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Approaches to prostatecetomy include traditional open surgery, conventional laparoscopic surgery or robot-assisted laparoscopic surgery.
With traditional prostate cancer surgery, the incision is between eight to ten inches long and patients usually remain in the hospital up to five days after surgery.
Minimally invasive, robotic-assisted prostate cancer surgery allows for small incisions, less blood loss and reduced recovery time.
The da Vinci Surgical System is a state-of-the-art surgical robot that gives surgeons more precise views of the prostate and surrounding tissue, as well as greater dexterity. With the robot, the surgeon makes five keyhole openings rather than the single large incision made during a traditional open prostatectomy.
Using the robot, the surgeon removes the prostate and surrounding pelvic lymph nodes (if indicated) through the small openings. Science, Technology and Medicine open access publisher.Publish, read and share novel research. Robot-Assisted Radical ProstatectomyJorn H Witt1, Vahudin Zugor1, Christian Wagner1, Andreas Schutte1 and Apostolos P Labanaris1[1] Department of Urology and Pediatric Urology, Prostate Center Northwest, St. Comparison of robotic-assisted versus retropubic radical prostatectomy performed by a single surgeon.Anticancer Res. Pele says poor health will keep him from opening ceremony of rio olympics, “in my life i’ve had fractures, surgeries, pain, hospital stays, victories and defeats in this march 20, 2015 file photo, brazilian soccer legend pele smiles during a media opportunity at a restaurant in london.
Brazilian soccer legend pele hospitalized in sao paulo, Retired brazilian soccer star pele is back in a hospital in sao paulo, just two months after undergoing surgery on his prostate. Brazilian soccer legend pele is ‘doing fine’ in hospital - Brazilian soccer star pele says he is “doing fine i was simply relocated to a special room within the hospital for privacy purposes only.
Pele says poor health will keep him from opening ceremony of rio olympics - “in my life i’ve had fractures, surgeries, pain, hospital stays, victories and defeats in this march 20, 2015 file photo, brazilian soccer legend pele smiles during a media opportunity at a restaurant in london. Brazilian soccer legend pele hospitalized in sao paulo - Retired brazilian soccer star pele is back in a hospital in sao paulo, just two months after undergoing surgery on his prostate.
Brazil soccer legend pele expected to leave hospital saturday - Sao paulo, may 8 (reuters) - brazilian soccer legend pele is expected to be released on saturday after undergoing prostate surgery, the hospital treating him in sao paulo said on friday. Soccer legend pele admitted to hospital - (cnn) -- brazilian football legend pele's condition has improved, according to a thursday evening statement from a sao paulo hospital.
SOCCERTODAY – Global anti-corruption campaigners at Transparency International elected Peruvian lawyer Jose Ugaz as its new head on Sunday marking a shift from quiet diplomacy in combating fraud and bribery toward more grassroots activism. SOCCERTODAY – Liverpool beat Queens Park Rangers 3-2 on an own goal in the fifth minute of injury time Sunday in the Premier League. SubscribeEnter your email address below to receive updates each time we publish new content. SOCCERTODAY – Stoke came from behind to beat Swansea 2-1 at the Britannia Stadium on Sunday as they climbed to 10th in the English Premier League table. In addition, patients are catheterized for two to three weeks, and there is a risk of side effects. Preservation of the nerves necessary for erections can be an extremely important goal for patients.
Incision of the endopelvic fascia on the left side (EF = endopelvic fascia, PFM = pelvic floor muscle, P = Prostate)8. Seminal vesical preparation on the left side (P = prostate, SV = seminal vesicle, V = Vas)12.
Victory left Mark Hughes’s men level on points with Manchester United, Arsenal and Tottenham Hotspur. A surgeon controls the robot from a remote console that precisely translates his hand, wrist and finger movements to the robotic arms inside the patient while providing a three-dimensional view of those movements. Patients who undergo robotic assisted surgery usually leave the hospital within two days, and some are able to return to normal activities within two weeks after the procedure. IntroductionOver the last decade, robot-assisted radical prostatectomy (RARP) has become a common used surgical procedure for the treatment of prostate cancer (PCa) (35,41).
