V02-10: Robot-assisted Simple Prostatectomy: Illustration of a Simplified Extraperitoneal, Transcapsular Technique
Robot-assisted simple prostatectomy (RASP) performed with the extraperitoneal (EP) technique (EP-RASP) minimizes the risk of bowel injury, particularly when bowel adhesions are expected with entry in the transperitoneal space. However, there is a perception of its technical difficulty owing to the limited space that can be expanded within the space of Retzius. In this video, we describe the step-by-step approach of our EP-RASP technique.
From January 2010 to July 2018, 33 consecutive patients who had undergone EP-RASP were identified from our institutional database. Procedures were performed as described in the accompanying video. A 3-cm para-umbilical incision is carried down to the anterior rectus sheath, in which a 1-cm incision is made. The underlying rectus muscle is pushed laterally, with entry into the EP space. Using a balloon dilator and a blunt-tipped trocar, the space of Retzius is further developed to allow placement of additional trocars. A transverse capsulotomy, approximately 2cm from the bladder neck, is performed a la Millin&[prime]s. Prostate adenoma is resected circumferentially. After ensuring hemostasis, the posterior bladder neck is sutured to the prostatic fossa, with subsequent closure of the capsulotomy. A 22Fr, 3-way Foley catheter is placed. A drain is left in the retropubic space. Patient is discharged within 1-2 days with the catheter in situ, which is then removed 10 days later.
Of the 33 patients, median values were: Age , ASA , Charlson Comorbidity Index , BMI [28.5]. 8 (24.2%) patients had prior abdominal surgeries. 25 (75.8%) patients were catheter-dependent. Adjunctive procedures were: Cystolithotomy , Umbilical hernia repair , Ureteroscopy . Median: Operative time [178mins], Estimated blood loss (EBL) [200ml], Hemoglobin change [2.8g/dL] and Hematocrit change [9%]; only 1 patient (3.0%) required one unit transfusion. Median length of stay (LOS) was 2 days. Clavien-Dindo complications were: 0 , I , II , IIIa , IIIb , IV and V . Median resected prostate weight was 122g. Incidental prostate cancer was found in 3 (9%); one patient required radiotherapy. No patients were catheter-dependent post-operatively; mean post-void residual was 29ml (range 0 to 250ml).
EP-RASP is a safe and efficacious technique for the management of large adenomas, particularly when it is preferable not to enter the peritoneal cavity.