Since the introduction of robot-assisted radical prostatectomy (RALP), robotics has become increasingly more commonplace in the armamentarium of the urologic surgeon. Robotic utilization has exploded across surgical disciplines well beyond the fields of urology and prostate surgery. The literature detailing technical steps, comparison of large surgical series, and even robotically focused randomized control trials are available for review. RALP, the first robot-assisted surgical procedure to achieve widespread use, has recently become the primary approach for the surgical management of localized prostate cancer. As a result, surgeons are constantly trying to refine and improve upon current technical aspects of the operation. Recent areas of published modifications include bladder neck anastomosis and reconstruction, bladder drainage, nerve sparing approaches and techniques, and perioperative and postoperative management including penile rehabilitation. In this review, we summarize recent advances in perioperative management and surgical technique for RALP. 1. Introduction Prostate cancer is the most common visceral malignancy diagnosed in American men. The American Cancer Society estimates 241,740 new diagnoses of prostate cancer [1]. It remains the second most common cause of cancer death in American men [1]. Although controversies remain over ideal diagnostic and treatment strategies for prostate cancer, complete removal of the prostate remains the gold standard in the surgical management of localized disease. Hugh Hampton Young first described the perineal prostatectomy over 100 years ago in 1905 [2]. Subsequently, the first retropubic radical prostatectomy (RRP) was performed by Millin in 1947 [3]. Anatomic studies in the 1970s and early 1980s led to improved appreciation of periprostatic features (dorsal venous complex, endopelvic fascia, autonomic innervation, and striated sphincter) to decrease morbidity of surgery and improve overall outcomes [4, 5]. More recently, in 1997, Schuessler et al. described the first LRP reporting the feasibility of technique despite its association with long operative times [6]. Since that time, numerous European and US centers continued to improve and refine technical aspects of the laparoscopic approach [7, 8]. Several robotic systems were introduced around the turn of the century. The da Vinci system (Intuitive Surgical Inc, CA, USA) was first introduced in 1999. Following a merger with Computer Motion Inc. (AESOP and ZEUS systems) in 2003, Intuitive Surgical has become the sole producer of robotic surgical
References
[1]
American Cancer Society, Facts and Figures, American Cancer Society, Atlanta, Ga, USA, 2012.
[2]
H. Young, “The early diagnosis and radical cure of carcinoma of the prostate: being a study of 40 cases and presentations of a radical operation which was carried out in 4 cases,” Bulletin of the Johns Hopkins Hospital, vol. 16, p. 315, 1905.
[3]
T. Millin, Retropubic Urinary Surgery, Livingstone, London, UK, 1947.
[4]
P. Walsh, “Anatomic radical prostatectomy: evolution of the surgical technique,” Journal of Urology, vol. 160, no. 6, pp. 2418–2424, 1998.
[5]
F. J. Bianco Jr., P. T. Scardino, and J. A. Eastham, “Radical prostatectomy: long-term cancer control and recovery of sexual and urinary function (‘trifecta’),” Urology, vol. 66, supplement 5, pp. 83–94, 2005.
[6]
W. W. Schuessler, P. G. Schulam, R. V. Clayman, and L. R. Kavoussi, “Laparoscopic radical prostatectomy: initial short-term experience,” Urology, vol. 50, no. 6, pp. 854–857, 1997.
[7]
B. Guillonneau, X. Cathelineau, E. Barret, F. Rozet, and G. Vallancien, “Laparoscopic radical prostatectomy: technical and early oncological assessment of 40 operations,” European Urology, vol. 36, no. 1, pp. 14–20, 1999.
[8]
K. Touijer, K. Kuroiwa, J. W. Saranchuk et al., “Quality improvement in laparoscopic radical prostatectomy for pT2 prostate cancer: impact of video documentation review on positive surgical margin,” Journal of Urology, vol. 173, no. 3, pp. 765–768, 2005.
[9]
D. R. Yates, C. Vaessen, and M. Roupret, “From Leonardo to da Vinci: the history of robot-assisted surgery in urology,” BJU International, vol. 108, no. 11, pp. 1708–1714, 2011.
[10]
C. C. Abbou, A. Hoznek, L. Salomon et al., “Laparoscopic radical prostatectomy with a remote controlled robot,” Journal of Urology, vol. 165, no. 6, part 1, pp. 1964–1966, 2001.
