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Keywords:

  • BPH;
  • enucleation of BPH;
  • robot-assisted;
  • prostatic adenoma

Introduction

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Specific Equipment/Materials
  5. Surgical Steps
  6. Postoperative Care
  7. From Surgeon to Surgeon
  8. Troubleshooting
  9. References

BPH is the most common prostatic disease in ageing men. If symptoms and/or clinical signs, e.g. residual urine, retention, UTIs, bladder stones and upper tract dilatation, are encountered and do not respond to medical therapy, surgical deobstruction is the therapy of choice.

With the perfection of TURP, the surgical techniques of open retropubic transcapsular enucleation of BPH [1, 2] and suprapubic transvesical enucleation of BPH [3, 4] were more and more restricted to treatment of large adenomas (>80 g) while TURP has become the standard for treating most cases.

With the advent of holmium laser enucleation of BPH [5], there has been a revival of the concept of enucleation of BPH. In comparative studies, open retropubic enucleation of BPH continues to serve as the reference standard, to which other techniques, e.g. holmium laser enucleation, are compared [6].

Laparoscopic prostate enucleation was first published in 2002 by Mariano et al [7] and a series of 17 patients was reported in 2005 by Sotelo et al [8].

Robot-assisted laparoscopic transcapsular enucleation of BPH (Millin procedure) was recently described by Asimakopoulas et al [9]. We herein describe our surgical technique of robot-assisted laparoscopic transperitoneal–transvesical enucleation of BPH (Hryntschak procedure), which was developed by Mihir Desai and Inderbir Gill from the University of Southern California, Los Angeles.

Planning and Preparation

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Specific Equipment/Materials
  5. Surgical Steps
  6. Postoperative Care
  7. From Surgeon to Surgeon
  8. Troubleshooting
  9. References

Robot-assisted transvesical enucleation of BPH is indicated for treating patients with a large prostatic adenoma (>80 g) with and without accompanying pathology, e.g. bladder stones. However, it is also applicable to smaller glands, where our preference continues to be TURP.

When there is infected urine and in cases with bladder stones, the urine must be sterilised preoperatively by a regimen of adequate antibiotic treatment. In all other cases, antibiotic prophylaxis is begun at surgery with a third-generation cephalosporin.

Specific Equipment/Materials

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Specific Equipment/Materials
  5. Surgical Steps
  6. Postoperative Care
  7. From Surgeon to Surgeon
  8. Troubleshooting
  9. References
  • da Vinci S/SiTM system;
  • 0 ° binocular telescope;
  • Robotic instruments: monopolar scissors, bipolar grasper (Maryland), ProGraspTM grasper, two large needle holders;
  • Instruments for the assistant: long suction/irrigation device (diameter 5 mm, length 45 cm Porges ElefantTM suction device, Coloplast, Denmark), laparoscopic grasper, laparoscopic scissors;
  • Trocars: 3 × 8 mm robotic trocars, 2 × 12 mm trocars, 1 × 5 mm trocar;
  • Retrieval bag;
  • Suture material:
    • 4/0 monofilament polydioxanone suture with a straight needle for stay sutures with a medium–large (green) nonabsorbable polymer Hem-o-lokTM clip above a knot at the end;
    • 0/0 monofilament polyglytone rapidly absorbable suture for ‘trigonization’ sutures between the posterior bladder neck and the urethral stump (15 cm);
    • 2/0 V-Loc 90 glycomer absorbable suture for bladder closure;
    • 2/0 monofilament poly-p-dioxanone absorbable suture on a HR 26 needle for closure of the bladder peritoneum (20 cm) with a medium–large (green) nonabsorbable polymer Hem-o-lok clip above a knot at the end;
  • Clips: medium–large (green) nonabsorbable polymer Hem-o-lok clips;
  • Endoclose (Carter-Thomason device);
  • Robotic patient support system (Sampli Ind., Brakel, Belgium)
  • 20/22 F transurethral balloon irrigation catheter with an elbowed tip (e.g. Coudé or Tiemann catheter)

Surgical Steps

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Specific Equipment/Materials
  5. Surgical Steps
  6. Postoperative Care
  7. From Surgeon to Surgeon
  8. Troubleshooting
  9. References

Figure 1

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Specific patient positioning and surgical team.

The patient is placed supine with the table flexed at the level of the hips. The legs are slightly abducted to allow for docking of the da Vinci surgical cart between the legs of the patient. The patient's legs are padded and securely fixed to the table. The patient rests on his shoulders on a specially designed soft cushioned pillow to prevent nerve compression injuries at the shoulder girdle. The patient's abdomen and genitals are scrubbed, and a transurethral balloon catheter is inserted. The assistant sits on the right side and the scrub nurse on the left side of the patient. Flat screen monitors are placed on both sides of the patient.

