Robot-Assisted Radical Prostatectomy: Advanced Surgical Techniques

Preface
Contents
Part I: Introduction to RALP
1: A Historical Perspective of RALP
Introduction
Brief History of Radical Prostatectomy
Robotic Surgery Historical Perspective
Major Technical Improvements for RARP Overtime
Single Port Robotic Radical Prostatectomy
Currently Available Platforms for Radical Prostatectomy
Da Vinci XI/DaVinci X
Versius
Revo-i
Senhance (Telelap ALF-X)
Future Perspectives on Robot-Assisted Radical Prostatectomy
Conclusions
References
2: Surgical Anatomy of the Prostate
Muller’s Description of the Neurovascular Bundles and Their Significance 1836
The Walsh Donker Contribution to Understanding of the Neurovascular Bundle Anatomy
The Royal Melbourne Hospital Anatomic Studies of the NVB and Urinary Sphincter 2004–2018
The Anatomy of the Urinary Sphincter and Implications for Radical Prostatectomy and Continence Preservation
Mechanism of Striated Sphincter Contraction
Anatomical Insights Regarding the Modifications in Robotic Surgery Without Evidence of Benefit
Preservation of Urethral Smooth Muscle
Suburethral Plication Stitch (The Rocco Stitch)
Seminal Vesical Sparing Prostatectomy
Summary and Conclusion
References
3: Robotic Training for RALP
Introduction
Simulation Training Tools for Robot Assisted Radical Prostatectomy
Virtual Reality Simulation
Dry Lab Simulation Training
Wet Lab Simulation Training
Assessment and Training
Non-Technical Skills Training
The Future for Simulation Training
Conclusion
References
Part II: Imaging in RALP
4: Magnetic Resonance Imaging in Prostate Cancer
Introduction
Historical Notes
MRI in Prostate Cancer
Prostate MRI
Prostate Anatomy and MRI Semiology
MRI Acquisition Protocol
T2-Weighted Imaging
Diffusion-Weighted Imaging and Apparent Diffusion Coefficient Map
Dynamic Contrast Enhanced Imaging
Prostate MRI Scoring and Reporting
Principles of Prostate MRI Reporting
PI-RADS Category Assignment
Scoring and Reporting of Peripheral Zone Findings
Scoring and Reporting of Transition Zone Findings
Scoring and Reporting of Central Zone and Anterior Fibromuscular Stroma Findings
Reporting Pitfalls in Prostate MRI
Pitfalls Related to Prostate Benign Diseases
Pitfalls Related to Anatomic Variants
Issue to Address and New Strategies
The Novel MRI-Based Pathway for Prostate Cancer Detection
Other Applications of MRI in Prostate Cancer
MRI for Local Staging and Therapy Planning
MRI for Disease Monitoring
Conclusions
References
5: PET/CT for Detection of Biochemical Recurrence Post Radical Prostatectomy
Introduction
Abdominopelvic Contrast-Enhanced Computerized Tomography (CT) Scan/Bone Scan
PET CT
Choline PET/CT
Fluoride PET and Fluciclovine PET/CT
PSMA-PET/CT
Conclusion
References
6: Augmented Reality in RALP
Introduction
3D Reconstruction in Precision Surgery
Augmented Reality RALP
Elastic Augmented Reality RALP
Automatic Augmented Reality RALP
Conclusions
References
Part III: Transperitoneal RALP Anterior Approach
7: The Bladder Neck Management
Introduction
Anatomical Considerations and Landmarks
Anterior Approach to the Bladder Neck
Prostate Defatting
Tips for Bladder Neck Identification
Anterior Incision of the Bladder Neck
Examination of the Bladder Neck
Posterior Incision of the Bladder Neck
Preservation of Bladder Neck
Lateral Approach to the Bladder Neck
Exposition of the “Lateral Triangle”
Dissection to the Seminal Vesicle