[11]
J. Binder and W. Kramer, “Robotically-assisted laparoscopic radical prostatectomy,” BJU International, vol. 87, no. 4, pp. 408–410, 2001.
[12]
M. P. Freire, W. W. Choi, Y. Lei, F. Carvas, and J. C. Hu, “Overcoming the learning curve for robotic-assisted laparoscopic radical prostatectomy,” Urologic Clinics of North America, vol. 37, no. 1, pp. 37–47, 2010.
[13]
G. Katz and R. Rodriguez, “Changes in continence and health-related quality of life after curative treatment and watchful waiting of prostate cancer,” Urology, vol. 69, no. 6, pp. 1157–1160, 2007.
[14]
M. J？nler, O. S. Nielsen, and H. Wolf, “Urinary symptoms,potency, and quality of life in patients with localized prostate cancer followed up with deferred treatment,” Urology, vol. 52, no. 6, pp. 1055–1063, 1998.
[15]
C. Selli, P. De Antoni, U. Moro, A. Macchiarella, G. Giannarini, and A. Crisci, “Role of bladder neck preservation in urinary continence following radical retropubic prostatectomy,” Scandinavian Journal of Urology and Nephrology, vol. 38, no. 1, pp. 32–37, 2004.
[16]
C. Deliveliotis, V. Protogerou, E. Alargof, and J. Varkarakis, “Radical prostatectomy: bladder neck preservation and puboprostatic ligament sparing—effects on continence and positive margins,” Urology, vol. 60, no. 5, pp. 855–858, 2002.
[17]
P. C. Walsh and P. Marschke, “Intussusception of the reconstructed bladder neck leads to earlier continence after radical prostatectomy,” Urology, vol. 59, no. 6, pp. 934–938, 2002.
[18]
J. L. Jorion, “Rectus fascial sling suspension of the vesicourethral anastomosis after radical prostatectomy,” Journal of Urology, vol. 157, no. 3, pp. 926–928, 1997.
[19]
F. Rocco, F. Gadda, P. Acquati et al., “Personal research: reconstruction of the urethral striated sphincter,” Archivio Italiano di Urologia, Andrologia, vol. 73, no. 3, pp. 127–137, 2001.
[20]
M. A. Campenni, J. D. Harmon, P. C. Ginsberg, and R. C. Harkaway, “Improved continence after radical retropubic prostatectomy using two pubo-urethral suspension stitches,” Urologia Internationalis, vol. 68, no. 2, pp. 109–112, 2002.
[21]
V. R. Patel, R. F. Coelho, K. J. Palmer, and B. Rocco, “Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes,” European Urology, vol. 56, no. 3, pp. 472–478, 2009.
[22]
M. Menon, F. Muhletaler, M. Campos, and J. O. Peabody, “Assessment of early continence after reconstruction of the periprostatic tissues in patients undergoing computer assisted (Robotic) prostatectomy: results of a 2 group parallel randomized controlled trial,” Journal of Urology, vol. 180, no. 3, pp. 1018–1023, 2008.
[23]
J. D. Sammon, F. Muhletaler, J. O. Peabody, M. Diaz-Insua, R. Satyanaryana, and M. Menon, “Long-term functional urinary outcomes comparing single- vs double-layer urethrovesical anastomosis: two-year follow-up of a two-group parallel randomized controlled trial,” Urology, vol. 76, no. 5, pp. 1102–1107, 2010.
[24]
D. E. Sutherland, B. Linder, A. M. Guzman et al., “Posterior rhabdosphincter reconstruction during robotic assisted radical prostatectomy: results from a phase II randomized clinical trial,” Journal of Urology, vol. 185, no. 4, pp. 1262–1267, 2011.
[25]
N. Joshi, W. de Blok, E. van Muilekom, and H. van der Poel, “Impact of posterior musculofascial reconstruction on early continence after robot-assisted laparoscopic radical prostatectomy: results of a prospective parallel group trial,” European Urology, vol. 58, no. 1, pp. 84–89, 2010.
[26]
J. Sammon, T. Kim, Q. Trinh et al., “Anastomosis during robot-assisted radical prostatectomy: randomized controlled trial comparing barbed and standard monofilament suture,” Urology, vol. 78, no. 3, pp. 572–579, 2011.
