Surgeon 029 – RP

• 2018 case
• Mid 40s Patient
• Pre-operative PSA of 7.1
• Biopsy pathology Gleason score 3+4=7
• T1c
• Bilateral nerve-sparing

Text Narration

Bladder neck dissection | Nerve-sparing | Apical dissection

Bladder neck dissection:

Setup:

I like to start with a 30 down lens.  The fourth arm is used to retract the bladder cephalad.  I try to start the incision a little bit behind where the bladder fibers insert into the prostate.  This is especially the case if there is cancer in the base of the prostate to avoid a positive bladder neck margin. 

Approach:

Once the incision is made in the midline I would like to carry it laterally onto the fat between the prostate and the bladder.  Tip: This will facilitate the dissection later after one goes through the bladder neck for easier identification for separating the prostate from the bladder.  Once the bladder neck is entered anteriorly the Foley balloon is deflated and the catheter is pulled through the opening in the bladder.  The eye of the Foley is grasped using the fourth arm and it is held up high in the pelvis.  The distal end of the Foley is placed on traction.  Tip: This helps to elevate the bladder neck.  If there is a median lobe present, the fourth arm instead is used to pull up directly on the median lobe rather than the Foley itself.  Once the inside of the bladder neck is exposed I like to continue by making my incision in the midline to separate the bladder neck from the prostate.  I then carry the incision laterally using the previous lateral incisions as landmarks.  Tip: If I see that the bladder neck is too patulous, I like to narrow it to at this point in the operation rather than after the prostate has been removed.  Although it disrupts the flow of the operation, the bladder neck is still held up and easier to visualize than after the prostate has been removed.  I like to use a 3-0 Monocryl dyed suture on an RB1 needle for the closure.  The bladder is continued to be separated from the prostate posteriorly until the vasa deferentia is encountered.  This is the landmark that I look for to know that I am in the right plane. I like to continue to take the bladder down as much as possible to facilitate the subsequent dissection of the vasa deferentia and seminal vesicles.

Nerve sparing:

Approach:

I actually start the nerve sparing after the prostate has been separated from the rectum, from below the prostate, after the seminal vesicle dissection. After this plane has been separated as wide as possible, I work on also separating the inside L and right corners of the prostate from their fascial attachments. 

Time point:

This video starting at the 1:35:50 point shows dissecting this L corner so that a weck clip can be placed across the fascial attachments so that incising  across them helps to open the corner up. The same is done in the R corner starting at the 1:38:40 point. Subsequently, I then switch from a 30 degree down lens to a 30 degree up lens manually. Tip: This is much easier to do with the Xi robot- which is what I now use- where all one has to do is push the toggling button that switches the 30 degree lens up and down.This allows better visualization to see below the prostate rather than for seeing above the rectum. 

Between the 1:40 and 1:44 point, with the prostate being pulled up with outward tractions on the S.V., using the robotic  4th arm Prograsp on the L and the wavy grasper by the bedside assistant on the  R, one then dissects the plane between the  nerve bundle and the underside of the prostate. One uses the L hand Maryland to pull up on the prostate and the scissors to get the plane started and push the edge of the bundle posteriorly to create a plane between the two. Tip: There can be some oozing of blood during this procedure and one needs to be careful not to get into the prostate.  One can continue the plane of dissection laterally or proximally and distally depending on where it is easiest to continue the plane. The more dissecting one can do from below, the easier it sets up the dissection that needs to be completed from above. This is done bilaterally.  After one has done as much as possible from below, attention is now turned to the more traditional nerve sparing portion of the operation which is done from above.

Set up:

For the nerve sparing starting from above, which starts where one clicks directly on the video for nerve sparing, I switch back to a 30 degree down lens.  Tip: I feel that it gives me better visibility posterior laterally where I can see the bundle be completely released from the side of the prostate. 

Approach:

