure. Additional instruments include 2 needle holders and the 5-mm robotic Weck clip applier. The flexible tip of a remotely operated suction irrigation is introduced through the access port and manipulated by the surgeon via a foot pedal. Sutures knotted to the tip of the suction facilitate manipulation of the suction. In cases of no assistance, cautery utilization and meticulous hemostasis help maintain a clear field, limiting the need for continuous suction manipulation.
In this approach, the surgeon lands directly on the prostate rather than dissecting and mobilizing the bladder. The extraperitoneal space is further developed under direct vision via the robotic instruments with care to prevent dropping of the inferior epigastric vessels. The fat overlying the prostate is dissected, and the anterior prostate adequately exposed. The endopelvic fascia is incised and the deep venous complex is ligated with a GS-22 V-Loc suture. The half-circle 27-mm needle helps avoid collisions of closely positioned instruments during suturing. During prostatovesical junction dissection, adequate traction of the bladder is maintained by the fenestrated bipolar grasper at the 6 o’clock position. The prostate was dissected in an antegrade fashion using electrocautery with the camera orientation changed to the 30° down orientation using the adjust feature, activated either by the camera pedal+clockwise rotation of the right master-control or pressing cobra mode on the console touch display. Once the catheter is visible, a Keith straight needle is introduced percutaneously superior to the pubis and passed through the catheter side holes for retracting the prostate upward. The posterior layer of Denonvilliers’ fascia is incised. My preference is to exchange both bipolar instruments with the fenestrated bipolar grasper at 9 o’clock to grasp the vas deferens and seminal vesicles upward, which are dissected en bloc. The SP robot also has a function wherein the instruments can be rotated 180° (around the clock) within the working space to change instrument orientation so that the camera and fenestrated forceps trade positions. The posterior plane is best developed by changing the orientation of the camera to 30° upward. The prostatic pedicles are then clipped with the robotic 5-mm Weck clips using a rotating maneuver during application to improve clip engagement. The neurovascular bundles are dissected off the prostate bluntly if indicated. For optimal traction without instrument collision, frequent changes in the camera control and relocation with continuous advancement of retraction arm are often needed. On the right side, the 9 and 12 o’clock bipolar instruments are interchangeable as the working/retracting arm. The previously ligated dorsal venous complex is divided and the urethra is transected at the prostatic apex. The specimen is retrieved into the “fishbowl” without the need for a specimen bag; it can also be retrieved and inspected if needed. Lymphadenectomy is performed, requiring the translocation feature that moves the entire port and instruments to either side of the pelvic wall. An extended template can also be performed.3 The vesicourethral anastomosis was performed using 2 connected CV-23 V-Loc sutures in a continuous fashion over an 18F silicon catheter. The proximally located wrist of SP instruments compared to multiport instruments limits the ability to throw suture at a full 90° (6 o’clock stitch). The multiple angulation points and the single point of entry reduce the lateral strength, and therefore sutures are better tightened in line to the camera rather than perpendicular. A drain is optional. The skin and fascial incision are closed after removing the access port.
Extraperitoneal single-port robot-assisted radical prostatectomy seems to be a safe and feasible surgical option for the treatment of localized prostate cancer. However, a learning curve could be attributed to the lack of bedside assistant, requiring additional tasks by the surgeon, eg, suctioning and retraction, as well as increased coordination between the instruments and the camera to compensate for a smaller overall field of view due to the shorter working distance between the articulating instruments and camera.
- Bertolo R, Garisto J, Gettman M, Kaouk J. Novel system for robotic single-port surgery: feasibility and state of the art in urology. Eur Urol Focus. 2018;4(5):669-673.
- Ghazi A, Erturk E, Joseph JV. Modifications to facilitate extraperitoneal robot-assisted radical prostatectomy post kidney transplant. JSLS. 2012;16(2):314-319.
- Ghazi A, Scosyrev E, Patel H, Messing EM, Joseph JV. Complications associated with extraperitoneal robot-assisted radical prostatectomy using the standardized martin classification. Urology. 2013;81(2):324-333.