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Falavolti et al. Early vascular control in robotic surgery

INTRODUCTION presented PSA value < 3.5 ng/mL; four patients
(22.2%) presented higher PSA value and underwent
Currently, minimally invasive surgery is the most previous trans-rectal ultrasound guided biopsy that
common surgical approach for symptomatic benign confirmed the diagnosis of benign prostatic hyperplasia.
prostatic hyperplasia (BPH). According to the EAU Uroflowmetry revealed in all patients a peak flow <
(European Association of Urology) guidelines, 10 mL/s and an average flow < 5 mL/s. The median
transurethral resection of the prostate represents prostatic adenoma weight estimated preoperatively
the treatment of choice for men with prostate size < by US was 95 g (range 80-195). Based on these
80 mL. Some patients can be affected by complex characteristics, our patients were classified as affected
[1]
conditions such as large adenoma (> 80 mL) by complex prostatic hyperplasia and were scheduled
associated with moderate-to-severe lower urinary to robot-assisted laparoscopic simple prostatectomy.
tract symptoms (LUTSs) and/or concomitant bladder We collected data about postoperative International
diverticulum. In these cases, the endoscopic approach IPSS evaluation, the duration of surgery, the estimated
should be replaced by more invasive procedures. blood loss, postoperative care and hospitalization.
Open surgeries such as Trans-Vesical or Retropubic Then, we statistically analyzed our results in a linear
Adenomectomies are indicated in case of large regression using the Fisher’s test.
adenoma and/or complex BPH but these techniques
often show massive intraoperative blood loss and Surgical technique
have the risk of blunt dissection particularly in the All patients were placed in supine position and the
area around the apex and the urinary sphincter. [2-5] For table in deep Trendelenburg fashion. The surgeries
this reason, new techniques have been developed to were performed with a transperitoneal approach under
combine the benefits of open simple prostatectomy with general anesthesia in each case. Positioning included
potential advantages of minimally invasive technique adequate padding of the pressure points on shoulder,
such as laparoscopic and robotic approaches. Robot- back, legs and arms. The first trocar (camera port)
assisted laparoscopic simple prostatectomy (RASP) was placed paraumbilical with the open (Hassan)
represents a new treatment alternative, in expert technique. After the pneumoperitoneum was obtained,
hands, for these complex cases. This new alternative we performed a peritoneoscopy and placed the other
combines the advantages of laparoscopic surgery robotic trocars under direct visualization. The abdomen
and three-dimensional vision, and increased digital was insufflated with a medium pressure of 12 mmHg
degrees of freedom, resulting in surgical precision carbon dioxide gas. The ports were placed according
and improved results. [6,7] The aim of the present study to Sotelo et al. [Figure 1]: two robotic ports (8 mm)
[7]
was to demonstrate the possibility of obtaining better placed 9 cm from the camera port on an imaginary
intraoperative and postoperative results with RASP line joining the anterior superior iliac spine to the
in terms of estimated blood loss, postoperative care umbilicus; the third robotic port (8 mm) was placed in
and hospitalization using a surgical variation to the the left iliac fossa. Two additional ports were placed
standard technique: the temporary bilateral internal for the assistant instruments: one of 5 mm between
iliac arteries clamping. the camera port and the first robotic arm on the upper
right side and one of 12 mm in the right iliac fossa. We
METHODS used both 0° and 30° optics, monopolar and bipolar
robotic instruments. The 4-arm da Vinci Surgical
®
Patients and methods System was docked and the intervention started with
We retrospectively reviewed 18 cases of RASPs the development of the Retzius space and the isolation
performed by two surgeons from March 2010 to of the internal iliac arteries bilaterally using two
May 2012 at two different hospitals. Each procedure vessel loops. Then, we cleared the anterior surface
was performed according to Sotelo’s technique [7] of the prostate capsule. In Figure 2 are showed the
with the addition of the temporary clamping of iliac arteries occluded with two Bulldog clamps. After
internal iliac arteries. All patients were affected by clamping the arteries, a horizontal cystotomy, through
severe symptomatic benign prostatic hyperplasia. the bladder mucosa, was made one centimeter cranial
Preoperative assessment included physical to the bladder neck. We dissected the adenoma along
examination, International Prostate Symptom Score the subcapsular plane taking care of the prostatic
(IPSS) evaluation, serum creatinine, prostate specific capsule. We used two 2-0 vicryl stitches on the
antigen (PSA), uroflowmetry (except for the patients adenoma surface for traction. Extra care was taken at
with an indwelling catheter) and volumetric suprapubic the apex of the prostate to avoid injury to the external
ultrasonography (US). The median preoperative IPSS sphincter. Accurate hemostasis was achieved before

was 25.2 (range 16-38). Fourteen patients (77.7%) removing the prostatic adenoma en bloc in an Endo-
36 Mini-invasive Surgery ¦ Volume 1 ¦ March 31, 2017