- 2018 case
- Late 60s Patient
- Pre-operative PSA of 5.6
- Biopsy pathology Gleason score 3+4=7
- Bilateral nerve-sparing
Setup and initial approach | Bladder neck dissection | Nerve-sparing | Apical dissection | Urethro-Vesical Anastomosis
Equipment needed: Robot; Robotic and assistant ports; Robotic instruments: monopolar scissor, fenestrated bipolar grasper, prograsp; Robotic camera and 0-degree robotic lens; Endo-GIA Vascular stapler with a 45mm vascular staple load
General Set-up Hints
- Orogastric tube to decompress the bowels
- Low lithotomy (or supine if using Davinci Xi system) position with the arms completely padded with foam and secured at the sides.
- Sequential compression devices of the lower extremities to prevent DVT.
- Foley catheter placed transurethrally sterilely on the field.
Bladder Neck Dissection
Set up: Removal of periprostatic fat to delineate the bladder neck, ligation of the superficial dorsal venous complex with an endo-GIA stapler, placement of a back bleeding stitch on the anterior surface of the prostate to be utilized for retraction. Elevate the prostate with the fourth arm using this stitch.
- Identify the bladder neck area by demonstrating the contour of the prostate and its junction with the bladder, using the robotic instruments and/or tugging on the catheter.
- Make an anterior incision by cleaving the bladder from the prostate.
- Upon bladder entry, deflate Foley balloon, pull the catheter back and elevate the prostate toward the anterior abdominal wall.
- Incise the bladder neck mucosa posteriorly.
- Proceed with posterior bladder neck dissection down until the space containing the seminal vesicles and vasa is identified.
Tips and tricks:
- Be as wide as possible anteriorly, don’t work in a hole
- Repeat the first step as needed, to demonstrate the contour of the prostate and its junction with the bladder, to ensure you are at the bladder neck
- Posteriorly, be careful with lateral dissections to avoid button-holes in the bladder
- Preoperative MRI may be useful for approaching large gland/median lobe
Set up: Orientate the prostate to provide a lateral view.
- Addressing the right side first, incise the lateral prostatic fascia until you identify the capsule of the prostate.
- Carry the dissection out to the apex and then back to the base of the prostate.
- Then begin to brush that layer out laterally to begin dropping the neurovascular bundles off of the prostate.
- Elevate the prostate and address the right prostate pedicle.
- Develop windows within the pedicle, ligate small bundles of tissue with Hemo-lock clips and divide them with shears.
- Carry this dissection distally to the point where you had incised the lateral prostatic fascia.
- At that juncture, the neurovascular bundle should be gently swept away from the prostate out toward the apex.
- Perform an identical dissection on the left side.
Tips and tricks
- Minimize the use of cautery, particularly monopolar cautery to prevent damage the neurovascular bundles
Set up: Put the prostate on gentle traction towards the head; ensure the Foley catheter is in place across the urethra
- Identify the urethra
- Confirm that the neurovascular bundle dissection extended beyond the urethra-prostate junction on both sides.
- Divide the remaining apical attachments on both sides.
- Incise the urethra with the scissors, identify the Foley catheter, pull the catheter back and divide the posterior urethra and the recto-urethralis muscle.
Tips and tricks: Check with assistant to ensure Foley is across the urethra before cutting, may fall out; no or minimize use of cautery
Equipment needed: Two needle drivers; A double arm 2-0 V-loc suture
- Begin the anastomosis at six o'clock on the bladder neck (outside in)
- Place each suture at the six o’clock position on the urethral stump (inside out)
- Draw the bladder down to the urethral stump; make sure it is not under tension
- Run each suture taking precise bites of bladder neck and urethral mucosa and musculature.
- Reverse one of the sutures
- Place a fresh Foley catheter inserted transurethrally across the anastomosis. Ensure no difficulty, inflate balloon, irrigate to ensure no leak before tying
- Tie the running anastomosis suture at the 12 o'clock position.
Tips and tricks:
- Always check to make sure the catheter is not cut by the suture with every bite through the urethra
- Use a fresh final Foley catheter
- Inflate the balloon with 10 cc initially prior to irrigation. After irrigation and tying the knot, inflate the balloon to approximately 15 cc total
- Reconstruct bladder neck as needed
- Not all leaks need to be repaired; refrain from taking down the anastomosis unless absolutely necessary
- Consider coude tip catheter or cystoscopy and placement of catheter over wire if difficulty with passage.