Figure 2

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Port placement.

The camera port (12 mm) is placed in a midline supra-umbilical position. Two robotic ports (8 mm) are placed pararectally on the left and on the right side, ≈10 cm lateral and slightly more caudal to the camera port. A 5-mm assistant port (for suction/irrigation) is placed midway between the camera port and the right robotic port. A 12-mm assistant port is placed ≈3 cm from the right iliac crest and slightly caudal to the right robotic port. This port allows introduction of needles and clip appliers. An 8-mm robotic port for the fourth arm is introduced on the left side in the corresponding position to the 12-mm assistant port on the right side. The resulting arrangement of ports reveals a semi-circular shape.

Figure 3

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After establishing the pneumoperitoneum with a Veress needle, the 12-mm optic trocar is introduced and the abdomen is inspected. When the other ports have been inserted, the table is set into an extreme Trendelenburg position and the surgical robotic cart is docked to the ports. Generally, the Maryland bipolar forceps are used with the left hand and the monopolar scissors with the right hand, as would be the case in open surgery for a right-handed surgeon. In a four-arm setting, which we use routinely, the ProGrasp forceps are used in the fourth arm on the lower left side.

The peritoneum of the bladder is incised longitudinally in the midline without any prior bladder mobilisation.

Figure 4

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The bladder is opened through a longitudinal incision in the midline over a distance of about 5–7 cm. The indwelling balloon catheter is grasped by the ProGrasp forceps. The 4/0 polydioxanone stay sutures using a straight needle and a medium–large (green) Hem-o-lok clip at the end above a knot are placed as stay sutures inside-out through the bladder wall and inside-out through the abdominal wall. These stay sutures serve for retraction of the margins of the bladder opening, the tension of which can be adjusted externally with the help of some mosquito clamps.

Figure 5

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After identification of both ureteric orifices, the bladder mucosa is circumcised with the monopolar scissors around the bladder neck. If there is an intravesically intruding medial prostatic lobe, for identification of the ureteric orifices (arrows), it is elevated with the Prograsp forceps on the fourth arm.

Figure 6

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The ProGrasp forceps continue to pull the BPH ventrally and cephalad into the bladder. The plane between the bladder neck fibres/prostatic capsule and the BPH is developed by opening the Maryland forceps for spreading the tissue and blunt dissection, and by using the monopolar scissors for coagulation and cutting of the adhesions. (Arrows at the ureteric orifices.)

Figure 7

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During further pulling of the BPH with the ProGrasp cephalad and into the bladder, the process of blunt and sharp dissection of the adenoma from the prostatic capsule is continued circumferentially. Again, connective tissue is bluntly dissected, coagulated and cut. Generally, there is minimal bleeding. With help of the long suction and irrigation device, bleeds from the prostatic capsule can be identified and coagulated with the bipolar Maryland forceps.

Figure 8

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The process of enucleation of the BPH from the prostatic capsule is extended towards the apex of the prostate. At this stage, the transurethral catheter should be reinserted for ease of identification of the intraprostatic urethra. By extending the preparation around the very most distal aspects of the apical BPH, the intraprostatic urethra is readily identified. It is easier accomplished to preserve a longer stump, as in open surgical enucleation of BPH, by now redirecting the dissection cephalad along the urethral stump (arrows). Apical dissection of the BPH can be exerted to an extent, which includes the paracollicular portions of BPH without endangering the integrity of the continence mechanism.

Figure 9

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The urethral stump is transected and further dissection of the subtrigonal BPH is directed cephalad. The suction/irrigation device may be used for elevation of the ventral aspects of the prostatic fossa.

Figure 10

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The completely enucleated BPH is placed in a laparoscopic retrieval bag. If there are any bladder stones, they may be harvested in the same retrieval bag or depending on number and size of stones in a second separate retrieval bag.

Figure 11

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The prostatic fossa is irrigated with the suction/irrigation device and careful punctual coagulation of remaining bleeders is performed with the bipolar Maryland forceps.

Figure 12

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The urethral stump, which generally is dorsally somewhat longer than ventrally, is re-approximated to the bladder neck with rapidly absorbable 0/0 polyglytone sutures at the 5-o'clock (shown) and 7-o'clock positions. (Arrows: ureteral orifices.)

Figure 13

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Final aspect of the prostatic fossa after ‘trigonization’ by the 5-o'clock and 7-o'clock sutures with the urethral stump.

