No funding was obtained for this research.

<ol><li>Mottet, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((EAU-EANM-ESTRO-ESUR-SIOG+Guidelines+on+Prostate+Cancer-2020+Update.+Part+1%3A+Screening%2C+Diagnosis%2C+and+Local+Treatment+with+Curative+Intent%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">EAU-EANM-ESTRO-ESUR-SIOG Guidelines on Prostate Cancer-2020 Update. Part 1: Screening, Diagnosis, and Local Treatment with Curative Intent.</a> European Urology. 79 (2), 243-262 (2021).</li>
<li>Ilic, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Laparoscopic+and+robotic-assisted+versus+open+radical+prostatectomy+for+the+treatment+of+localised+prostate+cancer%5BTitle%5D)+AND+%22The+Cochrane+Database+of+Systematic+Reviews%22%5BJournal%5D)">Laparoscopic and robotic-assisted versus open radical prostatectomy for the treatment of localised prostate cancer.</a> The Cochrane Database of Systematic Reviews. 9 (9), (2017).</li>
<li>Ab del Raheem, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retzius-sparing+robot-assisted+radical+prostatectomy+versus+open+retropubic+radical+prostatectomy%3A+a+prospective+comparative+study+with+19-month+follow-up%5BTitle%5D)+AND+%22Minerva+Urologica+e+Nefrologica%3A+The+Italian+Journal+of+Urology+and+Nephrology%22%5BJournal%5D)">Retzius-sparing robot-assisted radical prostatectomy versus open retropubic radical prostatectomy: a prospective comparative study with 19-month follow-up.</a> Minerva Urologica e Nefrologica: The Italian Journal of Urology and Nephrology. 72 (5), 586-594 (2020).</li>
<li>Gandaglia, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Comparative+effectiveness+of+robot-assisted+and+open+radical+prostatectomy+in+the+postdissemination+era%5BTitle%5D)+AND+%22Journal+of+Clinical+Oncology+%3A+Official+Journal+of+the+American+Society+of+Clinical+Oncology%22%5BJournal%5D)">Comparative effectiveness of robot-assisted and open radical prostatectomy in the postdissemination era.</a> Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology. 32 (14), 1419-1426 (2014).</li>
<li>Ficarra, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+review+and+meta-analysis+of+studies+reporting+urinary+continence+recovery+after+robot-assisted+radical+prostatectomy%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Systematic review and meta-analysis of studies reporting urinary continence recovery after robot-assisted radical prostatectomy.</a> European Urology. 62 (3), 405-417 (2012).</li>
<li>Martini, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Contemporary+techniques+of+prostate+dissection+for+robot-assisted+prostatectomy%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Contemporary techniques of prostate dissection for robot-assisted prostatectomy.</a> European Urology. 78 (4), 583-591 (2020).</li>
<li>Galfano, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+new+anatomic+approach+for+robot-assisted+laparoscopic+prostatectomy%3A+a+feasibility+study+for+completely+intrafascial+surgery%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery.</a> European Urology. 58 (3), 457-461 (2010).</li>
<li>Checcucci, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retzius-sparing+robot-assisted+radical+prostatectomy+vs+the+standard+approach%3A+a+systematic+review+and+analysis+of+comparative+outcomes%5BTitle%5D)+AND+%22BJU+International%22%5BJournal%5D)">Retzius-sparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes.</a> BJU International. 125 (1), 8-16 (2020).</li>
<li>Montorsi, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Best+practices+in+robot-assisted+radical+prostatectomy%3A+recommendations+of+the+Pasadena+Consensus+Panel%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Best practices in robot-assisted radical prostatectomy: recommendations of the Pasadena Consensus Panel.</a> European Urology. 62 (3), 368-381 (2012).</li>
<li>Stabile, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Multiparametric+MRI+for+prostate+cancer+diagnosis%3A+current+status+and+future+directions%5BTitle%5D)+AND+%22Nature+Reviews.+Urology%22%5BJournal%5D)">Multiparametric MRI for prostate cancer diagnosis: current status and future directions.</a> Nature Reviews. Urology. 17 (1), 41-61 (2020).</li>
