36
❳Hands On❲ Th e l ate st i n u ro lo g i c su rg i c al tech n i q u e s
an d o ffi ce - ba s e d pro ce du r e s
Robot-assisted RP: Recent
technical modifications
This approach, using tested oncologic open RRP principles,
yields favorable continence, potency, and margin rates
David B. Samadi, MD • Hugh J. Lavery, MD
S ince the original description of
the robot-assisted laparoscopic
prostatectomy (RALP) tech-
nique in 2002 (Urology 2002;
60:569-72), several technical
modifications have been reported. These
modifications are primarily designed to
reduce positive surgical margin rates and
improve continence and potency rates.
Our group’s current technique at the
Mount Sinai Medical Center,
as described in this article,
incorporates several of these
advancements. Our goal in
adopting these modifications
is to maintain the tested onco-
logic principles of open radi-
cal retropubic prostatectomy
(RRP) on a robotic platform,
Dr. Samadi incorporating evidence-based
medicine whenever possible.
To this end, we will focus on
three areas of advancement:
the handling of the dorsal
vein complex (DVC) and
endopelvic fascia (EPF), a
“high anterior release” tech-
nique of nerve sparing, and
Dr. Lavery bladder neck reconstruction.
We then describe our current
Dr. Samadi is chief of
robotics and minimally technique.
invasive surgery, and
Dr. Lavery is a robotic Dorsal vein complex
urology fellow at the In the original RALP tech-
Mount Sinai Medical
nique, the DVC was ligated in
Center, New York.
a figure-of-eight fashion early
in the procedure, following
dissection of the prostate from
the EPF lateral to the prostate. The suture
is placed in a notch located between the
Series Editor
Gerald L. Andriole, MD, is professor of surgery and chief,
division of urologic surgery, Washington University School
of Medicine, St. Louis. He is also the director of the Urologic
Research Center at Barnes-Jewish Hospital.
DVC and urethra, similar to the technique
used in open RRP. However, concerns
were raised that this stitch may affect api-
cal margin rates and functional outcomes.
Indeed, this has been a topic of debate since
1998, when Brendler modified his RRP
technique to avoid suture ligature of the
DVC (J Urol 1998; 159:1281-5), although
this modification did not gain widespread
popularity due to the significant blood loss
associated with it.
Urethral or sphincteric muscle fibers
may be inadvertently incorporated into
the stitch, affecting continence. Similarly,
We do not view the robot as a good unto itself, but,
rather, as a tool that permits enhanced anatomic
radical prostatectomy by improving vision and
allowing angles of dissection not possible with open
or straight laparoscopic instruments.
the stitch may catch the yet-to-be-dissected
neurovascular bundles and affect potency.
The DVC stitch also tends to bulk the tis-
sue anterior to the prostate, distorting its
anatomy and making the apical dissection
more difficult, potentially increasing the
rates of positive apical margins.
Several groups have begun advocating
cutting the DVC cold, without prior liga-
tion. The DVC is then oversewn following
removal of the specimen. Decreased rates of
apical positive surgical margins (J Endou-
rol 2009; 23:123-7; Eur Urol 2007; 51:648-
57) and faster recovery of continence (Eur
Urol 2009; 55:1377-83) have been demon-
strated with this modification.
Opening the EPF/nerve sparing
Preservation of the lateral EPF may be
associated with higher rates of continence
NOVEMBER 2009  •  Urology Times
after prostatectomy, due to preservation
of levator ani function (Eur Urol 2009;
55:892-900).
Traditionally, an incision into the lateral
EPF was used to access the DVC for its
ligation. However, the omission of the DVC
stitch permits the avoidance of this step and
any potential damage to the neurovascular
bundles it may entail. Use of a “veil” (Eur
Urol 2007; 51:648-57), “curtain” (Eur Urol
2005; 48:938-45), or “high anterior release”
(J Urol 2008;180:2557-64) technique of
nerve sparing has also been demonstrated
to have beneficial effects on potency.
Bladder neck
reconstruction
Little data exist on
the technique of blad-
der neck reconstruc-
tion during RALP, as
many robotic urolo-
gists do not routinely
perform it. The stan-
dard of care for open
RRP is a tennis-rac-
quet closure, which is our technique. To
date, however, there have been no reports
of tennis-racquet closure being performed
robotically. Our data on this technique have
been submitted for publication.
Mount Sinai technique
In the technique we use at Mount Sinai, we
attempt to recreate the classic open ana-
tomic RRP technique as closely as possible
on the robotic platform. Having completed
fellowship training in both urologic oncol-
ogy and laparoscopy, Dr Samadi’s tech-
nique as described below builds on onco-
logic principles learned with open radical
prostatectomy and transferred to a robotic
approach. We do not view the robot as a
good unto itself, but, rather, as a tool that
permits enhanced anatomic radical prosta-
tectomy by improving vision and allowing
www.urologytimes.com  •  NOVEMBER 2009 37