Opening of the Bladder Neck
Separation of the Bladder Neck from the Prostate
References
8: Extrafascial (No-Nerve Sparing)
Introduction
Fascia of the Prostate
Endopelvic Fascia
Anterior Periprostatic Fascia
Lateral Periprostatic Fascia
Posterior Prostatic Fascia and Seminal Vesicles Fascia (Denonvilliers’ Fascia)
Prostate Capsule
Neurovascular Bundle
Surgical Technique
Patient Position and Trocar Placement
Extra-Fascial Dissection
Conclusion
References
9: Posterior Approach to Seminal Vesicles
Introduction
Surgical Technique
Robotic System and Port Placement
Seminal Vesicle Exposure
Seminal Vesicle Dissection Via the Posterior Approach
Advantages
Outcomes
Conclusion
References
10: Retrograde Release of Neurovascular Bundles with Preservation of the Dorsal Venous Complex
Introduction
Pelvic Neuroanatomy
Veil of Aphrodite
Clipless Thermal Antegrade Approach
Clipless Athermal Antegrade Approach
The Retrograde Release of the NVB
Dorsal Venous Complex Preservation
Impact on Outcomes
Conclusion
References
11: The Hood Technique for Robotic-Assisted Radical Prostatectomy: Preserving Vital Structures in the Space of Retzius and the Pouch of Douglas
Introduction
The Anatomical and Functional Foundations of Continence
Innervation of the Urethral Sphincter
Support Structures of the Sphincter Complex
The Urethral Sphincter Complex
The Role of the Vesicle Angle in Continence
The Pathophysiology of Post-Radical Prostatectomy Urinary Incontinence (PPI)
The “Hood” Concept
The Hood Surgical Technique
Surgical Steps
Results
Effect of Technique on Urinary Continence (Fig. 11.12)
Conclusion
References
12: Apical Dissection During Trans-Peritoneal, Anterior Robot-Assisted Radical Prostatectomy
Introduction
Anatomy
Surgical Technique
Collar Technique
Conclusions/Discussion
References
Part IV: Intraoperative Assessment of Surgical Margins
13: Intra-operative Assessment of Surgical Margins: NeuroSAFE
Introduction
Preservation of the Peri-prostatic Structures
Avoidance of PSM
Role of Intra-operative Margin Assessment
Intra-operative Frozen Section (IFS): Quality of Evidence
Different Approaches to IFS on the Prostate
Directing IFS by Surgeon Discretion
Directing IFS by Pre-op MRI Discretion
IFS at Multiple Sites
NeuroSAFE Technique
NeuroSAFE Technique: Technical Description
NeuroSAFE Technique: Secondary Resection
NeuroSAFE Technique: Histological Outcomes
Frozen Section Concordance to Final Pathology
NeuroSAFE Technique: PSM Evidence and Secondary Resection
NeuroSAFE Technique: Oncological Outcomes
NeuroSAFE Technique: NVBs and Functional Recovery
NeuroSAFE Technique: Cost and Resources
NeuroSAFE PROOF Trial
Conclusions
References
14: Ex Vivo Fluorescence Confocal Microscopy
Introduction
Device Technical Features
FCM Technology: Historical Background
Current FCM Device Available for Clinical Application on Prostatic Tissue
Prostate Tissue Interpretation
Handling and Preparation of the Specimens
Benign Prostatic Tissue and Benign Prostatic Hyperplasia
Acinar Adenocarcinoma
Periprostatic Components
Current FCM Fields of Applications
Diagnostic Setting
Intra-operative Digital Frozen Sections During Radical Prostatectomy
FCM Learning Curve
Limits
Future FCM Fields of Application
Clinical Applications
Management and External Support Applications
Conclusions
References
Part V: Reconstruction of Continence Mechanisms
15: The Single Knot Running Vesico-Urethral Anastomosis
