Authors: René Sotelo, Rafael Clavijo, Robert De Andrade, Oswaldo Carmona, Octavio Almanzar, Roberto Garza, Golena Fernández, Juan Castro, Camilo Guidelman
Technique: We develop a novel intra fascial technique of robotic simple prostatectomy wherein a complete prostatectomy is performed, while preserving the pubo- prostatic ligaments, peri prostatic fascia and seminal vesicles. The bladder is dropped from the abdominal wall to enter the space of Retzius where the anterior prostate surface is de-fatted. The lateral prostate pedicles are controlled with 2.0 poliglactyn hemostatic suture. A back-bledding suture (2.0 monofilament PDS) is placed to control the anterior prostatic veins, this stitch also serves as a retraction suture to facilitate prostate dissection. Visceral endo-pelvic fascia is incised ventrally, media to the pubo-prostatic ligaments, high alone the lateral prostate surface for early release bilateral neurovascular bundles. This fascial incision is carried towards the prostate apex in a direction deep to the dorsal venous complex. Dorsal venous complex is transected and suture-ligated (3-0Vicryl). The urethra is dissected and transected as far proximally within the anterior prostate notch as possible to maximize urethral length. Careful sharp and blunt dissection of the neurovascular bundle and contiguous visceral endopelvic fascia is performed with robotic scissors in a retrograde manner. A horizontal cystotomy incision is created at the bladder neck and deepened over the prostate lobes until the prostate stroma is identified. Seminals vesicles are identified and transected at the prostate base. Any perforating blood vessels are controlled with 4.0 Vicryl stitches or PK device. Remnats of the seminal vesicles and vas deferens are closed with an overrunning suture of 3.0 vicryl. Two separate suture are used for the vesico-urethral anastomosis in a running fashion over a 20 Fr Foley catheter and checked for water-tightness.
Advantages: Reduce blood loss. Eliminate the need for postoperative bladder irrigation. Eliminate the risk of residual or future prostate cancer, without interrupting potency or continence.
Results: Removes approximately only 50% of the gland compare to over the 80% removal using the open approach. Preserving the pubo-prostatic ligaments, peri prostatic fascia and seminal vesicles. The max urine flow increased by 169.42%. The prostate specific antigen PSA decreased by 96.55%. All patients were completely continent within one month.
Conclusion: Robotic Intra –Fascial Simple Prosctactetomy appears to be a feasible procedure in select patients with obstructive large volume prostatomegaly. The entire prostate tissue is removed without compromising continence and potency, mirroring open surgery.