Laparoscopic approach has been developed for better visualization, minimal invasiveness and decrease of post-operative morbidity. Laparoscopic radical prostatectomy requires considerable skill and has a lengthy learning curve, and that´s the reason why at the beginning the operation time is so long. Alot of limitations of conventional laparoscopic approach can be overcome by the robotic surgical system da Vinci. Robotic assistance is becoming more and more useful for laparoscopic radical prostatectomy, specifically, where the objective is to preserve erectile function. Robotic assistance gives to laparoscopic surgery a lot of major advantages: 3D operative vision, a new generation of operative gestures (without any limits) and increased comfort for the surgeon during operative procedure. Many well renowned urologic teams and large centers have already adopted this technique for the practice of radical prostatectomy. It is clear today that robotic assistance allows a high quality of surgery, at least as good as laparoscopic or traditional surgery, with good conditions of safety for the patient and comparable oncological results. The problem is to know if the robotic approach, which is very expensive, represents a limit for its acquisition, can prove to be superior in results in any fields compared to the other kinds of prostatectomy. To answer to this question is very difficult to ascertain because of the subjectivity of appreciation of functional results and the need to develop prospective and if possible randomized clinical trials. Material and methods: We started robotic assisted surgery in December 2005, after several years of laparoscopic practice and can now present results of more than 250 cases of robotic prostatectomy. DVP was performed in patients with clinically localized prostate cancer. We used extraperitoneal surgical approach. All procedures were performed by the four-arm robotic system da Vinci (Intuitive Surgical California, USA). DVP was made in the retrograde manner in twenty-degree oblique position of the patient (Trendelenburg).We make a preperitoneal space by the digital dissection through the small incision under the navel. Two robotic ports are set up under the digital control in the right hypogastrium, the third robotic port and the assistant port are set up in left hypogastrium. We set the robotic camera trough the incision under the navel. The fibroadipose tissue covering the prostate was carefully removed to expose the pelvic fascia, puboprostatic ligaments, and superficial branch of the dorsal vein were discontinued. We perform the robot assisted endopelvic fascia incision in both sides of the prostate, stitch ligature through the dorsal vein complex. After that 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 are clamped with the hem-o-lok clips and discontinued. After division of the prostate from rectum we cut the urethra as close as possible to the apex. We put the prostate 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 suturing of the incisions. Results: We have had no cases of per operative accident, two cases of laparoscopic conversion due to robot malfunction, one case of reoperation for problems of anastomotic failures, two cases of rectal injury (it was recognized and at once repaired) and less than 1% of cases we had to provide blood transfusions. The average operating time was 176 min. The mean rate of positive margins was 22% in PC stage, ranging from 10% to 36% depending on the surgeon´s experience and the choice of preservation technique. Concerning the post operative continence rate, 74% of the patients were fully continent after three months. Erection with the ability for intercourse was obtained in 34% after three months (with or without oral medication). Conclusions: After two years of experience with robotic radical prostatectomy, these results demonstrate that this operative technique is safe, reproducible and can offer oncologic results comparable with the other techniques of radical prostatectomy. The main aspect of its evaluation as a surgical technique, will be in terms of the functional results which include continence, and, more importantly, post operative erections. Compared to laparoscopic radical prostatectomy the main benefit is much shorter learning curve.

Department of Urology Central Military Hospital Prague

3. český a mezinárodní andrologický kongres, Štiřín, 13.-15.6.2008