A nerve-sparing, robotic prostatectomy attempts to preserve these nerves so that the patient may be able to return to his prior erectile function. Nowadays, it is considered the dominant approach to radical prostatectomy (RP) in the United States, in European countries such as Belgium and Sweden as well as in other regions where health economic conditions permit (2,12,29).2.
Picozzi, Comparison of transfusion requirements between open and robotic-assisted laparoscopic radical prostatectomy. Anatomical considerationsThe aim of radical prostatectomy is not only to achieve optimal oncological outcomes but also to preserve the functional aspects of continence and potency (23). Pow-Sang, 2010 Optimizing cancer control and functional outcomes following robotic prostatectomy. Koh, 2007 Anaesthesia for robotic-assisted radical prostatectomy: considerations for laparoscopy in the Trendelenburg position. Hu, 2010 Salvage robotic assisted laparoscopic radical prostatectomy: indications and outcomes. In order to achieve this goal, a profound understanding of the prostate anatomy as well as the pelvic anatomy of the surrounding structures is mandatory. Gill, Comparison of radical prostatectomy techniques: open, laparoscopic and robotic assisted. Jarrard, Robotic-assisted laparoscopic and radical retropubic prostatectomy generate similar positive margin rates in low and intermediate risk patients.
Especially, regarding the functional aspects of continence and potency, the ongoing understanding of the anatomical structures and functional principles will surely lead to new unknown aspects in the future.
Tewari, 2011 Robotic-assisted laparoscopic prostatectomy: a critical analysis of its impact on urinary continence.
Costello, Patient outcomes in the acute recovery phase following robotic-assisted prostate surgery: a prospective study.
Walz et al have described the contemporary anatomy of the prostate and its surrounding structures in detail in 2010 (37).3. Djavan, Open Versus Laparoscopic Versus Robot-Assisted Laparoscopic Prostatectomy: The European and US Experience. Patient selectionPatient selection is the same as for the open or standard laparoscopic variants of RP and has been previously described in evidence-based guidelines. Davis, Transperitoneal versus extraperitoneal robotic-assisted radical prostatectomy: is one better than the other?
Costello, Operative details and oncological and functional outcome of robotic-assisted laparoscopic radical prostatectomy: 400 cases with a minimum of 12 months follow-up. Patients exhibiting a clinically localized disease, an expected negative surgical margin status and an individual life expectancy of more than 10 years are three principle indications to perform RP (10,39).4. Lotan, Cost comparison of robotic, laparoscopic, and open radical prostatectomy for prostate cancer.
Patient preparationBowel preparation is used in most institutions and can be achieved with a mild laxative or rectal preparation by enema (34). Abbou, 2003 Laparoscopic radical prostatectomy: description of the extraperitoneal approach using the da Vinci robotic system. Albala, 2005 Local cost structures and the economics of robot assisted radical prostatectomy.
Tewari, 2010 A cohort study investigating patient expectations and satisfaction outcomes in men undergoing robotic assisted radical prostatectomy.
We prefer preparation of the umbilicus with an alcoholic swab two hours before the procedure and a single shot perioperative antibiotic prophylaxis.5. Wilson, Robotic assisted laparoscopic salvage prostatectomy for radiation resistant prostate cancer.
Coughlin, 2010 Continence, potency and oncological outcomes after robotic-assisted radical prostatectomy: early trifecta results of a high-volume surgeon.
Zorn, Urinary and sexual quality of life 1 year following robotic assisted laparoscopic radical prostatectomy.
Either Verres needle or camera port placement under direct vision in "Hasson technique" is a possible. Laudone, 2010 Does prior abdominal surgery influence outcomes or complications of robotic-assisted laparoscopic radical prostatectomy?
We prefer the Hasson technique with minilaparatomy and camera port placement above or on the left side of the umbilicus under vision. Hu, Anatomic bladder neck preservation during robotic-assisted laparoscopic radical prostatectomy: description of technique and outcomes. Villers, 2010 A critical analysis of the current knowledge of surgical anatomy to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy. Risk factors for anastomotic leakage after preoperative chemoradiation plus low anterior resection and total mesorectal excision remain uncertain. After establishment of the pneumoperitoneum the robotic and assistant ports are placed under direct vision. After prior abdominal surgery a standard laparoscopic or robotic assisted adhesiolysis could be necessary.