Figure 14

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All-layer bladder closure with a non-locked 2/0 running V-Loc suture.

Figure 15

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Peritoneal closure with a 2/0 poly-p-dioxanone locked running suture with a medium–large (green) Hem-o-lok clip at the end above a knot (suture length 20 cm).

Postoperative Care

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Specific Equipment/Materials
  5. Surgical Steps
  6. Postoperative Care
  7. From Surgeon to Surgeon
  8. Troubleshooting
  9. References

On the day of the procedure the patient is kept on a liquid diet. A third-generation cephalosporin and non-opiate analgesics are administered with i.v. fluids. Thrombosis prophylaxis is administered as s.c. low-molecular heparin derivatives.

The bladder is continuously irrigated with saline through the three-way transurethral irrigation catheter. The flow of irrigation fluid and the period over which this irrigation is administered is adjusted according to the colour of the irrigate. Generally, irrigation is required for no longer than 1 day.

On the first postoperative day the patient receives a laxative. Regular diet is offered from the first postoperative day. The patient is encouraged to ambulate from the first day.

The paravesical drain is removed after 1–3 days depending on the amount of fluid drained.

A radiographic cystogram is taken on the fifth postoperative day to exclude extravasation. At this time, generally the transurethral catheter is removed and residual urine is checked after voiding by transabdominal ultrasonography.

From Surgeon to Surgeon

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Specific Equipment/Materials
  5. Surgical Steps
  6. Postoperative Care
  7. From Surgeon to Surgeon
  8. Troubleshooting
  9. References

Things to Make Life Easier

For placing the patient in an extreme Trendelenburg position during the procedure, adequate cushioning and specifically adequate support of the shoulder girdle is of utmost importance. Alternatively, the patient can be placed on a vacuum device as used for trauma patients, which models its shape to the body contours.

As a rather small bladder opening is used for the procedure, the robotic telescope must be inserted into the bladder. The fourth robotic arm, the suction/irrigation device of the assistant and the grasper of the assistant, all must be used at different steps of the procedure for retraction either of the bladder opening or the bladder neck/prostatic capsule to ensure adequate vision for dissection within the prostatic fossa.

Haemostasis can be done very precisely by bipolar coagulation or at the bladder neck with ‘figure-of-eight’ sutures using rapidly absorbable polyglytone monofilament sutures.

Troubleshooting

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Specific Equipment/Materials
  5. Surgical Steps
  6. Postoperative Care
  7. From Surgeon to Surgeon
  8. Troubleshooting
  9. References

If intraoperative bleeding is more than expected, the pressure of the pneumoperitoneum may be elevated temporarily to 15–20 cmH2O to allow better vision for punctual haemostasis. Generous use of irrigation is recommended in these circumstances rather than continuous suction, which lowers the pressure of the pneumoperitoneum and increases venous bleeding.

If after enucleation of a very large gland, the distance between the urethral stump and the posterior bladder neck is too wide to approximate these structures by the 5-o'clock and 7-o'clock sutures (‘trigonization’), the bladder neck sutures should be used for haemostasis only and the urethral stump should be attached wherever it reaches up in the prostatic capsule by a separate suture.

Further closure of the bladder neck using 0/0 monofilament polyglytone rapidly absorbable sutures is possible as in open transvesical enucleation of BPH but generally not required.

If insertion of the transurethral catheter is difficult, the problem usually arises in the area between the bulb of the urethra and the external sphincter. Use of a catheter with an elbowed tip (e.g. Coudé or Tiemann catheter) is recommended rather than a straight-tip Foley catheter.

If postoperatively increased fluid collection from the perivesical drain is encountered, creatinine in the fluid should be checked. If the creatinine level is serum-equivalent, the intraperitoneal drain may be removed even with fluid amounts of >300 mL/day. If the creatinine level is elevated above serum in the fluid, transurethral catheter drainage must be continued until the bladder is sealed.

If the bladder irrigation fluid is postoperatively bloodier than expected, tranexamic acid should be used both systemically and in the irrigation fluid. Tension on the catheter to pull the balloon against the bladder neck or blocking the balloon of the transurethral catheter in the prostatic fossa must be avoided. Generally, bleeding with the robot-assisted laparoscopic procedure has been minimal and no major bleeding problems have been encountered in our series.

References

  1. Top of page
  2. Introduction
  3. Planning and Preparation
  4. Specific Equipment/Materials
  5. Surgical Steps
  6. Postoperative Care
  7. From Surgeon to Surgeon
  8. Troubleshooting
  9. References