Category: Robotic Surgery: Lower Tract - Malignant
Introduction & Objective : During robotic assisted radical prostatectomy (RALP) the bladder neck (BN) can be a challenging scenario due to variations in anatomy. Some potential challenges include: Large median lobe (ML), unrecognized ureterocele, ureter orifices (UO) too close to the BN and salvage RARP after radiotherapy (XRT). In this video, we present the tips and tricks to managing difficult BN scenarios.
Challenging BN scenarios were summarized as follows: 1- Huge BN masses that distort anatomic planes, 2-UOs too close to BN that predispose ureteral injury/ligation, and 3- Prior XRT causing small prostate and extensive pelvic fibrosis. We presented our technique for each case scenario.
In patients with large ML, we divide the lateral BN fibers following anterior entry to increase exposure to the mass. Following delivery of ML out of the BN, it is elevated with the fourth arm. This maneuver facilitates the identification of UOs before making any incisions at the posterior BN. An unrecognized ureterocele may mimic as a ML. In this case, consistency of the mass is soft and ipsilateral UO may not be identified. The sac is incised transversely and delivered entirely out of the BN. Entry into the sac establishes the intraoperative diagnosis of ureterocele and helps to locate the UO.
UOs too close to the BN pose a high risk for ureteral injury. This case presented to our clinic with anuria 2 days after a RARP performed at an outside hospital. Review of his intraoperative video images showed bilateral ureteral ligation during BN reconstruction before vesicourethral (VU) anastomosis. UOs were in close proximity to the BN before posterior resection. During reoperation, we perform a midline anterior cystotomy to access the VU anastomosis, use iv. Methylene blue to identify the UOs, and place bilateral ureteral JJ stents following take-down of previous anastomotic sutures. Our re-do VU anastomosis provides a successful outcome.
In cases of salvage RARP, the anterior BN and prostate can be fused anteriorly to pubic tubercle. Following BN dissection and prostate resection, VU anastomosis can be challenging due to extensive pelvic fibrosis. We release the posterior BN attachments for further bladder mobilization. In case this does not provide a tension-free anastomosis, extra-length is achieved through anterior midline incision of the BN and “re-location” of the outlet.
Use of the 4th arm to increase exposure and facilitate location of UOs, and careful BN reconstruction are keys to prevent complications during challenging BN dissections. Anterior midline BN incision and BN “re-location” provide safe exposure and tension-free anastomosis in complex cases.
Travis Rogers– Florida Hospital Global Robotics Institute, Celebration, Florida
Fikret Onol– Florida Hospital Global Robotics Institute, Celebration, Florida
Hariharan Palayapalayam Ganapathi– Director of Clinical Outcomes, Florida Hospital, Celebration, Florida
Vipul Patel– Florida Hospital Global Robotics Institute, Celebration, Florida
Director of Clinical Outcomes