<li>Dindo, D., Demartines, N., Clavien, P. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Classification+of+surgical+complications%3A+a+new+proposal+with+evaluation+in+a+cohort+of+6336+patients+and+results+of+a+survey%5BTitle%5D)+AND+%22Annals+of+Surgery%22%5BJournal%5D)">Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey.</a> Annals of Surgery. 240 (2), 205-213 (2004).</li>
<li>Xylinas, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Evaluation+of+combined+oncological+and+functional+outcomes+after+radical+prostatectomy%3A+trifecta+rate+of+achieving+continence%2C+potency+and+cancer+control--a+literature+review%5BTitle%5D)+AND+%22Urology%22%5BJournal%5D)">Evaluation of combined oncological and functional outcomes after radical prostatectomy: trifecta rate of achieving continence, potency and cancer control--a literature review.</a> Urology. 76 (5), 1194-1198 (2010).</li>
<li>Walz, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+critical+analysis+of+the+current+knowledge+of+surgical+anatomy+related+to+optimization+of+cancer+control+and+preservation+of+continence+and+erection+in+candidates+for+radical+prostatectomy%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">A critical analysis of the current knowledge of surgical anatomy related to optimization of cancer control and preservation of continence and erection in candidates for radical prostatectomy.</a> European Urology. 57 (2), 179-192 (2010).</li>
<li>Walz, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+critical+analysis+of+the+current+knowledge+of+surgical+anatomy+of+the+prostate+related+to+optimisation+of+cancer+control+and+preservation+of+continence+and+erection+in+candidates+for+radical+prostatectomy%3A+An+update%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">A critical analysis of the current knowledge of surgical anatomy of the prostate related to optimisation of cancer control and preservation of continence and erection in candidates for radical prostatectomy: An update.</a> European Urology. 70 (2), 301-311 (2016).</li>
<li>Albisinni, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Systematic+review+comparing+Anterior+vs+Retzius-sparing+robotic+assisted+radical+prostatectomy%3A+can+the+approach+really+make+a+difference%5BTitle%5D)+AND+%22Minerva+Urology+and+Nephrology%22%5BJournal%5D)">Systematic review comparing Anterior vs Retzius-sparing robotic assisted radical prostatectomy: can the approach really make a difference.</a> Minerva Urology and Nephrology. , (2021).</li>
<li>Menon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Functional+recovery%2C+oncologic+outcomes+and+postoperative+complications+after+robot-assisted+radical+prostatectomy%3A+An+evidence-based+analysis+comparing+the+Retzius+sparing+and+standard+approaches%5BTitle%5D)+AND+%22The+Journal+of+Urology%22%5BJournal%5D)">Functional recovery, oncologic outcomes and postoperative complications after robot-assisted radical prostatectomy: An evidence-based analysis comparing the Retzius sparing and standard approaches.</a> The Journal of Urology. 199 (5), 1210-1217 (2018).</li>
<li>Olivero, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retzius-sparing+robotic+radical+prostatectomy+for+surgeons+in+the+learning+curve%3A+A+propensity+score-matching+analysis%5BTitle%5D)+AND+%22European+Urology+Focus%22%5BJournal%5D)">Retzius-sparing robotic radical prostatectomy for surgeons in the learning curve: A propensity score-matching analysis.</a> European Urology Focus. 7 (4), 772-778 (2021).</li>
<li>Galfano, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Retzius-sparing+robot-assisted+radical+prostatectomy%3A+early+learning+curve+experience+in+three+continents%5BTitle%5D)+AND+%22BJU+International%22%5BJournal%5D)">Retzius-sparing robot-assisted radical prostatectomy: early learning curve experience in three continents.</a> BJU International. 127 (4), 412-417 (2021).</li>
<li>Galfano, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Beyond+the+learning+curve+of+the+Retzius-sparing+approach+for+robot-assisted+laparoscopic+radical+prostatectomy%3A+oncologic+and+functional+results+of+the+first+200+patients+with+%3E%2F%3D+1+year+of+follow-up%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Beyond the learning curve of the Retzius-sparing approach for robot-assisted laparoscopic radical prostatectomy: oncologic and functional results of the first 200 patients with >/= 1 year of follow-up.</a> European Urology. 64 (6), 974-980 (2013).</li>