Introduction
The Single Knot Running Vesico-Urethral Anastomosis Technique
Complications of the Single-Knot Running VUA
Complex Situations
Barbed Sutures
Future Perspectives and Conclusions
References
16: Urethral Suspension
Introduction
Urethral Stitch Suspension
Urethral Sling Suspension
Combination Technique (Anterior Suspension and Posterior Reconstruction)
Complications with Urethral Suspension During RARP
Conclusions/Discussion
References
17: Posterior Reconstruction
Introduction
Anatomical Disruption of Prostatectomy
Posterior Reconstruction Description and Evolution
Impact on Outcomes
Conclusion
References
18: CORPUS: Complete Posterior Reconstruction to Improve Continence After Robotic Prostatectomy
Introduction
Surgical Technique
Results: Preliminary Study
Comment
Conclusion
References
19: Total Anatomical Reconstruction
Introduction
Technical Specifications
Dorsal Venous Complex (DVC)
Pubo-Prostatic Ligaments
Endopelvic Fascia
Bladder Neck
Urinary Sphincter and Urethral Length
Prostate Apex and Neurovascular Bundles
Bladder Neck and Posterior Reconstruction
Anterior Reconstruction
Total Anatomical Reconstruction: Surgical Technique
Demolitive Phase
Patient Positioning and Preliminary Time
Suture of Deep Venous Complex (DVC) and Bladder Neck Incision
Incision of Posterior Denonvilliers’ Fascia and Dissection of Prostatic Apex
Reconstructive Phase
Posterior Reconstruction
Urethro-Vesical Anastomosis
Anterior Reconstruction
Hemostasis, Peritoneal Reconstruction, Drainage, Specimen Extraction
Postoperative Care
Outcomes and Functional Results
RARP with TAR in Previously Treated Prostate
Conclusions
References
Part VI: Transperitoneal RALP Retzius-Sparing Approach
20: Transperitoneal RALP Retzius-Sparing Approach: Bocciardi Technique
Introduction
Surgical Technique
Outcomes
Positive Surgical Margins (PSMs)
Urinary Continence (UC)
Erectile Function (EF)
Complications
Conclusions
References
21: Transperitoneal Robot-Assisted Laparoscopic Radical Prostatectomy Retzius-Sparing Approach: Yonsei Technique
Introduction
Pre-operative Evaluation and Post-operative Medical Management
Patient Positioning, Trocar Insertion and Peritoneal Access
Da Vinci Si Template
Da Vinci Xi Key Differences
Da Vinci SP Key Differences
Revo-I Key Differences
Surgical Technique
Radical Prostatectomy
Pelvic Lymph Node Dissection
Specimen Extraction and Surgical Closure
Outcomes, Pitfalls, and Addressing Complications
Prostate Size
Organ Injury
Bleeding
Conclusion
References
22: Retzius Sparing Robot-Assisted Radical Prostatectomy: Evolution, Technique and Outcomes
Introduction and History
Anatomical Basis for Retzius-Sparing Prostatectomy
Current Technique for RSP
Current Evidence: Summary of Outcomes for Retzius-Sparing Radical Prostatectomy
Functional Outcomes
Urinary Continence
Sexual Function
Oncological Outcomes
Challenges, Limitations and Opportunities
Potentially Beneficial Scenarios
Modifications of the Retzius-Sparing Approach
References
23: UCL Technique
Introduction
UCL Technique of Retzius Sparing Robot Assisted Radical Prostatectomy
Positioning and Port Placement
Posterior Access
Dissection Posterior to the Prostate
Prostatic Pedicles and Lateral Dissection
Bladder Neck and Anterior Dissection
Apex and Urethra
Vesicourethral Anastomosis
Conclusion
References
Part VII: Extraperitoneal RALP
