The prostate cancer is significant cause of morbidity and mortality in the all advanced countries and in total the second most common cancer in men. On the present is possible to treat completely the patients suffering from localized prostate cancer. As the first way of treatment of localized prostate cancer is usually accepted the radical prostatectomy (RP). The aim of treatment is the radical tumor extirpation, the preservation of the erectile function and the urinary continence. Radical retropubic approach is the most common form of prostatectomy performed today. The outcome of operation depends not only on the surgeon’s training, but also predominantly on the practical interpretation. Regarding lack of operation space in retropubic approach, high vascularisation of prostatic gland, importance of preserving of neurovascular bundles, urinary bladder neck and urethral sphincter is the radical retropubic prostatectomy recognized as one of the most difficult surgical operations. Laparoscopic approach has been developed for better visualization, minimal invasivennes and decrease of post-operative morbidity associated with open RP. Laparoscopic radical prostatectomy requires considerable skills and has a lengthy learning curve, with long initial operating times. A lot of limitations of conventional laparoscopic approach can be overcome by the robotic surgical system da Vinci – da Vinci RP (dVP). Aim: Presentation of therapeutic outcomes of 80 dVPs performed at the Department of Urology in the Central Military Hospital Prague in the last year. Material and methods: dVP was performed in 80 patients with clinically localized prostate cancer in the period from January 2006 to February 2007. In 76 patients we used extraperitoneal surgical approach and in 4 patients transperitoneal approach. All procedures were performed by the four-arm robotic system da Vinci (Intuitive Surgical, California, USA). dVP was done in the retrograde manner in twenty-degree oblique position of the patient (Trendelenburg). We make a preperitoneal space digital dissection throw the small incision under the navel. Two robotic ports we set up under the digital control in the right hypogastrium, third robotic port and the assistant port we set up in left hypogastrium. Robotic camera we set to under-navel incision. In case of transperitoneal approach we set up all the port in the same place directly into the peritoneal cavity under the visual control after insufflations of CO2. The fibroadipose tissue covering the prostate is carefully dissected away to expose the pelvic fascia, puboprostatic ligaments, and superficial branch of the dorsal vein. We do the robot assisted endopelvic fascia incision in both sides of prostate, stitch the ligature through the dorsal vein complex. After we open the bladder neck, identify the deferents and excise the seminal vesicles. The key point is the identification and preservation of the neurovascular bundle. Lateral pedicles we clamp with the hemo-lock clips and excise them. After division of the prostate and rectum we transect the urethra as close to the apex as possible. The prostate we put into the extraction sack and we remove it out via the under-navel port. Urethrovesical anastomosis was closed by the continuous suture with the both side needles. Procedure was finished by the drain insertion and suture of the incisions. Results: In this study we compare the group of the initial 40 dVPs (1st) and the group of the next 40 procedures (2nd). The operating time in the 1st group was in average 260 minutes (150 – 450 min.) and the blood loss was 410 millilitres (100 – 4800 ml). In the 2nd group was the average operating time 170 minutes (110 – 230 min.) and the blood loss 70 millilitres (30 – 340 ml). The preparation of the preperitoneal space takes at average 5 minutes, the wiring of robotic system and set up of robotic arms 10 minutes in the 2nd group. The main aims of radical robot assisted prostatectomy are the reduction of blood loss, to decrease post-operative morbidity, reduction of the in-patient period and markedly break short the patient recovery including period of bladder catheterization. This method is safe as well for patient with high body mass index. The different outcomes in the first and the second group are due to learning curve. Conclusions: In short staff-training period it is possible reach good surgical outcomes by the da Vinci robotic system assistance comparable to open retropubic RP. The main advantages are lower blood loss, shorter in-patient period and patient recovery and shorter period of bladder catheterization. Compared to laparoscopic RP the main benefit is much shorter learning curve. The main benefits of the preperitoneal surgical approach are a lack of blood and urine in the peritoneal cavity and the lower chance of intraperitoneal organs injury. The main drawback of the dVP is the cost.

Department of Urology Central Military Hospital Prague Prague

2. český a mezinárodní andrologický kongres, Štiřín, 3.-5.5.2007