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V1234 RECONSTRUCTION OF THE POSTERIOR BLADDER NECK FOLLOWING UNCOMMON MISHAPS DURING ROBOTIC ASSISTED RADICAL PROSTATECTOMY
Vol. 187, No. 4S, Supplement, Monday, May 21, 2012
To improve exposure, a forceps held by the assistant comes from the left side to reach and pull medially the umbilical artery. After proximal dissection with harmonic scalpel, the forceps connected to the fourth arm retracts the external iliac vein laterally, to improve the access to the obturator fossa and to the internal iliac artery in depth. When dissection proceeds on the left side, the assistant retracts the iliac vessels laterally to allow the access to the obturator fossa and the fourth arm grasps the umbilical artery. The right supra-umbilical trocar pull the peritoneum up to the common iliac artery. With these two differents optimal exposures, on the right and on the left sides, extended pelvic lymph node dissection is performed safely, in particular in depth near the internal iliac vein and near the obturator nerve. CONCLUSIONS: This surgical technique for extended pelvic lymph node dissection is safe, standardized and reproducible. The fourth arm of the Da Vinci System provides significant assistance to perform Robotic-assisted laparoscopic extended pelvic lymph node dissection for prostate cancer. Source of Funding: None
V1233 A MODIFICATION FOR CONTROLLING THE DORSAL VASCULAR COMPLEX IN ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY Rens Jacobs*, Kevin L.J. Rademakers, Laurent M.C.L. Fossion, Kevin De Laet, Veldhoven, Netherlands INTRODUCTION AND OBJECTIVES: Controlling the dorsal vascular complex (DVC) in endoscopic extraperitoneal radical prostatectomy (EERPE) by (selective) suture ligation remains a challenging step during apical dissection of the prostate. In this study we report our results of the first 212 cases in which ligation of the DVC was omitted. The aim was to evaluate the consequences of this sutureless transection in terms of blood loss and oncologic control. METHODS: Between January 2006 and September 2011 212 patients underwent an EERPE for clinically localized or locally advanced prostate cancer in two different centers. All patients were operated by the same urologist. One hundred and forty-three patients (67.5%) simultaneously underwent an extended laparoscopic pelvic lymph node dissection (LPLND). EERPE was performed according an antegrade manner, as described by Stolzenburg. After complete dissection of the prostate the DVC was selectively divided using bipolar forceps and harmonic scalpel. Blood loss, transfusion need, operative time, pathological stage, margin status and complications were evaluated. RESULTS: Mean age of all patients was 64 years (44-74) and mean PSA was 13.2 ng/ml (0.87-190). Mean follow up was 28 months. Mean Gleason score was 6.6. Pathological stage was pT2 in 146 patients (68,9%), pT3 in 63 patients (29,7%), pT4 in 1 patient (0,47%) and pTx in 2 patients (0,94%). Positive margin rates for pT2 and pT3 tumors were 25.3% and 61.9% respectively. Of all positive margins 53.2% was located apically. The mean operative time was 180 min (105-364) for EERPE and 254 min (120-430) for EERPE with LPLND. The median estimated blood loss was 500 ml (50-4000). Six patients (2.8%) had a blood loss more than 2000 ml. Nine patients (4.2%) had a blood transfusion with a mean number of packed cells of 2.9 (1-6). Only one patient needed an extra suture ligation after transection of the DVC. One open conversion was performed due to bleeding from the internal iliac vein during LPLND. CONCLUSIONS: Sutureless transection of the DVC in EERPE is a feasible modification and is associated with an acceptable blood loss and oncologic control. It is not associated with a risk for additional complications. Because the 212 patients in this study were part of the surgeon’s learning curve even better results are to be expected over time. Functional outcomes of this technique need to be evaluated. Source of Funding: None
THE JOURNAL OF UROLOGY姞
e499
V1234 RECONSTRUCTION OF THE POSTERIOR BLADDER NECK FOLLOWING UNCOMMON MISHAPS DURING ROBOTIC ASSISTED RADICAL PROSTATECTOMY Lanna Cheuck*, Reza Ghavamian, Bronx, NY INTRODUCTION AND OBJECTIVES: Robotic radical prostatectomy is the most commonly employed surgical procedure of choice for the treatment of localized prostate cancer in the United States. With increasing utilization of the surgical platform a wide array of complications can occur. In this video, we demonstrate techniques for reconstruction of the bladder neck after some uncommon mishaps during robotic radical prostatectomy. METHODS: This video demonstrates 3 case scenarios where inadvertent injuries to the posterior bladder neck occurred during the dissection of the posterior bladder neck. The video is divided into 3 segments where these separate cases are presented and techniques and principles of repair for all three cases are demonstrated. RESULTS: In all three cases, the injuries