V4-01: Perineal Robot Assisted Laparoscopic Radical Prostatectomy (P-RALP)
VideoIntroductions and Objectives
We aimed to apply Perineal Robot Assisted Laparoscopic Radical Prostatectomy (P-RALP) in a patient with a past surgical history of abdominoperineal resection for ulcerative colitis and laparoscopic bilateral inguinal hernia repair with mesh, making the traditional retropubic approach difficult. The patient was 62 years old, impotent, with a PSA of 3.7ng/mL. Trans-perineal biopsy revealed Gleason 3+4=7 adenocarcinoma of the prostate.
The patient was placed in exaggerated lithotomy position. The incision was made at the apex of a semicircular line (3cm) extending between the two ischial tuberosities. Then we incised central tendon and levator ani muscle attachments in order to reach posterior surface of prostate. Subcutaneous adipose tissue was deepened in order to accommodate single-port placement. The robot approached from the patient’s head and docked. Camera port is placed in more anterior position while the robotic trocars are placed posterolaterally. Once insufflation was achieved we were able to visualize posterior surface of prostate clearly. The lateral lobes of prostate are dissected meticulously; neurovascular bundle and endopelvic fascia is left intact. We were able dissect seminal vesicles totally. The prostatic pedicle is controlled using a harmonic scalpel. The membranous urethra is identified and dissected while maintaining the integrity of the external urinary sphincter. The urethra is incised; a Hemolock clip is then placed on the catheter to keep the balloon inflated, the catheter can then be used as a handle to aid dissection. The apex is dissected however we do not need to transect or even control the dorsal vascular complex. The bladder neck dissection is completed circumferentially. The anastomosis is completed using a similar technique to retropubic approach; however for the perineal approach the bladder neck is in the background while the urethra is in the foreground. Barbed suture is used in a running fashion to complete the anastomosis. Skin and subcutaneous tissues is closed over a drain.
Operation time was 5 hours. Estimated blood loss was 50 ml. Hospital stay was 18 hours. Urethral catheter removed one week after surgery and patient was immediately continent. Final pathology was 3+4=7 Gleason score adenocarcinoma, T3a disease. Prostate weight was 46 gr. Postoperative PSA (45 days after surgery) was