Dr. Samadi
|
Since the original description of the robot-assisted laparoscopic prostatectomy (RALP) technique 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 oncologic principles of open radical retropubic
prostatectomy (RRP) on a robotic platform, 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" technique of nerve sparing, and bladder neck reconstruction. We then describe our current technique.
Dorsal vein complex
Dr. Lavery
|
In the original RALP technique, the DVC was ligated in 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 DVC and urethra,
similar to the technique used in open RRP. However, concerns were raised that this stitch may affect apical 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,
the stitch may catch the yet-to-be-dissected neurovascular bundles and affect potency. The DVC stitch also tends to bulk the
tissue 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 ligation. The DVC is then oversewn following removal
of the specimen. Decreased rates of apical positive surgical margins (J Endourol 2009; 23:123-7; Eur Urol 2007; 51:648-57) and faster recovery of continence (Eur Urol 2009; 55:1377-83) have been demonstrated with this modification.
Opening the EPF/nerve sparing
Gerald L. Andriole, MD
|
Preservation of the lateral EPF may be associated with higher rates of continence 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 bladder neck reconstruction during RALP, as many robotic urologists do not routinely
perform it. The standard of care for open RRP is a tennis-racquet 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.
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