- 1. Preoperative Setup
- 2. Surgical Technique
1. Preoperative Setup
A. Patient Positioning
Preoperative bowel preparation was performed identically to the open method. Under general anesthesia, the patient was positioned on the operating table with the lower limbs in abduction and the upper limbs placed closely next to the body. The patient’s arms and legs were fixed to the table and plenty of padding was placed in the pressure areas. After being placed in the steep Trendelenburg position, the patient was sterilized from the xyphoid process to the perineal region and a 20 Fr silastic Foley catheter was inserted.
B. Port Placement
CO2 gas was pumped through a Veress needle placed 3 cm superior to the umbilicus to create a pneumoperitoneum, and six ports were placed consecutively (Figure 1). The optical port (Visiport Auto-suture; 12mm) was placed on top of the Veress needle and the camera was inserted through the optical port. Under direct vision, 8-mm ports for three robot arms were placed, two bilaterally next to the rectus abdominis muscle near the pubis at the level of the umbilicus, and one medio-superiorly to the right anterior superior iliac spine (ASIS). These three ports are needed for the monopolar scissor on the right side, the Prograsper on the fourth arm, and the bipolar forcep on the left side. A 12-mm port was placed medio-superiorly to the left ASIS for the assistant surgeon to manipulate standard laparoscopic tools, and a 5-mm port was placed superiorly to the midpoint between the optic port and the left robot arm port to be used for irrigation and suction. After placing the ports, robots arms and other instruments were assembled onto the ports accordingly.
- (Figure 1)
2. Surgical Technique
A. Exposure of Extraperitoneal Space and Lymph Node Dissection
Adhesions between the peritoneum and distal large bowel were excised and the medial umbilical ligament was dissected from the lateral side to the inferior border of the ductus deferens and the superior border of the peritoneal wall using monopolar scissors. The bladder can be completely excised in the shape of a sand clock after the peritoneum is dissected along the ductus deferens. Bilateral extended pelvic lymph node dissection was performed. The reference points for the lymph node dissections include the Cloquet lymph node distally, bifurcation of the aorta proximally, and the genitofemoral nerve laterally. Starting from the pelvic area, dissection was performed along the inner margin of the external iliac artery, and after confirming the position of the obturator nerve, the surrounding lymph nodes were dissected as well as the lymph nodes in the proximal area. Further dissection was performed according the common iliac artery up to the aortic bifurcation after detachment of the posterior peritoneum. The external and internal iliac artery as well as the obturator nerve can be well observed after all the lymph nodes along the iliac artery are dissected (Figure 2). Extra care should be taken to avoid injuring the arteries by pushing the instrument vertically, as robot arms eliminate tactile feedback.
- (Figure 2. Pelvic lymphadenectomy. A: Iliac lymph node dissection. The external iliac artery (a), external iliac vein (b), and obturator nerve (c); )
- (Figure 2. Pelvic lymphadenectomy. B: Aortic bifurcation lymph node dissection. The aortic bifurcation (d), right (e) common iliac artery, and inferior vena cava (f).)
B. Dissection of Ureter
Ureters were identified near the bifurcation of the common iliac artery and dissected as far proximally as much as possible, and distally down to the bladder and then clipped and ligated. A frozen section specimen from the cut edge of the distal ureter was sent for tissue biopsy.
The superior vesicle artery was identified clipped and ligated. The inferior vesicle artery was manipulated in the same manner. The Denonvillier fascia was incised horizontally in the middle and the space between the rectum and bladder was identified and dissected. Dissection was continued bilaterally, and the seminal vesicle was identified and dissected. Along the prostate, dissection was continued to the apex, and an incision was made at the internal pelvic fascia to dissect along the lateral side of the prostate up to the puboprostatic ligament. The deep ventral venous plexus was manipulated with the bipolar forcep only and was not clipped or tied. After taking care of the bilateral vessels of the prostate, the urethra was identified and ligated. The frozen section specimen from the cut edge of the distal urethra was sent for tissue biopsy. The completely resected bladder and prostate were put in an entrapment bag and placed in the peritoneal cavity.
D. Retrieval of Specimen and Ileal Conduit Urinary Diversion
A new 6cm incision was made vertically directly below the umbilical line, and the resected bladder was removed extracorporeally. Through the incision, the left ureter was passed to the right through the mesenteric fundus of the sigmoid colon. The ileum was taken out extracorporeally through the same incision, and the ileal conduit was created with the general Bricker method. Ureteroileal anastomosis was performed consequently. Ureteroileal stents were placed bilaterally and a stoma was created at the position of the right port next to the rectus abdominis muscle.
E. Completion of Surgery
Drainage was placed at the site of the port at the right lower quadrant, and the operation was completed after suturing the incision directly below the umbilical line.