Alternatively to the transperitoneal approach, which is being preferred in our institution, an extraperitoneal approach is possible and may be considered in patients with history of e.g. To analyze, the associated risk factors with colorectal anastomosis leakage following preoperative chemo–radiation therapy and low anterior resection with total mesorectal excision for rectal cancer. Cookson, 2010 Comparison of transfusion requirements between open and robotic-assisted laparoscopic radical prostatectomy.

After port placement the patient is placed in a 30 - 40 degrees Trendelenburg position (in case of extraperitoneal approach 20 degrees Trendelenburg is adequate) (28). Univariate analysis was performed as to find the risk factors for colorectal anastomotic leakage. Preparation of cavum recii and ventral aspect of the prostateThe preparation begins in the midline, close to the umbilicus, by incising the peritoneum and releasing the bladder from the ventral abdominal wall. The lateral limit of the preparation is the vas deferens at the crossing above the iliac artery.
The procedure could also be performed with the use of only two robotic instrument arms, but leads to the need for a second assistant to apply the appropriate traction needed to the structures. Multivisceral resection was performed in 11 patients (13.8%), 32 patients (35%) had diverting stoma.
Mean preoperative hemorrhage was 577 ± 381 mL, and 27 patients (24%) received blood transfusion. The periprostatic fat is removed and separately send to the pathologist revealing in some cases lymph nodes.7.
Incision of the endopelvic fasciaThe endopelvic fascia is preparated on both sides and incised, beginning at the base (figure 2). In selected cases, the endopelvic fascia on the side where PCa was not detected through the biopsy, can be left intact.
The incision of the endopelvic fascia allows better vision of the contour of the prostate and is in our hands preferred in most cases. In male patients with rectal adenocarcinoma measuring > 4 cm, treated by preoperative chemoradiotherapy + low anterior resection with total mesorectal excision, a diverting stoma should be performed to avoid major morbidity due to anastomotic leak. For better exposure of the apex during the further preparation and for less bleeding we prefer the suturing of the DVC.9.
Suspension stitchWith the same needle and suture we perform a suspension stitch of the DVC and the pubovesicle ligaments at the periost of the symphysis.
Although the level of evidence for this manoeuvre is not high, it could also be considered as a back up stitch for the DVC.
Then a third stitch is additionally performed close to the bladder neck on the dorsal aspect of the prostate.
Lateral to the bladder neck, veins of the DVC can be indentified and coagulated or clipped.
In most cases, arteries are also present lateral to the bladder neck, which can be as well coagulated or clipped. The Prograsp is in this step of the procedure a very useful device by keeping traction on the bladder in the cranial direction.
After preparation of the bladder neck, the bladder neck is dorsally incised and the catheter elevated ventrally above the symphysis.
Then the dorsal aspect of the bladder neck is incised and the bladder released from the prostate.
Incision of the prostate with median lobe should be excluded by identifying the "drop off" phenomenon (Figure 5).
In case of a bladder neck sparing procedure the orifices usually don't have to be identified. After previous TURP or in patients with a large median lobe, a bladder neck sparing procedure is not possible.
Excision of the bladder up to the orifices in order to achieve a negative surgical margin status is possible. In such cases a consecutively stenting of the ureters and bladder neck reconstruction may be necessary.11.
Preparation of the vas deferens and the seminal vesiclesAfter releasing the bladder from the prostate the vesicoprostatic muscle is identified.
This structure has longitudinal fibers between the region of the trigonum and the prostate ventrally of the level of the vas deferens.
After the incision of the vesicle prostatic muscle the vas deferens can be identified and lifted up with the Prograsp.
From the medial side of the vas deferens the seminal vesicle fascia can be incised and the preparation can be performed to the tips of the seminal vesicles. The vas deferens is then clipped and the seminal vesicle is lifted up in a ventral direction for further preparation. Preparation is performed on both sides laterally and until the base of the prostate is reached. Usually, laterally to the seminal vesicles, an additional small artery can be identified and should be clipped.