<li>Hoffman, K. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Patient-reported+outcomes+through+5+years+for+active+surveillance%2C+surgery%2C+brachytherapy%2C+or+external+beam+radiation+with+or+without+androgen+deprivation+therapy+for+localized+prostate+cancer%5BTitle%5D)+AND+%22JAMA%22%5BJournal%5D)">Patient-reported outcomes through 5 years for active surveillance, surgery, brachytherapy, or external beam radiation with or without androgen deprivation therapy for localized prostate cancer.</a> JAMA. 323 (2), 149-163 (2020).</li>
<li>Dalela, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((A+pragmatic+randomized+controlled+trial+examining+the+impact+of+the+Retzius-sparing+approach+on+early+urinary+continence+recovery+after+robot-assisted+radical+prostatectomy%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">A pragmatic randomized controlled trial examining the impact of the Retzius-sparing approach on early urinary continence recovery after robot-assisted radical prostatectomy.</a> European Urology. 72 (5), 677-685 (2017).</li>
<li>Yossepowitch, O., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Positive+surgical+margins+after+radical+prostatectomy%3A+a+systematic+review+and+contemporary+update%5BTitle%5D)+AND+%22European+Urology%22%5BJournal%5D)">Positive surgical margins after radical prostatectomy: a systematic review and contemporary update.</a> European Urology. 65 (2), 303-313 (2014).</li>
<li>Vale, C. L., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Adjuvant+or+early+salvage+radiotherapy+for+the+treatment+of+localised+and+locally+advanced+prostate+cancer%3A+a+prospectively+planned+systematic+review+and+meta-analysis+of+aggregate+data%5BTitle%5D)+AND+%22Lancet%22%5BJournal%5D)">Adjuvant or early salvage radiotherapy for the treatment of localised and locally advanced prostate cancer: a prospectively planned systematic review and meta-analysis of aggregate data.</a> Lancet. 396 (10260), London, England. 1422-1431 (2020).</li>
<li>Lumen, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Safe+introduction+of+robot-assisted+radical+prostatectomy+after+a+training+program+in+a+high-volume+robotic+centre%5BTitle%5D)+AND+%22Urologia+Internationalis%22%5BJournal%5D)">Safe introduction of robot-assisted radical prostatectomy after a training program in a high-volume robotic centre.</a> Urologia Internationalis. 91 (2), 145-152 (2013).</li>
<li>Galfano, A., Secco, S., Bocciardi, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Mottrie+A.+Retzius-sparing+robot-assisted+laparoscopic+radical+prostatectomy%3A+An+international+survey+on+surgical+details+and+worldwide+diffusion%5BTitle%5D)+AND+%22European+Urology+Focus%22%5BJournal%5D)">Mottrie A. Retzius-sparing robot-assisted laparoscopic radical prostatectomy: An international survey on surgical details and worldwide diffusion.</a> European Urology Focus. 6 (5), 1021-1023 (2020).</li>
<li>Checcucci, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Precision+prostate+cancer+surgery%3A+an+overview+of+new+technologies+and+techniques%5BTitle%5D)+AND+%22Minerva+Urologica+e+Nefrologica%3A+The+Italian+Journal+of+Urology+and+Nephrology%22%5BJournal%5D)">Precision prostate cancer surgery: an overview of new technologies and techniques.</a> Minerva Urologica e Nefrologica: The Italian Journal of Urology and Nephrology. 71 (5), 487-501 (2019).</li>
<li>Grasso, A. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Posterior+musculofascial+reconstruction+after+radical+prostatectomy%3A+an+updated+systematic+review+and+a+meta-analysis%5BTitle%5D)+AND+%22BJU+International%22%5BJournal%5D)">Posterior musculofascial reconstruction after radical prostatectomy: an updated systematic review and a meta-analysis.</a> BJU International. 118 (1), 20-34 (2016).</li>
<li>Manfredi, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Total+anatomical+reconstruction+during+robot-assisted+radical+prostatectomy%3A+focus+on+urinary+continence+recovery+and+related+complications+after+1000+procedures%5BTitle%5D)+AND+%22BJU+international%22%5BJournal%5D)">Total anatomical reconstruction during robot-assisted radical prostatectomy: focus on urinary continence recovery and related complications after 1000 procedures.</a> BJU international. 124 (3), 477-486 (2019).</li>
</ol>

