Category: Robotic Surgery: New Techniques - Malignant

VS9-5 - "It's a RAPP" Robotic Assisted Perineal Prostatectomy. Descriptive Technique of the Inaugural Case in the United Kingdom

Sat, Sep 22
10:00 AM - 12:00 PM

Introduction & Objective :

Probably the most common prostate operation is the retropubic robotic assisted laparoscopic prostatectomy. We present an alternative approach on the experience of open perineal prostatectomy, which was the senior author’s are of expertise. The fusion of Robotic and open approaches, pioneered by our Visiting Co-author from the USA, was carried out on the first patient in the United Kingdom in 2018.


Methods :

The da Vinci Xi surgical system was used for our case: a 65 year old patient with a PSA of 8 ng/dL, with no previous abdominal surgical history. International Prostate Symptom Score was 5 and a multiparametric MRI of his prostate revealed a left apical lesion in a 54cc prostate. A transperineal biopsy confirmed Gleason 3+4 prostate cancer in 11/28 cores, with four cores taken from the lesion being involved with cancer. 

A Young’s retractor was inserted into the bladder. A 5cm semicircular incision was made between ischial tuberosities. The perineal body was identified, the posterior surface of the prostate was defined. The subcutaneous tissue was developed to accommodate a tight seal for the GelPOINT® Medium and a pre loaded gelcap: 8 mm robotic ports placed at 12 o’clock, 4 o’clock and 8 o’clock. A 10 mm assistant port was inserted at 6 o’clock.

15 mmHg was the set working pneumo pressure. The posterior surface of the prostate to the seminal vesicles were freed after Denonvilliers fascia was opened. The vascular pedicles were ligated using a robotic harmonic scalpel. The endopelvic fascia and neurovascular bundles were spared. The apex was dissected and the membranous urethra was incised sparing the external urethral sphincter complex. A Hem-o-lok clip was applied to the catheter and this was cut distally to keep the balloon inflated in the bladder. The anterior and lateral pelvic fascia planes of the prostate swept away widely, allowing sparing of the dorsal venous complex. The vesicourethral anastomosis was performed with two continuous running sutures. Total operative time was 300 minutes.

Results : He was discharged two days post operatively as per the patient’s request. He passed his trial without catheter successfully in two weeks. His histopathology has revealed complete excision with negative margins.

Conclusions :

Our Visiting Co-Author’s experience allowed us to now offer this technique to patients in the UK. The patient had minimal postoperative pain, minimal intraoperative bleeding. We will seek to further evaluate this approach with long term follow up of further cases, improved Robotic instruments, but would encourage other Units to revive this surgery once again. 


Jonathan P. Noël

Urology Registrar
The Royal Marsden NHS Foundation Trust
London, England, United Kingdom

A Senior Urology Registrar in London UK, I have identified Uro Oncology managed by minimally invasive methods afforded by Endouroogy, Laparoscopy and Robotics as the only future in surgery for my generation and those to come.

Innovations in these approaches should be shared at such Meetings, to exchange ideas, establish new contacts and improve the service we offer for our patients for the better.

I look forward to meeting you all at this year's WCE.

Bradley Russell

Surgical Care Practioner
The Royal Marsden NHS Foundation Trust
London, England, United Kingdom

Jihad Kaouk

Professor and Director, Center for Robotic and Image Guided Surgery Vice Chair, Surgical Innovations
Glickman Urologic Institute, Cleveland Clinic
Cleveland, Ohio

Jihad Kaouk, MD FACS

Dr. Jihad Kaouk is an American Board certified Urologist and Director, Center of Robotic and Image Guided Surgery at the Cleveland Clinic Glickman Urological Institute. He also serves as Professor of Surgery at the Cleveland Clinic Lerner College of Medicine, Vice Chair for Surgical Innovations and chair holder for the Zegarac-Pollock Endowed Chair in laparoscopic and robotic surgery.
In Innovations, he has performed several first ever done surgical procedures, including the first Robotic single port surgery through the belly button in 2008, the first completely transvaginal kidney removal in 2009, and the first robotic perineal prostatectomy in 2014 Dr. Kaouk holds 2 USA patents for medical devices used during partial nephrectomy and in robotic surgery.

Since 2005, Dr. Kaouk has served on committees at the national and local levels. From 2005-2008, he served in the American Urological Association’s Urologic Diagnostic and Therapeutic Imaging Task Force, from 2006-2010 he was on the Guidelines for the Management of small Renal Masses committee. Currently Dr Kaouk serves as Chairman elect on the AUA New Technology and Imaging committee, and is President Elect of (SURS) Society of Urologic Robotic Surgery. Dr Kaouk is associate editor of Urology journal.

Dr Kaouk have lectured in 130 scientific meetings, chaired 24 urologic meeting and performed live surgery in 18 medical centers worldwide. He authored 460 peer reviewed scientific publication, 26 book chapters and hundreds of scientific abstracts and surgical movies. Dr Kaouk received 32 honors and awards including Cleveland clinic innovator award twice, Teacher of the Year award, and EndoUrology 2017 Best Fellowship Program Director Award.

Presently, Dr Kaouk holds membership with the American Urological Association, the Endourological Society, Society of Urologic Oncology, Society of Robotic Surgery, and the Lebanese Order of Physicians. He is a fellow of the American college of Surgeons.

Christopher W. Ogden

Urology Consultant
The Royal Marsden NHS Foundation Trust
London, England, United Kingdom