sected bilaterally and the incision is
carried down to the vasa deferentia.
❳ UT Figure 1 ❲ The space of Retzius is developed
bluntly. Fat on the anterior surface of
the prostate is excised and included
with the permanent prostate speci-
men. This fat is sent for pathologic
analysis after recent findings dem-
onstrated that it occasionally harbors
lymph nodes, which, when positive,
portend poor prognosis (Urology
2007; 70:1000-3).
Step 2: Bladder neck transection.
Once the prostate is exposed, the
bladder neck is identified and the
medial aspect of the bladder neck
Anterior bladder neck dissection. Note preserva- incised with electrocautery until the
tion of lateral endopelvic fascia and dorsal vein Foley catheter is exposed. The cath-
complex. eter is grasped with the fourth robotic
arm and retracted anteriorly. Note that
the endopelvic fascia remains intact at
this point and the DVC is not ligated
ing/EPF incision. Following dissection of bilat-
eral SVs, the SVs are grasped with the fourth
robotic arm, retracted superio-laterally, and
rotated away from the side of nerve sparing (to
the left and counter-clockwise for right-sided
nerve sparing). Minimal traction is thus placed
on the neurovascular bundles (figure 2). It should
Care should be taken to visualize
the ureteric orifices prior to
reconstruction and to avoid their
inclusion in the sutures.
be emphasized that from this point onward, all
dissection and nerve sparing are performed
with blunt dissection, using the curved robotic
scissors. No cautery is used at any point. (In the

❳ UT Figure 2 ❲
Seminal vesicle retraction is performed superio-
medially, not anteriorly. This places less traction on
the neurovascular bundles.
angles of dissection not possible with open or
straight laparoscopic instruments. It should be
emphasized that this is an advanced technique
that should not be performed early in a novice
robotic surgeon’s learning curve.
Since 2003, Dr Samadi has performed more
than 1,600 RALPs, approximately half by this
technique. In the 12 months since the final
modifications were made to this technique in
early 2008, he has performed 421 RALPs. We
are able to achieve continence rates of 97% and
potency rates of 81% at 1 year (in 193 and 169
patients, respectively) while maintaining a 4%
rate of positive surgical margins. This proce-
dure, as described below, can be performed in a
mean operative time of less than 2 hours.
Step 1: Dropping the bladder. The medial
umbilical ligaments are coagulated and tran-
(figure 1). event of significant disease burden prohibitive
Step 3: Posterior bladder neck tran- of nerve sparing, the neurovascular bundle is
sected. The posterior aspect of the excised widely with a standard lateral incision
bladder is now exposed and a median of the endopelvic fascia.)
lobe or TUR defect should be appar- The posterior aspect of the prostate is dis-
ent, if present. (Management of medi- sected bluntly in antegrade fashion for several
an lobes can be quite complex, and is centimeters and the prostatic pedicle is exposed.
outside the scope of this discussion.) The large urethral branches are controlled using
The posterior aspect of the bladder a robotically applied Hem-o-lok clip (figure 3).
neck is transected with electrocautery, Starting at the lateral aspect of the SV, inter-
while keeping in the same plane as the fascial nerve sparing is performed in an ante-
anterior bladder neck dissection. grade fashion from the 5 o’clock to the 2 o’clock
Step 4: Seminal vesicle (SV) dissec- position on the prostate, similar to the “veil” or
tion. Given the proximity of the nervi “curtain” technique. Small capsular branches
erigentes of Walsh to the tips of the of the pedicle are controlled with small metal
seminal vesicles, their dissection clips applied robotically.
should be performed without cautery. Please see ROBOTIC RP, page 38
The vas deferens is dissected
several centimeters distally,
which facilitates the delivery
of the remainder of the SV. Once in the
correct plane and the glistening white
❳ UT Figure 3 ❲
of the vas is exposed, the thin layer of
connective tissue covering the SV is
bluntly dissected posteriorly as the SV
is pulled anteriorly.
After the entirety of the SV has been
exposed, the artery to the SV should
be seen entering laterally, where it is
clipped distally and transected. We
prefer the articulation afforded by the
robotic Hem-o-lok clip applier (Weck
Closure Systems, Research Triangle
Park, NC). Once one SV has been
dissected, it is retracted anteriorly to Posterior dissection and clipping of right pros-
facilitate the dissection of the contra- tatic pedicle. The nerve-sparing plane has been
lateral SV. developed.
Step 5: Posterior dissection/nerve spar-
38
❳Hands On❲ NOVEMBER 2009  •  Urology Times