The authors have no conflicts of interest.

During RS-RARP, the whole procedure is performed by approaching the bladder through the posterior end. Consequently, the main difference with SA-RARP is the preservation of the Retzius&#39; space. Preservation of Retzius&#39; space has several anatomical advantages7: First, the bladder is not detached from the abdominal wall and the umbilical ligaments are not transected. Therefore, the bladder remains in its anatomical position. Second, the anterior detrusor apron and puboprostatic ligaments are ...

To cure localized and selected cases of locally advanced prostate cancer, radical prostatectomy is one of the recommended treatment options1. Minimal invasive techniques (conventional laparoscopy and robot-assisted laparoscopy) have the advantage to lower blood loss, postoperative pain, and duration of hospitalization as compared to open radical prostatectomy2,3. Among the minimal invasive techniques, robot-assisted surgery combines the advantages of minimal invasive surgery with increased dexterity and freedom of movement of the surgical instruments and with 3-dimensional perioperative vision. In well-resourced countries, robot-assisted radical prostatectomy (RARP) has become the predominant mode to perform radical prostatectomy4.
Urinary incontinence, temporary or definitive, is a common side effect of radical prostatectomy, irrespective of the mode by which it has been performed5. With open (abdominal), laparoscopic, and &#34;standard&#34; anterior RARP (SA-RARP), radical prostatectomy is performed by an anterior approach in which the retropubic (Retzius&#39;) space is opened6. Thanks to the increased dexterity associated with RARP, an alternative anatomic approach is possible in which the prostate is resected through the rectovesical pouch or Douglas&#39; pouch as first described by Galfano et al.7. This posterior approach leaves the Retzius&#39; space intact (&#34;Retzius-sparing RARP&#34;; RS-RARP). The main advantage of RS-RARP appears to be a higher and faster recovery of urinary continence8. This study aims to describe in detail (as suggested by the Pasadena consensus panel9) the steps of RS-RARP supported by audiovisual material and to report on the early functional and oncological outcomes of the first cases in a single center.

