Robotic surgery has had the greatest impact on the treatment of localized prostate cancer as Robotic Radical Prostatectomy is the most commonly performed robotic surgical procedure. Although, Robotic Radical Prostatectomy is a relatively new procedure it has grown rapidly in popularity, and is now the most common surgical approach to treat localized prostate cancer. As with open radical prostatectomy, Robotic Radical Prostatectomy involves removal of the entire prostate and seminal vesicles with re-connection of the urethra and bladder. The goal of Robotic Radical Prostatectomy is to remove all of the cancer without disrupting normal urinary, bowel and sexual function. Since the DaVinci Robot provides a magnified field of vision along with enhanced surgical dexterity, Robotic Radical Prostatectomy can usually be performed with less blood loss and fewer side effects than the typical open radical prostectomy. Studies have also suggested that cancer control rates may be improved with robotic surgery.
*Expected outcomes for typical patient (< 65 years of age) based on personal experience and that reported in the literature. Results for individual patients are dependent on age and prostate size as well as other co-morbidities such as obesity, diabetes, heart disease, erectile dysfunction, and history of prior abdominal surgery.
Robotic prostatectomy is performed through 6 “key holes.” Three holes are used to insert the robotic working instruments, 1 hole is used to insert the robotic telescope and the remaining 2 holes are used for the surgical assistant to pass sutures and insert a suction device into the abdomen. The camera port is enlarged slightly after the procedure is completed to allow for the removal of the prostate.
There are a group of large veins called the DVC overlying the urethra and prostate that must be divided in order to remove the prostate. Sutures are placed so that minimal bleeding occurs when the DVC is divided. This maneuver also allows for preservation of maximal urethral length.
The neurovascular bundles (the nerves responsible for erectile function) are gently and meticulously dissected off of the prostate so that they will be out of harms way and not damaged when the prostate is removed.
The primary blood supply for the prostate, are the prostatic pedicles. In the process of removing the prostate the pedicles must be divided on either side of the prostate. The fastest way to accomplish this without significant bleeding is to use electrocauterization. Unfortunately, since the neurovascular bundles run very close to the prostatic pedicles and the use of electrocautery can permanently damage or destroy these that are critical for erections. Therefore, in order to prevent electrocautery damage to the neurovascular bundle, vascular clamps are place on the pedicles and the pedicles are divided using scissors without electrocautery. Bleeding is prevented by placing sutures prior to removing the vascular clamps.
Prior to radical prostatectomy men have 2 urinary sphincters that are responsible for preventing urine leakage. The internal sphincter provides involuntary continence while the external sphincter is the one that you can volitionally control. In other words you are usually unaware when your internal sphincter is working, and when you consciously prevent urine leakage it is the external sphincter that you use. The process of removing the prostate damages the internal sphincter so men rely entirely on their external sphincter for urinary control once their prostates have been removed. It is therefore critical that the external sphincter is well preserved and that a maximal length of urethra is preserved. To accomplish this goal the urethra is carefully dissected out of the prostate before it is divided.
Since the urethra runs through the prostate a segment of it must be cut our in order to remove the entire prostate. Thus after the prostate has been removed with bladder must be reconnected to the urethra. The robotic approach allows for a running suture closure to be performed which usually provides a more water tight closure than when interrupted sutures are used.
During the normal process of prostate removal some of the attachment of the urethra to the urinary control mechanism are released. In the past these attachments have not been reconstructed, but recently it has been determined patients recover urinary control faster when the urethral support is reconstructed. We have devised a simplified technique to reconstruct the urinary control mechanism during robotic prostatectomy called PRASS.
After the prostate and seminal vesicle are freed up they are placed in a plastic bag that is inserted through one of the ports. The bag is then removed through a small incision above the umbilicus. The length of the incision depends on the size of the prostate but is typically less than 2 inches.