Robot-assisted radical prostatectomy: Recent technical modifications

November 1, 2009

Since the original description of the robot-assisted laparoscopic prostatectomy technique in 2002, several technical modifications have been reported.

Our group's current technique at the Mount Sinai Medical Center, as described in this article, incorporates several of these advancements. Our goal in adopting these modifications is to maintain the tested oncologic principles of open radical retropubic prostatectomy (RRP) on a robotic platform, incorporating evidence-based medicine whenever possible. To this end, we will focus on three areas of advancement: the handling of the dorsal vein complex (DVC) and endopelvic fascia (EPF), a "high anterior release" technique of nerve sparing, and bladder neck reconstruction. We then describe our current technique.

Dorsal vein complex

Urethral or sphincteric muscle fibers may be inadvertently incorporated into the stitch, affecting continence. Similarly, the stitch may catch the yet-to-be-dissected neurovascular bundles and affect potency. The DVC stitch also tends to bulk the tissue anterior to the prostate, distorting its anatomy and making the apical dissection more difficult, potentially increasing the rates of positive apical margins.

Several groups have begun advocating cutting the DVC cold, without prior ligation. The DVC is then oversewn following removal of the specimen. Decreased rates of apical positive surgical margins (J Endourol 2009; 23:123-7; Eur Urol 2007; 51:648-57) and faster recovery of continence (Eur Urol 2009; 55:1377-83) have been demonstrated with this modification.

Opening the EPF/nerve sparing

Traditionally, an incision into the lateral EPF was used to access the DVC for its ligation. However, the omission of the DVC stitch permits the avoidance of this step and any potential damage to the neurovascular bundles it may entail. Use of a "veil" (Eur Urol 2007; 51:648-57), "curtain" (Eur Urol 2005; 48:938-45), or "high anterior release" (J Urol 2008;180:2557-64) technique of nerve sparing has also been demonstrated to have beneficial effects on potency.

Bladder neck reconstruction

Little data exist on the technique of bladder neck reconstruction during RALP, as many robotic urologists do not routinely perform it. The standard of care for open RRP is a tennis-racquet closure, which is our technique. To date, however, there have been no reports of tennis-racquet closure being performed robotically. Our data on this technique have been submitted for publication.