V4-09: Descriptive Technique for Robotic Radical Perineal Prostatectomy Combined With Extended Pelvic Lymph Node Dissection
We aimed to apply extended pelvic lymph node dissection following Robotic Radical Perineal Prostatectomy on a cadaveric model.
The cadaver was placed in exaggerated lithotomy position. The incision was made at the apex of a semicircular line (6cm) extending between the two ischial tuberosities. Then we put a suspension suture on central tendon and passed it towards perineal skin. Subcutaneous adipose tissue was deepened in order to accommodate single-port placement. The robot approached from the head and docked. Central tendon attachments and Denonvillier fascia were dissected and transected in order to reach the apex of the prostate. The prostate and the seminal vesicles are dissected keeping the endopelvic fascia intact. The sulcus between Denonvillier fascia and Levator ani muscle fibers was swept and incised laterally and then the junction of endopelvic fascia and lateral pelvic fascia was reached. We were able to find obturator fossa behind that junction. Once the lymph nodes in the obturator fossa were dissected a respectable view of the external iliac vessels was achieved. Then the extended lymph node dissection was completed bilaterally. The anastomosis is completed with a continuing suture technique using RB-1 needle 4/0 Monocryl suture.
We operated 4 cadavers. The operation time for the first and the fourth cadavers was 6 and 3 hours respectively. We did not puncture the big vessels accidentally. We were able to realize the distal ureters and vas deferens clearly, especially within the last two operations. We noticed two major challenging points. First, the ipsilateral robotic arm was clashing with the ipsilateral pubic arm when we tried to do more lateral dissections around the external iliac vessels. Secondly, the maneuver capability of robotic arms is enough to reach and take the whole lymph nodes out but might not be enough to fix an accidental puncture associated with big vessels.
The major limitation of the radical perineal prostatectomy techniques is the missing lymph node dissection. This cadaver study is encouraging in terms of that missing point as robotic instruments allow surgeon to explore deeper areas with more anatomical details. Further experience is needed to accommodate that technique in real patients but it promises it is not imposible.
Funding: Oktay AKCA received grant from TUBITAK.