V6-01: Nerve-sparing transdouglas robotic assisted prostatectomy: complete posterior approach.

Video

Introductions and Objectives
The proposed mechanisms of urinary incontinence after radical prostatectomy include damage of the pelvic floor and urethral sphincter, damage to pelvic floor innervation, and loss of anterior urethral support. Some authors have published the role of preservation of the anterior suspensory apparatus (puboprostatic ligaments, elevador of ani and dorsal vein complex) to contribute to the early recovery of urinary continence after robotic radical prostatectomy. The complete posterior approach is a new micro-invasive surgical approach for the surgery of prostate cancer that enables a complete preservation of the anterior urethral support. The aim of this video is to describe the technique and shows the feasibility and safety of it.

Methods
A Da Vincci Surgical System with 30° optic and basic laparoscopic and robotic instruments are used. A transperitoneal approach is used and an horizontal peritoneal incision at the level of the Douglas pouch is performed. This access allows an easy dissection of the vesiculodeferential complex. A nerve-sparing prostatectomy is performed, hemostasis of the vessels is done without the use of monopolar cautery in order to avoid injuring the nerves and 2 mm clips are used for it. Bladder neck is carefully dissected and a complete preservation of the anterior suspensory apparatus (endopelvic fascia, dorsal vein complex, puboprostatic ligaments and elevetor of ani) is done. An adequate urethral length is preserved in order to performed in a comfortable conditions an anastomosis using a continuous suture.

Results
During 1 month a total of 5 patients underwent this new approach of complete posterior robotic radical prostatectomy. The patients characteristics were mean age 64.9 years; mean PSA: 6.8mg/dl; mean volumen prostate (cc): 27cc; biopsy Gleason: 3+3 in all cases and clinical stage: T1c in 4 cases and T2a in 1 case. The mean time of surgery was 90 min. The mean blood loss was less than 100 cc. No drain was inserted. The Foley urethral catheter was removed 9 days after surgery. Mean follow up was12 months. All patients recovered inmediately the continence and the erectile function was recovered total or partial for all of them during the follow up.

Conclusions
This technique is a minimal invasive approach that appears to helps in early return of continence, reduce blood loss and allows a good way to improve the neurovascular bundles preservation. Patients must be carefully selected. Small prostate volume and localized prostate cancer are the most important selection criteria This technique is safe, time efficient in experienced hands, and effective.

Funding: None