[27]
D. Kaushik, K. Clay, S. G. Hossain, E. Park, C. A. Nelson, and C. A. Lagrange, “Effect of robotic manipulation on unidirectional barbed suture integrity: evaluation of tensile strength and sliding force,” Journal of Endourology, vol. 26, no. 6, pp. 711–715, 2012.
[28]
A. D. Asimakopoulos, C. Pereira Fraga, F. Annino, P. Pasqualetti, A. A. Calado, and C. Mugnier, “Randomized comparison between laparoscopic and robot-assisted nerve-sparing radical prostatectomy,” Journal of Sexual Medicine, vol. 8, no. 5, pp. 1503–1512, 2011.
[29]
D. S. Finley, K. Osann, A. Chang, R. Santos, D. Skarecky, and T. E. Ahlering, “Hypothermic robotic radical prostatectomy: impact on continence,” Journal of Endourology, vol. 23, no. 9, pp. 1443–1450, 2009.
[30]
L. P. Msezane, W. Reynolds, O. N. Gofrit, A. L. Shalhav, G. P. Zagaja, and K. C. Zorn, “Bladder neck contracture after robot-assisted laparoscopic radical prostatectomy: evaluation of the incidence, risk factors, and impact on urinary function,” Journal of Endourology, vol. 22, no. 2, pp. 377–383, 2008.
[31]
L. S. Krane, M. Bhandari, J. O. Peabody, and M. Menon, “Impact of percutaneous suprapubic tube drainage on patient discomfort after radical prostatectomy,” European Urology, vol. 56, no. 2, pp. 325–331, 2009.
[32]
J. D. Sammon, Q. Trinh, S. Sukumar et al., “Long-term follow-up of patients undergoing percutaneous suprapubic tube drainage after robot-assisted radical prostatectomy (RARP),” BJU International, vol. 110, no. 4, pp. 580–585, 2012.
[33]
A. Tewari, S. Rao, and A. Mandhani, “Catheter-less robotic radical prostatectomy using a custom-made synchronous anastomotic splint and vesical urinary diversion device: report of the initial series and perioperative outcomes,” BJU International, vol. 102, no. 8, pp. 1000–1004, 2008.
[34]
P. Walsh, “Radical prostatectomy for localized prostate cancer provides durable cancer control with excellent quality of life: a structured debate,” Journal of Urology, vol. 163, no. 6, pp. 1802–1807, 2000.
[35]
P. Walsh and P. Donker, “Impotence following radical prostatectomy: insight into etiology and prevention. 1982,” Journal of Urology, vol. 167, no. 2, pp. 1005–1010, 2002.
[36]
D. M. Quinlan, J. Epstein, B. S. Carter, and P. C. Walsh, “Sexual function following radical prostatectomy: influence of preservation of neurovascular bundles,” Journal of Urology, vol. 145, no. 5, pp. 998–1002, 1991.
[37]
F. Rabbani, A. Stapleton, M. W. Kattan, T. M. Wheeler, and P. T. Scardino, “Factors predicting recovery of erections after radical prostatectomy,” Journal of Urology, vol. 164, no. 6, pp. 1929–1934, 2000.
[38]
Y. D. Dubbelman, G. R. Dohle, and F. H. Schr？der, “Sexual function before and after radical retropubic prostatectomy: a systematic review of prognostic indicators for a successful outcome,” European Urology, vol. 50, no. 4, pp. 711–720, 2006.
[39]
W. J. Catalona, G. Carvalhal, D. E. Mager, and D. S. Smith, “Potency, continence and complication rates in 1,870 consecutive radical retropubic prostatectomies,” Journal of Urology, vol. 162, no. 2, pp. 433–438, 1999.
[40]
P. C. Walsh, P. Marschke, D. Ricker, and A. L. Burnett, “Use of intraoperative video documentation to improve sexual function after radical retropubic prostatectomy,” Urology, vol. 55, no. 1, pp. 62–67, 2000.
[41]
M. Menon, A. Shrivastava, S. Kaul et al., “Vattikuti institute prostatectomy: contemporary technique and analysis of results,” European Urology, vol. 51, no. 3, pp. 648–658, 2007.