<table><tbody><tr><td>adhesive tape</td><td>BSNmedical</td><td>15200028</td><td>Tensoplast</td></tr><tr><td>assistant trocar 5mm</td><td>Aesculap</td><td>EKO17R</td><td>reusable trocar</td></tr><tr><td>assistant trocar 12mm</td><td>Conmed</td><td>iAS12-120LPi</td><td>AirSeal trocar</td></tr><tr><td>barbed wire</td><td>Covidien</td><td>VLOCM0024</td><td>for vesico-urethral anastomosis</td></tr><tr><td>Cadiere forceps</td><td>Intuitive</td><td>470049</td><td>robotic instrument, grasper</td></tr><tr><td>camera 30&amp;deg;</td><td>Intuitive</td><td>470027</td><td>endoscope</td></tr><tr><td>cefazolin</td><td>Sandoz</td><td>BE217296</td><td>Belgian farmaceutical registration</td></tr><tr><td>CO2-insufflator</td><td>Conmed</td><td>AS-iFS2</td><td>AirSeal insufflator</td></tr><tr><td>Da Vinci Xi system</td><td>Intuitive</td><td>600062</td><td>robotic system</td></tr><tr><td>endobag</td><td>Covidien</td><td>173050G</td><td>Endo Catch 10mm</td></tr><tr><td>endoscopic hem-o-lok applier</td><td>Teleflex</td><td>544995T</td><td>to apply the locking clips</td></tr><tr><td>fenestrated bipolar forceps</td><td>Intuitive</td><td>470205</td><td>robotic instrument, bipolar forceps</td></tr><tr><td>Hasson cone 8mm trocar</td><td>Intuitive</td><td>470398</td><td>only at the camera trocar</td></tr><tr><td>heparin, low molecular weight (enoxaparin)</td><td>Sanofi</td><td>BE144347</td><td>Belgian farmaceutical registration</td></tr><tr><td>hydrogel coated latex transurethral catheter</td><td>Bard</td><td>D226416</td><td>Biocath</td></tr><tr><td>insufflation cable</td><td>Conmed</td><td>ASM-EVAC1</td><td>AirSeal Tri-lumen filtered tube set</td></tr><tr><td>laparoscopic grasper</td><td>Aesculap</td><td>PO235R</td><td>Atraumatic wave grasper, double action</td></tr><tr><td>large needle driver</td><td>Intuitive</td><td>470006</td><td>roboic instrument, needle driver</td></tr><tr><td>locking clip</td><td>Grena</td><td>5-13mm</td><td>Click&#039;aVplus</td></tr><tr><td>metallic clips 5mm</td><td>Aesculap</td><td>PL453SU</td><td>for vessel ligation</td></tr><tr><td>monopolar curved scissor</td><td>Intuitive</td><td>470179</td><td>robotic instrument, hot shears</td></tr><tr><td>mosquito clamp</td><td>Innovia Medical</td><td>MQC2025-D</td><td>to secure bladder suspension stitch</td></tr><tr><td>natriumlaurylsulfoacetate-sorbitol-natriumcitratedihydrate clysma</td><td>Johnson &amp;amp; Johnson Consumer BV</td><td>RVG 05069</td><td>Belgian farmaceutical registration</td></tr><tr><td>polyglactin 3.0 suture</td><td>Ethicon</td><td>V442H</td><td>stay suture bladder neck, subcutaneous sutures</td></tr><tr><td>polyglactin 1 suture</td><td>Ethicon</td><td>D9708</td><td>stay suture fascia and fascia closurie</td></tr><tr><td>povidone-iodine alcoholic solution</td><td>Mylan</td><td>BE230736</td><td>Belgian farmaceutical registration</td></tr><tr><td>robotic trocar 8mm</td><td>Intuitive</td><td>470002</td><td>standard length</td></tr><tr><td>Skin stapler</td><td>Covidien</td><td>8886803712</td><td>skin closure</td></tr><tr><td>sterile drapes robotic arms</td><td>Intuitive</td><td>470015</td><td>draping system robotic arms</td></tr><tr><td>suction-irrigation device</td><td>Geyi</td><td>GYSL-5X330</td><td>laparoscopic use by assitant</td></tr><tr><td>suspension sutures</td><td>Ethicon</td><td>628H</td><td>Ethilon 2-0 nylon suture</td></tr><tr><td>thrombo-embolus deterrent stockings</td><td>Covidien</td><td>7203</td><td>T.E.D. stockings</td></tr><tr><td>warming blanket device</td><td>3M</td><td>54200</td><td>Bear Hugger</td></tr></tbody></table>

retzius-sparing robot-assisted radical prostatectomy

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.

All patients with local or locally advanced prostate cancer with a life expectancy &#62;10 years and with no anesthesiologic contra-indications were offered RS-RARP as one of the treatment options for their disease. Patients undergoing cytoreductive radical prostatectomy for metastatic prostate cancer in the context of a clinical trial or salvage radical prostatectomy were not offered RS-RARP, and patients with anterior tumors were preferably offered SA-RARP. Patients with a follow-up of fewer than 3 months were excluded...

Watch this Scientific Journal Video about Retzius-Sparing Robot-Assisted Radical Prostatectomy at JoVE.com

Retzius-Sparing Robot-Assisted Radical Prostatectomy

Robot-assisted Retzius-sparing radical prostatectomy is a technique that enables to preserve urinary continence or facilitates recovery of urinary continence in the majority of patients. Patients must be informed about the risk of a positive surgical margin.

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The ...

retzius-sparing-robot-assisted-radical-prostatectomy

Research

JoVE Journal

Medicine

7.5K Views.  Ghent University Hospital. Robot-assisted Retzius-sparing radical prostatectomy is a technique that enables to preserve urinary continence or facilitates recovery of urinary continence in the majority of patients. Patients must be informed about the risk of a positive surgical margin.

