Robot-assistedsurgeryindications Major indication : radicalprostatectomy Surgery is in constant motion Lookingforperfection to reach the “TRIFECTA” Curethe patient from his cancer Obtainingearlycontinence Preserving erectilefunction
Robot-assistedsurgeryindications Major indication : radicalprostatectomy Surgery is in constant motion Lookingforperfection to reach the “TRIFECTA” Cure the patientfromhiscancer Obtainingearlycontinence Preserving erectilefunction
Robotic-assisted surgery How to achieve the ideal outcome?
Accurate patient selection (age, comorbidity, oncological risk group)
Anatomical milestones The Journal of Urology Vol. 121: 198-200; 1979 An Anatomical Approach to the Surgical Management of the Dorsal Vein and Santorini’s Plexus during Radical Retropubic Surgery William G. Reiner & Patrick C. Walsh V. Ficarra
Apicaldissection : tips & tricks Urethral stump length, PSM and continence after RALP first 200 cases: transection of the urethra at the prostatourethral junction: PSM 17,6% (74% apical) continence at 6 mo: 89% second 200 cases: transection 3-6 mm distal to the prostatourethral junction: PSM 7.5% (apical 5.5%) continence at 6 mo: 91% Borin, et al 2007
“croissant” “doughnut” Prostate Shape and Sphincter Preservation Myers R Prostate shape, external striated urethral sphincter and radical prostatectomy: the apical dissection. J Urol 1987; 138 (3): 543-50
Anatomy of the Prostate Apex Graefen M et al, Eur Urol 2006
Importance of urethral length and fibrosis Paparel et al. EurUrol 2009:55;629–639
Importance of urethral length and fibrosis Post-RP T2-weighted image from a 61-yr-old continentpatientshowing no postoperativefibrosis: grade 0 for the urethralwall (arrow) and for the peri-urethraltissue (dashedarrows) Paparel et al. EurUrol 2009:55;629–639
Importance of urethral length and fibrosis Post-RP T2-weighted endorectal MRI from a 56-yr-old patientshowinggrade I urethralfibrosis (arrow) and grade III circumferentialperiurethralfibrosis (dashedarrows). Paparel et al. EurUrol 2009:55;629–639
Importance of urethral lenght Paparel et al. EurUrol 2009:55;629–639
Vision onto the Prostate Apex antegradetechnique, wherelateraldissection is done >> bettervisualisation of sphincteric complex & apex
Functional organisation of the NVB Costello A. et al BJU Inter 2004; 94: 1071-1076
Puboprostatic ligament preservation has been proposed to achieve accelerated return of continence after nerves-paring procedures.
Even with this technique, the rates of immediate post-operative continence remain low.
A possible explanation could be that because there is demonstrable anatomic continuity with the bladder, there are no conceivable means of preserving the pubovesical ligaments during RALP, and there must be interruption at some point to expose the prostatourethral junction
The management of the dorsal vascular complex (DVC) could also have important implications in continence recovery
It has been demonstrated that the ‘‘cut and ligate’’ of the DVC technique offers quicker continence recovery than a ‘‘ligate and cut’’ technique.
However, both selective and standard ligation present inherent drawbacks; thus, a ‘‘no touch’’ approach might be the ideal way to manage the DVC
Asimakopoulos et al. EurUrol 2010;58:407–417
Selective vs. standard ligation of the DVC Potential drawbacks Asimakopoulos et al. EurUrol 2010;58:407–417
The curved arrow indicates the avascular plane present between the point at which the detrusor apron (DA) leaves the prostate (to attach to the pubis) to the anterior prostate-urethral junction. From this level, it starts the anterior dissection of the pubovesical complex Asimakopoulos et al. EurUrol 2010;58:407–417
The anterior surface of the prostate has been totally freed from both the detrusor apron and the dorsal vascular complex * Bladder neck ** Membranous urethra Asimakopoulos et al. EurUrol 2010;58:407–417
At catheter removal, 80% (24 patients) were completely dry (0 pads), while 20% (6 patients) used a single liner for security
One month after surgery, according to the ICSmaleSF questionnaire (0max, 24 min), 28 patients presented a score of 0, while two patients scored 1 (loss of urinewhen coughing or sneezing) at catheter removal
After 3 mo, 22 of 30 patients (73%) presented an IIEF score >17 (with or without PDE-5 inhibitors).
13 of 22 potent patients had an Erection Hardness Score of 3, and 9 of 22 patients had a score of 4.