[42]
V. R. Patel, R. Thaly, and K. Shah, “Robotic radical prostatectomy: outcomes of 500 cases,” BJU International, vol. 99, no. 5, pp. 1109–1112, 2007.
[43]
K. C. Zorn, O. Gofrit, M. A. Orvieto, A. A. Mikhail, G. P. Zagaja, and A. L. Shalhav, “Robotic-assisted laparoscopic prostatectomy: functional and pathologic outcomes with interfascial nerve preservation,” European Urology, vol. 51, no. 3, pp. 755–763, 2007.
[44]
M. Menon, A. Tewari, J. Peabody et al., “Vattikuti Institute prostatectomy: technique,” Journal of Urology, vol. 169, no. 6, pp. 2289–2292, 2003.
[45]
M. Menon, A. Shrivastava, M. Bhandari, R. Satyanarayana, S. Siva, and P. K. Agarwal, “Vattikuti institute prostatectomy: technical modifications in 2009,” European Urology, vol. 56, no. 1, pp. 89–96, 2009.
[46]
A. Tewari, J. O. Peabody, M. Fischer et al., “An operative and anatomic study to help in nerve sparing during laparoscopic and robotic radical prostatectomy,” European Urology, vol. 43, no. 5, pp. 444–454, 2003.
[47]
A. J. Costello, M. Brooks, and O. J. Cole, “Anatomical studies of the neurovascular bundle and cavernosal nerves,” BJU International, vol. 94, no. 7, pp. 1071–1076, 2004.
[48]
K. Kiyoshima, A. Yokomizo, T. Yoshida et al., “Anatomical features of periprostatic tissue and its surroundings: a histological analysis of 79 radical retropubic prostatectomy specimens,” Japanese Journal of Clinical Oncology, vol. 34, no. 8, pp. 463–468, 2004.
[49]
C. Eichelberg, A. Erbersdobler, U. Michl et al., “Nerve distribution along the prostatic capsule,” European Urology, vol. 51, no. 1, pp. 105–111, 2007.
[50]
A. Tewari, A. Takenaka, E. Mtui et al., “The proximal neurovascular plate and the tri-zonal neural architecture around the prostate gland: importance in the athermal robotic technique of nerve-sparing prostatectomy,” BJU International, vol. 98, no. 2, pp. 314–323, 2006.
[51]
A. Srivastava, S. Grover, P. Sooriakumaran, G. Tan, A. Takenaka, and A. K. Tewari, “Neuroanatomic basis for traction-free preservation of the neural hammock during athermal robotic radical prostatectomy,” Current Opinion in Urology, vol. 21, no. 1, pp. 49–59, 2011.
[52]
A. K. Tewari, A. Srivastava, M. W. Huang et al., “Anatomical grades of nerve sparing: a risk-stratified approach to neural-hammock sparing during robot-assisted radical prostatectomy (RARP),” BJU International, vol. 108, no. 6, part 2, pp. 984–992, 2011.
[53]
K. J. Kowalczyk, A. C. Huang, N. D. Hevelone et al., “Stepwise approach for nerve sparing without countertraction during robot-assisted radical prostatectomy: technique and outcomes,” European Urology, vol. 60, no. 3, pp. 536–547, 2011.
[54]
T. A. Masterson, A. M. Serio, J. P. Mulhall, A. J. Vickers, and J. A. Eastham, “Modified technique for neurovascular bundle preservation during radical prostatectomy: association between technique and recovery of erectile function,” BJU International, vol. 101, no. 10, pp. 1217–1222, 2008.
[55]
A. Mattei, R. Naspro, F. Annino, D. Burke, R. Guida Jr., and R. Gaston, “Tension and energy-free robotic-assisted laparoscopic radical prostatectomy with interfascial dissection of the neurovascular bundles,” European Urology, vol. 52, no. 3, pp. 687–695, 2007.
[56]
A. Mandhani, P. J. Dorsey Jr., R. Ramanathan et al., “Real time monitoring of temperature changes in neurovascular bundles during robotic radical prostatectomy: thermal map for nerve-sparing radical prostatectomy,” Journal of Endourology, vol. 22, no. 10, pp. 2313–2317, 2008.
[57]
F. Khan, E. Rodriguez, D. S. Finley, D. W. Skarecky, and T. E. Ahlering, “Spread of thermal energy and heat sinks: implications for nerve-sparing robotic prostatectomy,” Journal of Endourology, vol. 21, no. 10, pp. 1195–1198, 2007.