Video: Retzius-Sparing Robot-Assisted Radical Prostatectomy

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection (DP-CAR) for Pancreatic Cancer: Surgical Planning and Technique

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), relying on collateral flow to the liver through the gastroduodenal artery (GDA). In the current manuscript, the technical conduct of robotic DP-CAR is outlined. The greater curve of the stomach is mobilized with care to avoid sacrificing the gastroepiploic vessels. The stomach and liver are retracted cephalad to facilitate dissection of the porta hepatis. The hepatic artery (HA) is dissected and encircled with a vessel loop. The gastroduodenal artery (GDA) is carefully preserved. The common HA is clamped and triphasic flow in the proper HA via the GDA is confirmed using intra-operative ultrasound. A retropancreatic tunnel is made over the superior mesenteric vein (SMV). The pancreas is divided with an endovascular stapler at the neck. The inferior mesenteric vein (IMV) and splenic vein are ligated. The HA is stapled proximal to the GDA. The entire specimen is retracted laterally with further dissection cephalad to expose the superior mesenteric artery (SMA). The SMA is then traced back to the aorta. The dissection continues cephalad along the aorta with the bipolar energy device used to divide the crural fibers and celiac nerve plexus. The specimen is mobilized from the patient's right to left until the origin of the celiac axis is identified and oriented towards the left. The trunk is circumferentially dissected and stapled. Additional dissection with hook cautery and the bipolar energy device fully mobilizes the pancreatic tail and spleen. The specimen is removed from the left lower quadrant extraction site and one drain is left in the resection bed. A final intra-operative ultrasound of the proper HA confirms pulsatile, triphasic flow in the artery and liver parenchyma. The stomach is inspected for evidence of ischemia. Robotic DP-CAR is safe, feasible and when used in conjunction with multi-modality therapy, offers potential for long-term survival in selected patients.

Robot Assisted Distal Pancreatectomy with Celiac Axis Resection DP-CAR for Pancreatic Cancer: Surgical Planning and Technique

We present our operative approach to robot assisted distal pancreatectomy, splenectomy, and celiac axis resection (DP-CAR), demonstrating that the procedure is safe and feasible with proper planning, patient selection, and surgeon experience.

Malignant pancreatic tumors involving the celiac artery can be resected with a distal pancreatectomy, splenectomy and celiac axis resection (DP-CAR), ...

Cancer Research

Robotic Pancreatoduodenectomy for Pancreatic Head Cancer: a Case Report of a Standardized Technique

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several studies have described the safety of RPD in case of a replaced or aberrant right hepatic artery, but detailed video descriptions of the approach are lacking. This case report describes a step-&#173;by-&#173;step technical video in case of a replaced right hepatic artery. A 58-year-old woman presented with an incidental finding of a 1.7 cm pancreatic head mass. RPD was performed using the da Vinci Xi system and involves a robotic-assisted pancreatico- and hepatico-jejunostomy and open gastro-jejunostomy at the specimen extraction site. The operation time was 410 min with 220 mL of blood loss. The patient had an uncomplicated postoperative course and was discharged after 5 days. Pathology revealed a pancreatic head cancer. RPD is a feasible and safe procedure in case of a replaced hepatic artery when performed in selected patients in high-volume centers by experienced surgeons.

Robotic pancreatoduodenctomy (RPD) has been highly standardized in recent years and may be used in selected patients with pancreatic head cancer, including those with a replaced right hepatic artery. This case report describes a standardized and reproducible technique for RPD, which includes the approach of the Dutch LAELAPS-3 training program to an aberrant vasculature.

Robotic pancreatoduodenectomy (RPD) for pancreatic cancer is a challenging procedure. Aberrant vasculature may increase the technical difficulty. Several ...

A Teleoperated Robotic System-Assisted Percutaneous Transiliac-Transsacral Screw Fixation Technique

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. Transiliac-transsacral screws provide a longer lever arm to withstand the perpendicular vertical shear forces. However, the screw channel is so long that a minor discrepancy can lead to iatrogenic neurovascular injuries. The development of medical robots has improved the precision of surgery. The present protocol describes how to use a new teleoperated robotic system to execute transiliac-transacral screw fixation. The Robot was operated remotely to position the entry point and adjust the orientation of the sleeve. The screw positions were evaluated using postoperative computed tomography (CT). All the screws were safely implanted, as confirmed using intraoperative fluoroscopy. Postoperative CT confirmed that all the screws were in the cancellous bone. This system combines the doctor's initiative with the Robot's stability. The remote control of this procedure is possible. Robot-assisted surgery has a higher position-retention capacity compared with conventional methods. In contrast to active robotic systems, surgeons have full control over the operation. The robot system is fully compatible with operating room systems and does not require additional equipment.

