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How is a da Vinci® prostatectomy performed?

Patient positioning:

The patient is positioned in the so-called Trendelenburg position, with spread legs and feet higher than the head. This slight slant shifts the organs located in the abdomen towards the head, which provides the surgeon with more room in the pelvic area during da Vinci® surgery.

Preparation and positioning of the patient-side robotics unit:

After positioning the patient, a urinary catheter is inserted into the patient’s bladder. Five small incisions (6-11 mm) are then made, which are arranged in a semi-circle around the navel. It is through these incisions that the so-called trocars (ports) are inserted.
Three of the total of five ports direct the micro-surgical instruments of the robotics unit and the 3D camera into the surgical field. The two additional ports are intended for the assisting physician, who is located directly at the surgical table.
After positioning the trocars the patient-side robotics unit can be applied. Under slight pressure, the abdomen is filled with medical CO2 gas, in order to enlarge the working area.

Begin of the da Vinci® prostatectomy:

At the beginning of the da Vinci® surgery, the abdominal area is checked for adhesions, which could interfere with surgery. Then the anterior peritoneum is removed from the abdominal wall in order to access the lesser pelvis. If conditions are unobtrusive, the lymph nodes in the area of the lesser pelvis are initially carefully removed. After surgery, these are sent for histological analysis, together with the prostate. The histological analysis provides important information on the spread and outlook of the disease.

The prostate is surrounded by connective tissue, muscle fibres and blood vessels, which is why the prostate must first be exposed. The transition from the prostate to the bladder is identified using the urinary catheter previously inserted. It is at this transition that the prostate is carefully separated from the bladder. In the next step, the seminal vesicles and the seminal duct, which are located behind the bladder, are detached. As a result of the direct vicinity of the rectum to the prostate it is important that a good overview is obtained before carefully detaching the two from one another. If the retention of erection nerves was discussed prior to surgery, these will carefully be dissected from the side of the prostate in the next step.

In so doing, the da Vinci® surgical system assists the surgeon significantly in identifying and precisely detaching the fine nerves, thanks to its magnification and 3D image. In order to remove the prostate completely, the urethra must be severed in a final step. It must be ensured that the external sphincter muscle is not injured so that continence is retained.

Now the prostate has been completely removed and is placed into a so-called specimen pouch. This is only removed from the patient’s body at the end of surgery. In some cases several immediate sections are removed for histological examination, in order to analyse whether the surrounding tissue no longer contains any tumour cells and the vicinity of the prostate is thus tumour-free.
After the repeated control of the sphincter muscle, the urinary bladder is reconnected to the urethra by means of a suture. Finally, the catheter is used to fill the bladder with approx. 200 ml medical saline solution to check the tightness of the suture. If the suture is tight it is checked whether bleeding has stopped. In so doing, the CO2 pressure in the abdomen is gradually reduced.

Now the da Vinci® surgical system can be undocked from the patient; the specimen pouch containing the surgical specimen is removed via an extension of the navel incision. After removal of the trocars the small incisions are sutured using absorbable suture material.
The wound is covered by a sterile dressing; generally, wound drainage is not required.

Follow-up of da Vinci® surgery:

Generally, the junction between the urinary bladder and the urethra is checked for tightness five days after da Vinci® surgery by means of an x-ray involving a contrast medium and the urinary catheter removed.

On the following day, if the progression of wound healing is unobtrusive, the patient is discharged.