Surgeon 051 – RP

• 2018 case
• Late 60s Patient
• Pre-operative PSA of 5.6
• Biopsy pathology Gleason score 3+4=7
• T1c
• Bilateral nerve-sparing

Text Narration

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.

Approach:  

• 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

Nerve-Sparing Procedure

Set up: Orientate the prostate to provide a lateral view.

Approach: 

• 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

Apical Dissection

Set up: Put the prostate on gentle traction towards the head; ensure the Foley catheter is in place across the urethra

Approach:

• 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

Urethro-Vesical Anastomosis

Equipment needed: Two needle drivers; A double arm 2-0 V-loc suture  

Approach: 

• 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.