[58]
T. E. Ahlering, E. Rodriguez, and D. W. Skarecky, “Overcoming obstacles: nerve-sparing issues in radical prostatectomy,” Journal of Endourology, vol. 22, no. 4, pp. 745–749, 2008.
[59]
G. W. Chien, A. A. Mikhail, M. A. Orvieto et al., “Modified clipless antegrade nerve preservation in robotic-assisted laparoscopic radical prostatectomy with validated sexual function evaluation,” Urology, vol. 66, no. 2, pp. 419–423, 2005.
[60]
I. S. Gill, O. Ukimura, M. Rubinstein et al., “Lateral pedicle control during laparoscopic radical prostatectomy: refined technique,” Urology, vol. 65, no. 1, pp. 23–27, 2005.
[61]
F. P. Secin, T. Jiborn, A. S. Bjartell et al., “Multi-institutional study of symptomatic deep venous thrombosis and pulmonary embolism in prostate cancer patients undergoing laparoscopic or robot-assisted laparoscopic radical prostatectomy,” European Urology, vol. 53, no. 1, pp. 134–145, 2008.
[62]
J. B. Forrest, J. Q. Clemens, P. Finamore et al., “AUA best practice statement for the prevention of deep vein thrombosis in patients undergoing urologic surgery. Urologic laparoscopic and/or robotically assisted urologic laparoscopic procedures,” Journal of Urology, vol. 181, no. 3, pp. 1170–1177, 2009.
[63]
J. Schmitges, Q. Trinh, M. Sun et al., “Venous thromboembolism after radical prostatectomy: the effect of surgical caseload,” BJU International, vol. 110, no. 6, pp. 828–833, 2012.
[64]
A. Cestari, N. M. Buffi, E. Scapaticci et al., “Simplifying patient positioning and port placement during robotic-assisted laparoscopic prostatectomy,” European Urology, vol. 57, no. 3, pp. 530–533, 2010.
[65]
G. Koc, N. Tazeh, F. N. Joudi, H. N. Winfield, C. R. Tracy, and J. A. Brown, “Lower extremity neuropathies after robot-assisted laparoscopic prostatectomy on a split-leg table,” Journal of Endourology, vol. 26, no. 8, pp. 1026–1029, 2012.
[66]
M. Belkin, R. D. Brown, J. G. Wright, W. W. LaMorte, and R. W. Hobson II, “A new quantitative spectrophotometric assay of ischemia-reperfusion injury in skeletal muscle,” American Journal of Surgery, vol. 156, no. 2, pp. 83–86, 1988.
[67]
I. M. Anusionwu and E. J. Wright, “Compartment syndrome after positioning in lithotomy: what a urologist needs to know,” BJU International, vol. 108, no. 4, pp. 477–478, 2011.
[68]
R. Keene, J. M. Froelich, J. C. Milbrandt, and O. B. Idusuyi, “Bilateral gluteal compartment syndrome following robotic-assisted prostatectomy,” Orthopedics, vol. 33, no. 11, p. 852, 2010.
[69]
S. Sharma, H. L. Kim, and J. L. Mohler, “Routine pelvic drainage not required after open or robotic radical prostatectomy,” Urology, vol. 69, no. 2, pp. 330–333, 2007.
[70]
D. Canes, M. S. Cohen, and I. A. Tuerk, “Laparoscopic radical prostatectomy: omitting a pelvic drain,” International Braz J Urol, vol. 34, no. 2, pp. 151–158, 2008.
[71]
A. Fuller, A. Fernandez, and S. E. Pautler, “Incisional hernia after robot-assisted radical prostatectomy-predisposing factors in a prospective cohort of 250 cases,” Journal of Endourology, vol. 25, no. 6, pp. 1021–1024, 2011.
[72]
B. J. Leibl, C. Schmedt, J. Schwarz, K. Kraft, and R. Bittner, “Laparoscopic surgery complications associated with trocar tip design: review of literature and own results,” Journal of Laparoendoscopic and Advanced Surgical Techniques A, vol. 9, no. 2, pp. 135–140, 1999.