were adequately repaired and techniques for reconstruction are demonstrated. Tips and tricks to ensure an optimal outcome are discussed. The first case demonstrates a button hole injury of the posterior bladder neck and mid-trigone. The second case demonstrates inadvertent extensive bipolar injury of the posterior bladder neck. The surgeon intended to utilize the monopolar cautery on the robotic scissors. The wrong pedal was pressed and the bipolar cautery was deployed on the bipolar grasper that was holding the bladder neck, cauterizing the midtrigone and the posterior bladder neck. In both these cases the injury was recognized and repaired. In both cases the subtrigonal smooth muscle layer (vesicoprostatic smooth muscle layer) was utilized as a flap and bolster to reinforce and vascularize the bladder neck. The third case demonstrates subtrigonal ureteral transection in a patient with extensive scar tissue from a previous microwave therapy of the prostate, that was recognized and repaired. The technique for a stented ureteral repair is demonstrated. CONCLUSIONS: With increasing utilization of robotic prostatectomy, certain uncommon complications can arise even in experienced hands. We demonstrate certain uncommon injuries to the posterior bladder neck and their repair. It is important to recognized these complications intraoperatively and employ sound and established surgical principles to reconstruct the posterior bladder neck. Source of Funding: None
V1235 ANATOMICAL BASIS FOR THE CATHETER LESS ROBOTIC RADICAL PROSTATECTOMY Balaji Kalyanaraman*, Krishnanath Gaitonde, John Babcock, Ahmad Hamidinia, Nilesh Patil, Cincinnati, OH INTRODUCTION AND OBJECTIVES: To describe the surgical steps involved in performing a catheter less robotic radical prostatectomy. METHODS: At the University of Cincinnati we perform the catheter less robotic radical prostatectomy in appropriate patients with localized prostate cancer. After the prostate is disconnected from the urethra and bagged, the following steps are performed: 1) The posterior reconstruction with the Denonvillier’s fascia i.e Rocco stitch. 2) Then, the vesico-urethral anastomosis is performed using a continuous technique as described by van Velthoven. 3)The suture used is a self retaining barbed absorbable monocryl suture (3-0)which provides tight approximation of the mucosal edges of the bladder and urethra. 4) At the end of the anastomosis 240 ml of normal saline is instilled in the bladder to detect the water tightness of the anastomosis. 5) A 14 Fr. suprapubic tube(SPT) is intoduced into the bladder via the anterior abdominal wall.
To improve exposure, a forceps held by the assistant comes from the left side to reach and pull medially the umbilical artery. After proximal dissection with harmonic scalpel, the forceps connected to the fourth arm retracts the external iliac vein laterally, to improve the access to the obturator fossa and to the internal iliac artery in depth. When dissection proceeds on the left side, the assistant retracts the iliac vessels laterally to allow the access to the obturator fossa and the fourth arm grasps the umbilical artery. The right supra-umbilical trocar pull the peritoneum up to the common iliac artery. With these two differents optimal exposures, on the right and on the left sides, extended pelvic lymph node dissection is performed safely, in particular in depth near the internal iliac vein and near the obturator nerve. CONCLUSIONS: This surgical technique for extended pelvic lymph node dissection is safe, standardized and reproducible. The fourth arm of the Da Vinci System provides significant assistance to perform Robotic-assisted laparoscopic extended pelvic lymph node dissection for prostate cancer. Source of Funding: None
V1233 A MODIFICATION FOR CONTROLLING THE DORSAL VASCULAR COMPLEX IN ENDOSCOPIC EXTRAPERITONEAL RADICAL PROSTATECTOMY Rens Jacobs*, Kevin L.J. Rademakers, Laurent M.C.L. Fossion, Kevin De Laet, Veldhoven, Netherlands INTRODUCTION AND OBJECTIVES: Controlling the dorsal vascular complex (DVC) in endoscopic extraperitoneal radical prostatectomy (EERPE) by (selective) suture ligation remains a challenging step during apical dissection of the prostate. In this study we report our results of the first 212 cases in which ligation of the DVC was omitted. The aim was to evaluate the consequences of this sutureless transection in terms of blood loss and oncologic control. METHODS: Between January 2006 and September 2011 212 patients underwent an EERPE for clinically localized or locally advanced prostate cancer in two different centers. All patients were operated by the same urologist. One hundred and forty-three patients (67.5%) simultaneously underwent an extended laparoscopic pelvic lymph node dissection (LPLND). EERPE was performed according an antegrade manner, as described by Stolzenburg. After complete dissection of the prostate the DVC was selectively divided using bipolar forceps and harmonic scalpel. Blood loss, transfusion