than 50 mL. Arteries are

often present at the 11 and
❳ UT Figure 4 ❲ ❳ UT Figure 5 ❲ 1 o’clock position, which
can be coagulated with
bipolar cautery if bleed-
ing is excessive. In the rare
instance when bleeding is
excessive, the DVC can be
oversewn in running fash-
ion prior to removal of the
specimen.
Step 7: Bladder neck
reconstruction. The bladder
neck is reconstructed with
a posterior tennis-racquet
closure with a running 2-
Completed right-sided nerve sparing. Lateral endo- Apical dissection after dorsal vein complex is cut 0 polyglactin suture on a
pelvic fascia remains intact and nerves are released cold. Note long urethral stump and excellent visual- CT needle, as described for
high on prostate. ization of apex. open RRP (figure 6). Care
should be taken to visualize
the ureteric orifices prior to
right side and rotated in a clockwise reconstruction and to avoid their inclusion in
fashion to set up the left-sided nerve the sutures. The bladder neck is narrowed to
❳ UT Figure 6 ❲ sparing.
Step 6: DVC/Apical dissection. After
the caliber of an 18F catheter.

both neurovascular bundles have been

spared to the apex, the pneumoperi- Fat on the anterior surface of the
toneum is temporarily increased to
20 mm Hg. The anesthesiologist is prostate occasionally harbors lymph
instructed to carefully monitor end nodes, which when positive portend
tidal CO2.
The DVC and puboprostatic liga- poor prognosis.
ments are cut with cold scissors as
the prostate is retracted superiorly Step 8: Urethrovesical anastomosis. Using the
and rotated anteriorly as in open RRP. technique of van Velthoven, two 3-0 Monocryl
The apex of the prostate, urethra, and sutures on UR-6 needles of different colors are
neurovascular bundles can easily be tied together and run cirumferentially around
Posterior tennis-racquet bladder neck reconstruc- visualized and dissected free (figure the urethro-vesical anastomosis. The exagger-
tion. (All photos courtesy of David B. Samadi, MD, 5). Minimal suction is used during ated curve of the UR needle facilitates accu-
and Hugh J. Lavery, MD) this step to minimize blood loss from rate placement of sutures in the reconstructed
the open DVC. bladder neck. We do not advocate the use of
The urethra is dissected circum- posterior fascial reconstruction prior to the
robo t ic RP ferentially and cut with cold scissors to leave anastomosis because randomized evidence
as long a urethral stump as possible, maintain- has demonstrated its inefficacy (J Urol 2008;
continued from page 37
ing the striated sphincter. After the specimen 180:1018-23).
Once the endopelvic fascia has been released is removed and bagged, the DVC is oversewn
anteriorly for several centimeters at the 2 o’clock with a running 3-0 polyglactin suture on an Conclusion
position, a robotically applied Hem-o-lok clip SH needle, taking care to avoid the dissected Selective adoption of technical advancements
is placed on the lateral fascia parallel with the neurovascular bundles.Arterial and venous promoted in the field of robotic prostatectomy
plane of dissection to control tributaries of the bleeding is easily controlled with this suture, has resulted in a robot-assisted procedure with
DVC. The fascia is then incised with the cold without distorting the anatomy of the urethra excellent oncologic and functional outcomes.
scissors. This proceeds in an antegrade fashion or sphincter. We believe that this procedure is the most
until the apex is dissected and the DVC exposed The pneumoperitoneum is returned to 15 faithful reproduction of an anatomic retropu-
(figure 4). mm Hg as soon as possible. Blood loss for bic prostatectomy yet described for robotic
The fourth robotic arm is then shifted to the this portion of the procedure is rarely more prostatectomy. UT