Teleoperated robotic system-assisted percutaneous transiliac-transsacral screw fixation is a feasible technique. Screw channels can be implemented with high accuracy owing to the excellent freedom of movement and stability of the robotic arms.

Transiliac-transsacral screw fixation is challenging in clinical practice as the screws need to break through six layers of cortical bone. ...

Engineering

Technical Detail for Robot Assisted Pancreaticoduodenectomy

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic platform, including three-dimensional vision, wristed instruments, and improved ergonomics, allow the surgeon to recapitulate the principles of open pancreatoduodenectomy allowing safe oncologic dissection, hemostasis, and meticulous reconstruction. Over the course of the past decade, significant strides have been achieved in outlining the safety, feasibility, and learning curve of the robotic Whipple. When performed by high volume pancreatic surgeons experienced in RPD, recent comparative effectiveness studies show potential advantages compared to the open technique, including reductions in hospital stay and morbidity. National data also show reductions in conversion rates compared to its laparoscopic counterpart. Although long-term oncologic data are still needed, short-term oncologic surrogates of margin resection and lymph node harvest suggest no compromise in oncologic outcomes. As pancreatic surgeons increasingly integrate robotics into their practice, proficiency-based training and credentialing will be necessary for the safe application and dissemination of RPD. Here, we provide the detailed steps of a robotic pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.&#160;

The following manuscript details a stepwise approach to the robot-assisted pancreaticoduodenectomy performed at the University of Pittsburgh Medical Center.

Since its first report in 2003, robotic pancreaticoduodenectomy (RPD) has gained popularity among pancreatic surgeons. Inherent advantages of the robotic ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

Robotic Radical Cystectomy, Pelvic Lymph Node Dissection, and Intracorporeal Ileal Conduit Urinary Diversion

The robotic approach to radical cystectomy is compelling because of its oncologic equivalence to open radical cystectomy (ORC), its association with lower surgical blood loss, its potential association with shorter hospital stay after surgery. These factors suggest that the robotic approach to radical cystectomy may be an important component of enhanced recovery programs aimed at reducing surgical morbidity. This paper describes the importance of the cranial placement of robotic trocars, the use of Cadiere forceps for atraumatic bowel grasping, pelvic lymph node dissection (PLND), and utero-enteric anastomoses. Also discussed are steps that are critical for the successful outcome of RARC. In spite of the increased operating times and associated costs and the costs of robotic surgical platforms and equipment, adoption of the robotic technique by bladder cancer surgeons has increased. This paper describes a systematic and reproducible method that details robotic extended pelvic lymph node dissection, cystectomy/cystoprostatectomy, and intracorporeal ileal conduit urinary diversion.

This paper describes robotic radical cystectomy, pelvic lymph node dissection, and intracorporeal ileal conduit urinary diversion.

The robotic approach to radical cystectomy is compelling because of its oncologic equivalence to open radical cystectomy (ORC), its association with lower ...

Robot-Assisted Kidney Transplantation

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed in the supine Trendelenburg position. Kidney allografts are provided by a living donor. Before vascular anastomosis, the kidney allograft is prepared by inserting a double-J stent in the ureter, and the temperature for the anastomosis is lowered by wrapping it in an ice-packed gauze. A 12 mm or 8 mm port for the robotic camera and three 8 mm ports for robotic arms are placed. A peritoneal pouch is created for the kidney allograft by raising the peritoneal flaps on both sides over the psoas muscle before dissecting the iliac vessels and bladder. A 6 cm Pfannenstiel incision is made to insert the kidney into the peritoneal pouch, lateral to the right iliac vessels. 
After clamping the external iliac vein with Bulldogs clamps, a venotomy is performed, and the graft renal vein is anastomosed to the external iliac vein in an end-to-side continuous manner with a 6/0 polytetrafluoroethylene suture. After clamping the graft renal vein, the iliac vein is declamped. This is followed by clamping of the external iliac artery, arteriotomy, arterial anastomosis with a 6/0 polytetrafluoroethylene suture, clamping of the graft renal artery, and declamping of the external iliac artery. Reperfusion is then carried out, and ureteroneocystostomy is performed using the Lich-Gregoir technique. The peritoneum is closed at a few locations with polymer locking clips, and a closed-suction drain is placed through one of the working ports. After deflating the pneumoperitoneum, all incisions are closed.