Dorsal preparation of the prostateAt this point the left seminal vesicle is pulled in cranioventrally direction with the Prograsp instrument, the same manoeuvre is performed with a French grasper by the assistant on the right side. The dorsal prostatic fascia, also known as the Denonvilliers fascia, is identified and incised. The dorsal prostatic fascia is in most situations a multilayer fascia and especially in low risk cancer situations can be left on the rectum. This technique gives an additional dorsally support which may help to achieve a good early continence situation. Pedicles and neurovascular structures (bundle)At this point the right base of the prostate is lifted with the Prograsp in left lateral direction and the right pedicle is exposed. In cases where a nerve sparing procedure is possible the lateral prostatic fascia is incised ventrally on the prostate and the preparation of the pedicle is performed close to the base of the prostate. Afterwards the neurovascular structures are separated from the prostate by leaving the capsule of the prostate intact. These neurovascular structures are located on the lateral aspect of the prostate, often starting high ventrally and covering the prostate to the dorsal side. In most cases these important structures have the shape of a veil or sheath covering the whole lateral aspect of the prostate. In low risk patients the preparation can be performed close to the prostate in an intrafascial approach (Figure 7), in medium risk patients the preparation can be performed in an interfascial way by leaving the small artery which travels laterodorsally on the prostate on the specimen.
Distance between the anal verge and the distal limit of the tumor was determined by rigid rectoscopy with patients placed in a jackknife position. If an extraprostatic extension is visible or in high risk patients a wide resection of the neurovascular structures should be performed. Colonoscopy was performed in all patients, except in those cases with rectal tumor stenosis. The tableside assistant uses the French grasper to lift the prostate in cranial and lateral direction. Apical dissectionAt this point the prostate remains only fixed on the urethra and the dorsal vascular complex. Patients with distant metastatic disease at the time of pretreatment evaluation were excluded from the study.
Traction is supplied on the prostate in a cranially direction and the dorsal vascular complex is divided. It is of crucial importance to respect the shape of the prostate to preserve as much as possible functional tissue of the urethra and the surrounding structures for good early continence and also late continence results (31). The urethra is exposed ventrally (Figure 8) and laterally on both sides and then incised on the ventrally half of the circumference. The top of the field was placed at midpoint of the body of L5; the lateral borders 1 cm outside the bony pelvis, and the inferior margin at the anal verge.
AnastomosisThe anastomosis can be performed in a single knot technique or as preferred in our hands and most other institutions in a running suture technique.
The first two stitches of the anastomosis are performed at 5 o'clock on the bladder, followed by a stitch at the urethra at 5 o'clock in an inside-out fashion followed by a 6 o'clock stitch outside-in on the bladder, followed by a stitch on the same position at the urethra.
After performing a third stitch on the bladder side at 7 o'clock the bladder is approximated to the urethra.
One hour before surgery, 5,000 IU of subcutaneous heparin was administered and after surgery, every 12 hr, until the patient was fully mobile. In order to achieve a better dorsal stabilization, the dorsal prostatic fascia at the urethral side as well as at the level of the seminal vesicles, is also included during anastomosis (dorsal reconstruction).A dorsal reconstruction can be also performed solitary. Nevertheless, when comparing both techniques we did not find any differences in postoperative continence results as well as strictures or leakage at day 3-5.
An abdominal midline incision was performed, followed by meticulous exploration of the abdominal cavity to search for any possible metastatic disease. The barbed wire can be pulled only in one direction so the approximation of the structures is easier to perform.
The inferior mesenteric artery was ligated at its origin from the aorta, or immediately under the ascending left colic artery. The left colon and splenic flexure were mobilized and the inferior mesenteric vein was ligated below the lower edge of the pancreas to achieve a tension–free anastomosis. A complete mesorectal and pararectal dissection was performed according to the method described by Heald et al.,7 preserving the sympathetic and parasympathetic nerves. At the end of the procedure checking of all possible bleeding sites after reducing the intraabdominal pressure should be performed. If there is any doubt that the anastomosis might be insufficient, a drain should be placed, in all other cases this is not necessary.
Bladder neck reconstructionIn cases where a bladder neck sparing procedure is not possible and the bladder neck is wide, a bladder neck reconstruction is necessary.

