Abstract
Introduction:
We present a video of a robotic radical prostatectomy (RobRP) using a retrograde approach, in a manner similar to the open radical retropubic prostatectomy, and unlike the standard antegrade RobRP. First reported in 2008, 1 this approach has the advantage of enabling early identification and, potentially, protection of the neurovascular bundle (NVB) at the prostatic apex. Moreover, the retrograde RobRP adds a sense of familiarity to the urologist accustomed to performing the open retropubic prostatectomy.
Methods:
The bladder is dropped off the anterior abdominal wall. The endopelvic fascia is opened. The dorsal venous complex is controlled using a GS-21 suture, and a back-bleeding stitch is placed. The lateral prostatic fascia is dissected sharply from the base of the prostate to its apex. The NVB is dissected sharply off the prostatic apex. With the NVB secured, the urethra is incised at the prostatic apex, exposing the Foley catheter. The extracorporeal (proximal) end of the Foley catheter is cut and brought into the pelvis. This end is clipped using a hem-o-lok clip. The third robotic arm is used to apply cephalad tension on the proximal end of the Foley catheter, exposing the urethra posteriorly. The urethra is incised posteriorly. The prostate is dissected sharply off the rectum in a retrograde fashion. The prostatic pedicles are controlled using hem-o-lok clips. Dissection is performed along the vesicoprostatic junction anteriorly until the Foley catheter is encountered. The Foley balloon is drained, and the distal end of the Foley catheter is brought out through the vesicoprostatic incision. Gentle caudal traction is applied to both ends of the Foley catheter using the third robotic arm, providing exposure of the vesicoprostatic junction posteriorly. Dissection along the vesicoprostatic junction is continued posteriorly, with exposure and isolation of the vas deferens and seminal vesicles. The vas deferens are cut after application of hem-o-lok clips. Hem-o-lok clips are used to control what remains of the prostatic pedicles. An endocatch bag is used for specimen extraction. The vesicourethral anastomosis is performed using a running 3'0 Maxon suture.
Results:
A unilateral nerve-sparing RobRP is performed using a retrograde approach. To date, 15 cases have been performed using this approach. Patients were initially selected for small prostate size (<50 cc) and low cancer volume.
Conclusions:
Retrograde RobRP is a feasible approach. Our technique closely mimics the traditional open approach. In our hands, the main technical challenge of this approach is the initial dissection of the prostatic apex off the rectum. Further studies and longer follow-up are needed to explore any advantages of the retrograde approach, if any, over the antegrade approach. Careful patient selection is recommended with early experience.
No competing financial interests exist.
Runtime of video: 8 mins 06 secs
This video was presented at the 2010 meeting of the American Urological Association's North Central Section (Chicago, Illinois). A poster version was presented at the 2010 meeting of the Society of Urologic Oncology (Bethesda, Maryland).