I start on the left side.  The fourth arm which contains the Prograsp grabs the left base of the prostate and pulls it medially to help expose the region of the left neurovascular bundle.  The left arm which holds the bipolar Maryland grasper pulls the thin layer of levator fascia, which covers the superior margin of the neurovascular bundle laterally while the scissors on the right hand help to create a plane to separate the neurovascular bundle from the lateral prostatic fascia both sharply and bluntly depending on how the plane looks.  Tip: The plane is developed throughout the length of the bundle trying to continue it posterior laterally where the tissue separation allows the plane to develop the most naturally. One tries to “connect the dots” to connect to the plane that was established from the earlier dissection that was started from below.  When it does not look like a plane is progressing like it should, I try and move to another area of the bundle to see if I can get the plane going in another location.  The bipolar Maryland tips are used to both dissect the plane between the bundle and side of the prostate along with the point of the scissors when sharp dissection is needed.  There can be oozing of blood during the procedure.  Unless it is arterial, I just let it be since it significantly diminishes once the prostate is removed. Tip: One has to be careful during the separation of the bundle from the prostate to not inadvertently enter the capsule of the prostate.  I try to minimize the amount of traction on the bundle itself.  There is less traction on the bundle when the nerve dissection is done in a retrograde fashion, as shown in this case compared to an antegrade approach which requires much more traction on the bundle as the bundle is dissected in an antegrade fashion.  I like to spread the jaws of the bipolar Maryland longitudinally parallel to the bundle, pulling the bundle laterally while the scissors work the space medial to the bundle to separate the bundle from the side of the prostate. Once one finds the plane that was established from below, the rest of dissection becomes much easier.  Once I see the perirectal fat, then I know that the bundle at this point is completely dissected away from the side of the prostate.   Tip: It is much easier to then continue the plane both distally and proximally once the bundle is completely away from the side of the prostate again after the perirectal fat can be seen posteriorly.  Once the bundle is dissected as proximally as one can, down to where the Prograsp is holding at the base of the prostate, then the Prograsp is repositioned down to the left perivesical tissue close to the left base bundle.  The bedside assistant grabs the left seminal vesicle using the wavy graspers and pulls it medially.  One can then identify the bundle as it courses proximally and complete the dissection of attachments between the bladder and the prostate coursing to the left superior base of the prostate.  Tip: During this portion, it is important to identify the location of the neurovascular bundle posterior laterally to avoid injuring it during this portion of the procedure.  These attachments are taken using Weck clips.  Light cautery can also be used.  After the attachments to the L base of the prostate are taken, attention is turned to the contralateral side.  Here now the right base of the prostate is pulled medially with the Prograsp on the fourth arm of the robot.  The Maryland on the left arm is used to help lift up the levator fascia away from the prostatic fascia on the right side of the prostate.  The scissors are used to dissect the levator fascia away from the R side of the prostate to expose the plane between the neurovascular bundle and the prostate posterior laterally.  One works along the length of the bundle until one finds a plane that allows for the separation of the bundle from the side of the prostate to continue.  Again this is done using a retrograde approach.  On the right side of the prostate, the bipolar Maryland in the L arm pulls the prostate medially.  It helps to open up the jaws of the Maryland.  The right arm which has the monopolar scissors dissects the bundle laterally away from the posterior lateral side of the prostate.  Tip: Once one can see posteriorly all the way down to the perirectal fat between the prostate and bundle, this makes the dissection much easier as previously mentioned.  One then continues the plane proximally until encountering the pro-grasp in the fourth arm holding the right base of the prostate.  Subsequently the fourth arm is repositioned and is used to grab the right seminal vesicle pulling it medially.  Tip: One can then identify the right neurovascular bundle and locate it at the R base of the prostate to avoid injuring it by staying above it when taking the connections between the bladder and superior aspect of the R base of the prostate.   Once the bundle is completely free from the right base of the prostate, the Prograsp can then pull the right base of the prostate and rotate it medially allowing exposure of the distal part of the bundle and then allow its complete dissection distally. Tip:  It is always best to leave the distal dissection of the bundle until the right base of the bundle is completely dissected since one can then mobilize the prostate much easier to get to the distal bundle for an easier dissection.

Apical dissection:

Setup:

For the apical dissection I go back to the 0 degree lens.  

Approach:

I make sure that there is a Foley catheter in the urethral with the balloon inflated since the catheter can slip out if the balloon is not inflated. The fourth arm is used to grab the base of the prostate and pull it caudad for traction.  I continue using my Maryland grasper on the left hand and hot monopolar curved scissors on the right hand.  I start by cauterizing the deep dorsal vein complex just behind the stitch that I have used to tie off the deep dorsal vein complex. The L hand uses downward traction on the proximal DVC.  After I have gone partly through the DVC, I readjust the fourth arm Prograsp on the base of the prostate to give me more countertraction.  I carefully go through that the dorsal vein complex since I want to make sure I do not inadvertently cut into the membranous urethra too distally since urethral length equates to postoperative urinary continence and also quicker return to continence.  I also look on each side of the urethra to make sure that I have identified the neurovascular bundles as one can inadvertently cut into them if one is not aware of their location relative to the urethra.  I also incise attachments lateral to the urethra such as to the rectourethralis attachments to facilitate mobilization of the urethra.  Tip: It is important to have a good field of view during this portion of the case. Bleeding from the DVC can obscure visualization of the urethra and affect the quality of the apical dissection. I like to go through the anterior urethra using cold scissors at the just distal to the apical notch of the prostate. Tip: One can dissect the apical notch caudad if needed to gain extra membranous urethral length if one feels that one has a short urethral stump provided the tumor is not apical.   Once the anterior urethral wall is incised and I see the Foley catheter, I get my Maryland behind the urethra to pull up on it to facilitate its dissection away from the posterior prostate lip.  The Foley balloon is deflated and the Foley catheter is pulled back so that the tip of the Foley is seen and then the posterior urethra is incised just distal to the posterior lip of the apical prostate.  In this particular case, this patient has a lip of prostatic tissue that extends more distally than the anterior lip of the prostatic notch.  After the prostate is completely free, it is placed in the Endo Catch bag.  I then like to place the fourth arm on the bladder and pull it cephalad.  The prostate bed is suctioned and irrigated.  I look to see whether or not I need to take any distal margins of any tissue that I think may look suspicious for residual prostate tissue left on the urethral stump.    I try and take care of any obvious bleeding before starting the anastomosis.