This paper provides technical details for robot-assisted kidney transplantation from a living donor.

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed ...

Robotic Central Pancreatectomy with Roux-en-Y Pancreaticojejunostomy

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of the pancreas. The aim of central pancreatectomy is to prevent postoperative life-long endocrine and exocrine insufficiency. The downside of central pancreatectomy is the high rate of postoperative pancreatic fistula, which is the main reason that many surgeons do not routinely use central pancreatectomy in eligible patients. Most studies report open or laparoscopic central pancreatectomy with a pancreatico-gastrostomy anastomosis in adults. This is the first description of a standardized approach to robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy reconstruction in an adolescent (16-year-old boy) with a pseudopapillary tumor in the body of the pancreas. The operation time was 248 min with 20 mL of blood loss. The postoperative course was uneventful except for the short-term medical treatment for a grade B pancreatic fistula. Robotic central pancreatectomy can be safely applied in selected patients in experienced centers.

Robotic central pancreatectomy may be used in selected patients in experienced centers. This protocol presents all steps and the feasibility of a robotic central pancreatectomy with Roux-en-Y pancreaticojejunostomy in a 16-year-old adolescent patient.

Central pancreatectomy is a parenchyma-sparing alternative to distal pancreatectomy in patients with a benign or low-grade malignant tumor in the body of ...

Robot-assisted Total Mesorectal Excision and Lateral Pelvic Lymph Node Dissection for Locally Advanced Middle-low Rectal Cancer

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex procedures. The high-quality 3-D visual, multijoint arm and natural tremor filtration allow the surgeon to expose and dissect more accurately with minimal invasion. Total mesorectal excision is the standard surgical technique for the treatment of resectable rectal cancer. To reduce the lateral recurrence rate, lateral pelvic lymph node dissection can be performed, as it is a safe and feasible procedure for locally advanced middle-low rectal cancer with a high possibility of metastasis to the lateral lymph nodes. However, the complexity of the anatomic structures and the high postoperative complication rate limit its application. Recently, several surgeons have increasingly used robotic techniques for total mesorectal excision and lateral pelvic lymph node dissection. Compared with open and laparoscopic surgery, the robotic technique has several advantages, such as less blood loss, fewer blood transfusions, minimal trauma, shorter postoperative hospitalization, and quicker recovery. A robotic approach is generally regarded as a reasonable alternative for complicated procedures such as lateral pelvic lymph node dissection, although there are a limited number of high-quality prospective randomized controlled studies reporting direct evidence. Here, we provide the detailed steps of robot-assisted total mesorectal excision and lateral pelvic lymph node dissection performed at the First Affiliated Hospital of Xi&#39;an Jiaotong University.

The robotic technique described herein aims to detail a stepwise approach to robot-assisted total mesorectal excision and lateral pelvic lymph node dissection for locally advanced (T3/T4) rectal cancer located below the peritoneal reflection.

Since their approval for clinical use, da Vinci surgical robots have shown great advantages in gastrointestinal surgical operations, especially in complex ...

Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was approved for in-human use in Europe. Possible applications for this new robotic system are being explored, and standardized approaches are evolving. In lieu of this, a gastric wedge resection and the standardized setup for upper gastrointestinal procedures using this new system are presented here. This safe and feasible robotic procedure is demonstrated in a 69-year-old patient with a gastric tumor. All steps of the surgery are described in a detailed and reproducible manner. The article also details trocar positioning, arm adjustments, and required surgical instruments. Docking time amounted to 13 min, whereas the console time took 115 min. The patient was discharged after 4 days after ensuring an uneventful course. The presented method is also suitable for other surgical purposes, such as fundoplications or hiatoplasties, and ensures both generalizability and reproducibility.

Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was ...