Challenging Cases in Robotic Radical Prostatectomy

Abstract

Robotic surgeons are faced with an increasing array of complex clinical scenarios in the management of localized prostate cancer. With appropriate preparation and resource utilization, many of these “difficult cases” can be handled safely and efficiently. Securing obese patients adequately to the operating table and preventing port slippage is important in minimizing long case times and complications in these patients. In patients with large prostates, a well-developed posterior plane prior to bladder neck transection minimizes risk of injuring nearby structures. Use of a retraction suture or the fourth arm to elevate a median lobe can assist in patients with significant intravesical prostatic lobes. Bladder neck reconstruction may be necessary, and however be easily performed with lateral figure-of-eight stitches, which can also internalize the ureteral orifices. RARP can safely be performed in patients with prior bladder outlet, hernia, or multiple abdominal operations, although patients with prior TURP may have an increased risk of postoperative incontinence. An extended lymphadenectomy can be efficiently performed robotically, and increases prognostic and therapeutic yield of the operation without significantly increasing morbidity.