24: Robot-Assisted Radical Prostatectomy: The Extraperitoneal Approach and the Future with Single Port
Introduction
The URMC EP Approach to the RARP
Preoperative and Perioperative Considerations
Operative Procedure
Patient Positioning and Set Up
EP Access and Trocar Placement
Endopelvic Fascia Dissection
Dorsal Vessel Complex Ligation
Bladder Neck Dissection
Vas Deferens and Seminal Vesicle Dissection
Incision of Denonvillier’s Fascia and Posterior Dissection
Securing the Prostatic Pedicle
Neurovascular Bundle Dissection
Apical Dissection
Lymph Node Dissection (LND)
Posterior Reconstruction
Vesicourethral Anastomosis
Drain Placement
Specimen Extraction and Wound Closure
Post-operative Care
Discussion
References
25: The CUF Technique: Extraperitoneal Robot-Assisted Radical Prostatectomy
Introduction
Technique
References
Part VIII: Pelvic Lymph Node Dissection
26: Predictive Models in Prostate Cancer
Introduction
Main Body of the Chapter
Models Predicting the Presence of PCa at Biopsy
Models Predicting Adverse Pathological Features at Final Surgical Specimen
Models Predicting Oncological Outcomes of Candidates to Radical Treatment (Preoperative Setting)
Model Predicting Oncological Outcomes After Radical Prostatectomy (Postoperative Setting)
Conclusion
References
27: Extended Lymphadenectomy Technique
Introduction
Patient Selection
Extent of PLND
Therapeutic Efficacy of ePLND
Technical Aspects of ePLND
Sentinel Node Biopsy
Multi-Port vs. Single-Port Robotic Surgery Platform
Salvage ePLND
MD Anderson Experience and Technique
Impact of ePLND on Perioperative and Postoperative Morbidity
Surgical Strategies for Lymphocele Prevention
References
28: Fluorescence Guided Node Dissection
Introduction
History of Fluorescence
Physics of Fluorescence
Tumor Specific Fluorescent Tracers
Prostate Cancer Specific (Fluorescent) Tracers
Combining Fluorescent Tracers and Radioactive Tracers
Fluorescence Guided Urological Surgery
Conclusions
References
29: Radioguided Surgery in Recurrent Prostate Cancer
Introduction
PSMA PET Refines Indication for SLND
Tracers for PSMA-Radioguided Surgery
Preoperative Work-Flow
Description of Surgical Technique
Complications of SLND
Outcomes of PSMA Radioguided SLND
Future Developments
Conclusion/Discussion
References
Part IX: Techniques to Prevent Lymphocele Formation in RALP
30: Four Point Peritoneal Flap Fixation
Introduction
Lymphocele Following Radical Prostatectomy
Prevention of Lymphoceles
Peritoneal Flap Interposition
Four-Point Peritoneal Flap Fixation
Surgical Principle
Conclusions
References
31: PLEAT: A New Technique for Preventing Lymphoceles After Robotic Prostatectomy and Pelvic Lymph Node Dissection
Introduction
Description of the Technique
Comparative Study [10]
Results [10]
Comment
References
Part X: Perineal RALP
32: Tugcu Bakirkoy Technique
Introduction/Historical Background
Indications and Contraindications
Patient Selection
Surgical Technique
Preoperative Care
Surgical Instruments, Devices, Materials
Patients’ Position
Steps
Step I: Initial Perineal Dissection and Single Port Placement
Step II: Robotic Perineal Radical Prostatectomy
Step III: Bilateral Robotic Pelvic Lymph Node Dissection
Step IV: Vesico-Urethral Anastomosis
Postoperative Care
Conclusion
References
33: Bari Technique for Robotic Radical Perineal Prostatectomy
Introduction
Surgical and Functional Anatomy
Surgical Indications
Robotic System and Instruments