This is often the case after TURP and may also be evident in a large median lobe or in advanced cancer situations with the need of a partial bladder excision. Although several techniques of bladder neck reconstruction have been described, it can be performed in a tennis-racket fashion like as in open surgery, ventrally at the end of the anastomosis or, as we prefer, lateral on both sides.
In our opinion the most important goal of the bladder neck reconstruction is not the adjustment of the diameter of the bladder neck to the urethra but the lateralization of the orifices from the anastomosis. Major morbidity was defined as complications requiring surgical treatment, a prolonged hospital stay, and life–threatening complications.
For this reason we prefer a both side lateral bladder neck reconstruction beginning on each lateral aspects of the bladder neck in a continuous fashion with 3-0 polyglyconate monofilic suture. Definition of anastomotic leakage was clinical as the presence of gas, pus or fecal discharge from the drain, pelvic abscess, peritonitis, discharge of pus per rectum, rectovaginal or recto–bladder fistula. Stenting of the uretersIn situations where it is necessary to resect the bladder near to the orifices a stenting of the ureters should be considered. This could be done easily by placing a hydrophilic stiff guide wire into the ureter up to the pyelon and stenting the ureter afterwards with the double J-stent. The stent could be left in place for 2 - 4 weeks or could also be removed after the bladder neck reconstruction has been performed.17. Lymph node dissectionIn situations where lymph node dissection is necessary, the nodes can be removed at the beginning of the procedure, before performing the anastomosis or at the end of the procedure. Sixteen patients (17.4%) had diabetes mellitus, 13 had arterial hypertension and 10 mixed cardiopathy. We usually perform the lymph node dissection after the removing of the prostate, this allows us to use a possible waiting time for frozen sections to perform the lymph node dissection.
The lymph nodes on the external iliac artery, the extern iliac vein and the fossa obturatoria are removed. Clinically, 15 patients (16.3%) had tumor attachments to neighboring pelvic organs, or tumor attachments that were tethered or fixed to the pelvic sidewall. In T3 cancers also an extended lymph node dissection up to the aortic bifurcation could be easily performed in a transperitoneal approach (42).
Care should be taken of the obturator nerve, the ureters and additional obturatic vessels which can be found in many cases.18. Postoperative careAt the end of the procedure we change the transurethral catheter, in selected cases also a suprapubic tube could be inserted and the transurethral catheter can be removed on the first postoperative day. The patient should be mobilized on the day of surgery, on the first postoperative day the time of mobilization should reach 6 hours. Colorectal anastomoses were performed as follows: double stapling technique (n = 47) and single stapling (n = 45). By suturing the skin and with an additional gluing of the skin the patient can take a shower on the first postoperative day.
We usually discharge the patient on day 6 postoperatively after removing of the catheter on day 5. We also perform routinely a cystogram, but with a extravasation rate of lower than 3% a cystogram can also be reserved for special situations. Demographic characteristics of those patients with and without protective colostomy are shown in table 1. Intraoperative complicationsA bowel lesion, especially in patients who have a history of prior surgery, may occur and can be repaired by suturing easaly. Rectal injuries, a typical complication observed in retropubic RP, is very rare with an incidence of less than 0.2% in our series. If this is done no permanent damage of the nerve will occur.At the end of the procedure all possible sites of bleeding (pedicles, dorsal vascular complex, and iliac vessels) should be checked before undocking the robot by reducing the intraperitoneal pressure to zero. The trocars should be removed under direct visions to check for bleeding from trocar sites. Urinary extravasationIf the cystogram shows an extravasation the catheter is left inside for additional 10 days, the catheter can then be removed with or without an additional cystogram (8). If there is a large urinary extravasation with urine in the peritoneal cavity there is a high risk of peritonitis, in these cases a stenting of the ureters and maybe an additional percutaneous drainage of the ureters may be necessary. Postoperative bleedingIn hemodynamic instable patients a postoperative bleeding should be considered and can be evaluated by ultrasound or CT-scan (8). Postoperative subileusIn about 5% of the patients, bowel movement back to normal conditions is delayed (30). This could be avoided by earlier mobilization of the patient, oral fluid intake of about 2.5 litres per day and administering a laxative.