need, operative time, pathological stage, margin status and complications were evaluated. RESULTS: Mean age of all patients was 64 years (44-74) and mean PSA was 13.2 ng/ml (0.87-190). Mean follow up was 28 months. Mean Gleason score was 6.6. Pathological stage was pT2 in 146 patients (68,9%), pT3 in 63 patients (29,7%), pT4 in 1 patient (0,47%) and pTx in 2 patients (0,94%). Positive margin rates for pT2 and pT3 tumors were 25.3% and 61.9% respectively. Of all positive margins 53.2% was located apically. The mean operative time was 180 min (105-364) for EERPE and 254 min (120-430) for EERPE with LPLND. The median estimated blood loss was 500 ml (50-4000). Six patients (2.8%) had a blood loss more than 2000 ml. Nine patients (4.2%) had a blood transfusion with a mean number of packed cells of 2.9 (1-6). Only one patient needed an extra suture ligation after transection of the DVC. One open conversion was performed due to bleeding from the internal iliac vein during LPLND. CONCLUSIONS: Sutureless transection of the DVC in EERPE is a feasible modification and is associated with an acceptable blood loss and oncologic control. It is not associated with a risk for additional complications. Because the 212 patients in this study were part of the surgeon’s learning curve even better results are to be expected over time. Functional outcomes of this technique need to be evaluated. Source of Funding: None
THE JOURNAL OF UROLOGY姞
e499
V1234 RECONSTRUCTION OF THE POSTERIOR BLADDER NECK FOLLOWING UNCOMMON MISHAPS DURING ROBOTIC ASSISTED RADICAL PROSTATECTOMY Lanna Cheuck*, Reza Ghavamian, Bronx, NY INTRODUCTION AND OBJECTIVES: Robotic radical prostatectomy is the most commonly employed surgical procedure of choice for the treatment of localized prostate cancer in the United States. With increasing utilization of the surgical platform a wide array of complications can occur. In this video, we demonstrate techniques for reconstruction of the bladder neck after some uncommon mishaps during robotic radical prostatectomy. METHODS: This video demonstrates 3 case scenarios where inadvertent injuries to the posterior bladder neck occurred during the dissection of the posterior bladder neck. The video is divided into 3 segments where these separate cases are presented and techniques and principles of repair for all three cases are demonstrated. RESULTS: In all three cases, the injuries were adequately repaired and techniques for reconstruction are demonstrated. Tips and tricks to ensure an optimal outcome are discussed. The first case demonstrates a button hole injury of the posterior bladder neck and mid-trigone. The second case demonstrates inadvertent extensive bipolar injury of the posterior bladder neck. The surgeon intended to utilize the monopolar cautery on the robotic scissors. The wrong pedal was pressed and the bipolar cautery was deployed on the bipolar grasper that was holding the bladder neck, cauterizing the midtrigone and the posterior bladder neck. In both these cases the injury was recognized and repaired. In both cases the subtrigonal smooth muscle layer (vesicoprostatic smooth muscle layer) was utilized as a flap and bolster to reinforce and vascularize the bladder neck. The third case demonstrates subtrigonal ureteral transection in a patient with extensive scar tissue from a previous microwave therapy of the prostate, that was recognized and repaired. The technique for a stented ureteral repair is demonstrated. CONCLUSIONS: With increasing utilization of robotic prostatectomy, certain uncommon complications can arise even in experienced hands. We demonstrate certain uncommon injuries to the posterior bladder neck and their repair. It is important to recognized these complications intraoperatively and employ sound and established surgical principles to reconstruct the posterior bladder neck. Source of Funding: None
V1235 ANATOMICAL BASIS FOR THE CATHETER LESS ROBOTIC RADICAL PROSTATECTOMY Balaji Kalyanaraman*, Krishnanath Gaitonde, John Babcock, Ahmad Hamidinia, Nilesh Patil, Cincinnati, OH INTRODUCTION AND OBJECTIVES: To describe the surgical steps involved in performing a catheter less robotic radical prostatectomy. METHODS: At the University of Cincinnati we perform the catheter less robotic radical prostatectomy in appropriate patients with localized prostate cancer. After the prostate is disconnected from the urethra and bagged, the following steps are performed: 1) The posterior reconstruction with the Denonvillier’s fascia i.e Rocco stitch. 2) Then, the vesico-urethral anastomosis is performed using a continuous technique as described by van Velthoven. 3)The suture used is a self retaining barbed absorbable monocryl suture (3-0)which provides tight approximation of the mucosal edges of the bladder and urethra. 4) At the end of the anastomosis 240 ml of normal saline is instilled in the bladder to detect the water tightness of the anastomosis. 5) A 14 Fr. suprapubic tube(SPT) is intoduced into the bladder via the anterior abdominal wall.