Bari Technique
Patient’s Positioning and Operative Room Disposition
Perineal Dissection and GelPOINT Port Placement
Bari Nerve-Sparing Technique
Vas Deferens and Seminal Vesicles Dissection
Prostate Apex and Membranous Urethra Isolation
Anterior Dissection and Preservation of the Support of the Bladder Neck
Vesicourethral Anastomosis
Pelvic Floor and Skin Closure
Postoperative Management and Follow-Up
Results
Oncological Results
Functional Results
Nerve-Sparing Approach and Erectile Function Recovery
Complications
Conclusion
References
34: Single Port Robotic Perineal Radical Prostatectomy
Introduction
Indications
Description of Technique
Preoperative
Intraoperative
Perineal Access and SP Docking
Posterior Dissection and Seminal Vesical and Vasa Deferentia
Vascular Pedicle and Nerve Sparing
Apical Dissection
Bladder Neck
Pelvic Lymph Node Dissection
Vesicourethral Anastomosis and Closure
Postoperative
Outcomes
Intraoperative and Perioperative
Oncologic
Functional
Complications
Conclusions
References
Part XI: Single-Port RALP
35: Different Access of Single-port Robotic Prostatectomy on da Vinci Si: Changzheng Hospital Technique
Introduction
Transperitoneal
Extraperitoneal
Perineal
Transvesical
Outcomes
Discussion
References
36: Single Port Extraperitoneal Radical Prostatectomy
Introduction
Indications
Description of Technique
Preoperative
Intraoperative
Extraperitoneal Access and SP Docking
Bladder Neck Transection, Seminal Vesicle and Vasa Deferentia Dissection
Ligation of the Prostatic Vascular Pedicles and Nerve Sparing
Apical Attachments and Urethral Division
Vesicourethral Anastomosis, Extraction, and Closure
Postoperative
Outcomes
Intraoperative and Perioperative
Oncologic
Functional
Complications
Conclusions
References
37: UIC Technique
Introduction
History
Available Technology
Patient Selection
Financial Considerations
Generational Difference
Current Surgical Set up
Radical Prostatectomy
Extraperitoneal (See Video)
Intraperitoneal Retzius Sparing (Needs Video)
Post-operative Management
Conclusion
References
38: Fudan Zhongshan Technique: Single-Port Suprapubic Transvesical Robotic Assisted Radical Prostatectomy
Introduction
Patient Selection
Indications and Contraindications
Preoperative Evaluations
Instrumentation
Surgical Technique
Patient Positioning and Port Placement
Circular Incision of the Bladder Neck
Dissection of Vas Deferens and Seminal Vesicles and Separation of Denonvillier’s Fascia
Separation of Lateral Ligaments and Nerve-Sparing
Control of the Dorsal Vein Complex (DVC) and Dissection of the Urethra
Vesico-Urethral Anastomosis
Discussion
Conclusions
References
Part XII: Special Situations in RALP
39: Large Median Lobe: Robot-Assisted Radical Prostatectomy (RARP)
Introduction
Perioperative Results
Management and Prevention
Presurgical Assessment
Intraoperative Management
Conclusion
References
40: Large Volume Gland with Small Pelvis
Introduction
Tips and Tricks in RALP for Vesico-Urethral Anastomosis and Posterior Reconstruction in Cases Involving A Large Prostate Size and/or Narrow Pelvis
RALP, Robotic-Assisted Laparoscopic Prostatectomy
Studies and Outcomes in Narrow Pelvis Cases
Studies and Outcomes in Large Prostate Size Cases
Operation Time, Blood Loss, Transfusion Rates, and Surgical Margin
Biochemical Recurrence (BCR)
Potency and Continence
Postoperative urinary health-related quality of life (HRQOL).