[73]
N. Kadar, H. Reich, C. Y. Liu, G. F. Manko, and R. Gimpelson, “Incisional hernias after major laparoscopic gynecologic procedures,” American Journal of Obstetrics and Gynecology, vol. 168, no. 5, pp. 1493–1495, 1993.
[74]
S. Bhoyrul, J. Payne, B. Steffes, L. Swanstrom, and L. W. Way, “A randomized prospective study of radially expanding trocars in laparoscopic surgery,” Journal of Gastrointestinal Surgery, vol. 4, no. 4, pp. 392–397, 2000.
[75]
S. Beck, D. Skarecky, K. Osann, R. Juarez, and T. E. Ahlering, “Transverse versus vertical camera port incision in robotic radical prostatectomy: effect on incisional hernias and cosmesis,” Urology, vol. 78, no. 3, pp. 586–590, 2011.
[76]
S. R. Brown and P. B. Goodfellow, “Transverse verses midline incisions for abdominal surgery,” Cochrane Database of Systematic Reviews, vol. 19, no. 4, Article ID CD005199, 2005.
[77]
T. C. Regan, R. M. Mordkin, N. L. Constantinople, I. J. Spence, and S. W. Dejter Jr., “Incidence of inguinal hernias following radical retropubic prostatectomy,” Urology, vol. 47, no. 4, pp. 536–537, 1996.
[78]
F. Rabbani, L. Yunis, K. Touijer, and M. S. Brady, “Predictors of inguinal hernia after radical prostatectomy,” Urology, vol. 77, no. 2, pp. 391–395, 2011.
[79]
J. Stranne, J. Hugosson, and P. Lodding, “Inguinal hernia is a common complication in lower midline incision surgery,” Hernia, vol. 11, no. 3, pp. 247–252, 2007.
[80]
J. H. Ku, C. W. Jeong, Y. H. Park, M. C. Cho, C. Kwak, and H. H. Kim, “Nerve-sparing procedure in radical prostatectomy: a risk factor for hernia repair following open retropubic, pure laparoscopic and robot-assisted laparoscopic procedures,” Scandinavian Journal of Urology and Nephrology, vol. 45, no. 3, pp. 164–170, 2011.
[81]
G. Haber, M. White, R. Autorino et al., “Novel robotic da vinci instruments for laparoendoscopic single-site surgery,” Urology, vol. 76, no. 6, pp. 1279–1282, 2010.
[82]
M. A. White, R. Autorino, G. Spana, S. Hillyer, R. J. Stein, and J. H. Kaouk, “Robotic laparoendoscopic single site urological surgery: analysis of 50 consecutive cases,” Journal of Urology, vol. 187, no. 5, pp. 1696–1701, 2012.
[83]
M. A. White, G. Haber, R. Autorino et al., “Robotic laparoendoscopic single-site radical prostatectomy: technique and early outcomes,” European Urology, vol. 58, no. 4, pp. 544–550, 2010.
[84]
N. S. van den Berg, F. W. B. van Leeuwen, and H. G. van der Poel, “Fluorescence guidance in urologic surgery,” Current Opinion in Urology, vol. 22, no. 2, pp. 109–120, 2012.
[85]
C. von Bodman, K. Matsushita, C. Savage et al., “Recovery of urinary function after radical prostatectomy: predictors of urinary function on preoperative prostate magnetic resonance imaging,” Journal of Urology, vol. 187, no. 3, pp. 945–950, 2012.
[86]
F. Rocco, L. Carmignani, P. Acquati et al., “Restoration of posterior aspect of rhabdosphincter shortens continence time after radical retropubic prostatectomy,” Journal of Urology, vol. 175, no. 6, pp. 2201–2206, 2006.
[87]
R. F. Coelho, S. Chauhan, M. A. Orvieto et al., “Influence of modified posterior reconstruction of the rhabdosphincter on early recovery of continence and anastomotic leakage rates after robot-assisted radical prostatectomy,” European Urology, vol. 59, no. 1, pp. 72–80, 2011.
[88]
X. Hurtes, M. Rouprêt, C. Vaessen et al., “Anterior suspension combined with posterior reconstruction during robot-assisted laparoscopic prostatectomy improves early return of urinary continence: a prospective randomized multicentre trial,” BJU International, vol. 110, no. 6, pp. 875–883, 2012.