Early port herniaPort-site hernias lead to pain at the site of the hernia and could be diagnosed with a CT-scan (25).
By univariate analysis the significant risk factors were: diabetes mellitus, use of pelvic drainage, and duration of surgery.
Non-recognized bowel injuriesThe clinical symptoms of an unrecognized bowel injury are often milder than in open surgery. Multivariate analysis identified the anastomotic distance from the anal verge within 7 cm as the only risk factor.
ConclusionRobotic assisted radical prostatectomy is a widely used and standardized procedure with excellent oncological and functional results, especially in experienced hands (9,19). However, both series mixed inflammatory with neoplasic disease, colon and rectal anastomoses and were unsuccessful to find the risk pattern for anastomotic leakage in patients who underwent PCRT plus low anterior resection with TME.
The magnification of 10 to 20 times, the excellent degrees of freedom for movement of the instruments and the intuitive handling of the machine are advantages compared with the open or standard laparoscopic approaches (7,27,33,36). Although evidence for better oncological and functional results are still unproven robotic assisted radical prostatectomy (1,3,15,21,26,39) is in many countries now the standard of care for the surgical removal of the prostate (4,6,22).
The only independent risk factor for anastomotic leakage was the anastomosis from the anal verge, 27% in the anastomosis located < 7 cm from the anal verge us. Rullier, et al.,25 reported a series based on 272 anterior resections for rectal cancer performed by the same surgical team. In low anastomosis located within 5 cm of the anal verge, obesity was statistically associated with anastomotic leakage. However, in the former series patients did not receive preoperative radiotherapy and in the later series, only 28 patients received preoperative radiotherapy and 19 received intraoperative radiotherapy, the rate of anastomotic leakage was 14% and 21%, respectively. Their rate of anastomotic leakage was 10.2% and the risk factors found by multivariate analysis were male gender and the presence of a diverting stoma. In the current series, the male gender risk factor was confirmed, but not the presence of diverting stoma.
However, Pakkastie, et al.,11 and the results of the current series showed that proximal diversion did not reduce the anastomotic leakage rate. The authors agree with Wexner, et al.,28 that the presence of a diverting stoma does not decrease the rate of anastomotic leakage, but it does decrease the incidence of disseminated fecal peritonitis. The Stockholm Colorectal Cancer Study Group and the Basingstoke Bowel Cancer Research Project13 reported a comparative study where no differences in anastomotic leakage after low anterior resection between patients treated by preoperative radiotherapy and those treated with TME without preoperative radiotherapy (10% and 9% us. However, high incidence of perineal wound complications was found in the group of patients treated by abdominoperineal resection plus combined treatment (26%) vs. However, no differences with regard to postoperative morbidity and mortality between both groups were reported. Pucciarelli, et al.,29 reported that the administration of PCRT did not affect the postoperative complications after low anterior resections. The incidence of leaks that required surgical intervention was significantly lower in those with a protective stoma (3.6 vs.
In the current series similar results were found diminishing the severity of intra–abdominal sepsis, admission in the intensive care unit and the rate of hospital stay.
In these patients a diverting stoma should be performed as to avoid major morbidity by anastomotic leakage. Modified clearing technique to identify lymph node metastases in post–irradiated surgical specimens from rectal adenocarcinoma. Fleming ID, Cooper JS, Henson DE, Hutter RVP, Kennedy BJ, Murphy GP, Lippimcott–Raven Publishers.
Effect of the introduction of total mesorectal excision for the treatment of rectal cancer. Effect of a surgical training program on outcome of rectal cancer in the county of Stockholm.
Leakage from stapled low anastomosis after total mesorectal excision for carcinoma of the rectum. Risk factors for anastomosis dehiscence after very deep colorectal and coloanal anastomosis. Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients.
Risk factors for anastomotic leakage after low anterior resection with total mesorectal excision. Influence of a defunctioning stoma on leakage rates after low colorectal anastomosis and colonic J pouch–anal anastomosis.
Preoperative combined radiotherapy and chemotherapy for rectal cancer does not affect early postoperative morbidity and mortality in low anterior resection.

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