Conclusions
References
41: Robot Assisted Laparoscopic Radical Prostatectomy in Kidney Transplant Recipients
Introduction
Surgical Approaches to Radical Prostatectomy in KTRs
Outcomes Following RALP in KTRs
Perioperative Outcomes
Functional Outcomes
Oncological Outcomes
Graft Outcomes
Authors Take
References
42: Patients with Previous BPH Surgery
Introduction
Effects of BPH Surgery on Prostate
Surgical Outcomes of Prostatectomy in Patients with Previous BPH Surgery
Management
Prevention
Preoperative Assessment
Intraoperative
Postoperative Care
Conclusion
References
43: Salvage Robot-Assisted Radical Prostatectomy
Introduction
Comparing Salvage Options After Focal Therapy Failure
Salvage Robot-Assisted Radical Prostatectomy After Whole Gland Therapy vs. Focal Therapy
Technical Considerations & Recommendations
Post Radiotherapy
Post Brachytherapy
Post HIFU
Post Cryotherapy
Post Electroporation
Conclusion
References
44: Super-Extended Robot Assisted Radical Prostatectomy in Locally Advanced Prostate Cancer
Introduction
Main Body of the Chapter
Surgical Technique for Super-Extended Robot-Assisted Radical Prostatectomy
Technique for Extended and Super-Extended Pelvic Lymph Node Dissection
Postoperative Outcomes
Surgical Outcomes
Functional Outcomes
Oncological Outcomes
The Role of Pelvic Lymph Node Dissection
Conclusion
References
45: Prostatectomy in Oligometastatic Prostate Cancer
Introduction
Defining Oligometastatic Prostate Cancer
Curative Therapy for Oligometastatic Prostate Cancer
Rationale for Local Curative Therapy
Rationale for Metastatic Directed Therapy
Surgical Management of Oligometastatic Prostate Cancer
Surgery for Locally Advanced Disease
Surgery for Oligometastatic-Primary Prostate Cancer
Conclusion
References
46: Inguinal Hernia Repair During Robot-Assisted Radical Prostatectomy
Introduction
Inguinal Hernia Repairing During Radical Prostatectomy
Preoperative Management
Surgical Technique
Postoperative Management
Conclusion
References
47: Robot Assisted Partial Prostatectomy for Anterior Cancer
Introduction
APP Patients Selection
Results
Discussion
Conclusion
References
48: Complications in Robotic-Assisted Laparoscopic Radical Prostatectomy: Prevention and Management
Complications of Patient Positioning
Complications During Port Positioning
Access Complications
Vascular Injuries
Visceral Injuries
Secondary Trocar Placement Complications
Intraoperative Complications
Bowel Injury During Instrument Exchange
Vascular Lesions
Rectal Injury
Obturator Nerve Injury
Urinary Tract Injuries
Complications from Technical Errors and Robotic Malfunction
Electrocautery or Thermal Energy Injuries
Instrument Malfunction
Needle Loss
Final Steps Consideration
Postoperative Complications
Hemorrhage
Urinary Anastomotic Leakage
Port Site Hernia
Stricture and Bladder Neck Contracture
Lymphoceles
Thromboembolic Events
Conclusions
References
Part XIII: Functional Recovery After RALP
49: Functional Recovery After RALP: Erectile Function
Introduction
Pathophysiology of ED After Radical Prostatectomy
Robotic Surgery
Robotic Nerve-Sparing Surgery: Anatomy
Robotic Surgical Techniques to Preserve Sexual Function
Penile Rehabilitation
Vacuum Erection Devices
Intracavernosal Injections
Phosphodiesterase-5 Inhibitors
Sildenafil
Combination Therapy
Other Experimental Therapies for ED
ED Therapy: Prosthesis
Conclusions/Discussion
References
50: Functional Recovery POST-RALP: Continence
Introduction
Pathophysiology of Incontinence After Radical Prostatectomy
Preoperative Setting
Preoperative Preventative Strategies
Intraoperative Setting
Bladder Neck Preservation
Bladder Neck Reconstruction
Nerve-Sparing Approach
Maximal Urethral Length Preservation (MULP)
Endopelvic Fascia Preservation
Retzius-Sparing Approach
Selective Ligature of Dorsal Venous Complex
Pubo-Prostatic Ligament Preservation
Anterior Reconstruction
Posterior Reconstruction
Postoperative Setting
Role of Postoperative Length of Catheterization
Diagnostic Work-Up
Conservative Strategies
Pelvic Floor Muscle Exercise
Pharmacological Treatment
Surgical Treatments
Male Slings
Artificial Urinary Sphincter
Alternative Options
Urethral Bulking Agents
Adjustable Balloons
Intravesical Onabotulinum Toxin A Injections
Conclusions
References
Index