V08-01: Challenging Scenarios During Bladder Neck Dissection in Robot-Assisted Laparoscopic Radical Prostatectomy
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 BN masses, ureter orifices (UO) too close to the BN and salvage RALP. In this video, we present the tips and tricks to managing difficult BN scenarios.
Challenging BN scenarios were summarized as: 1-BN masses that distort anatomic planes, 2-Too close UOs 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 lateral BN fibers to increase the exposure. Following delivery of ML out of the BN, it is elevated with the 4th arm. This facilitates identification of UOs before making the posterior BN incision. In similar cases, an unrecognized ureterocele may mimic as ML. However, consistency of the mass is softer and ipsilateral UO may not be identified. The sac is incised transversely after delivery from the BN, establishing the intraoperative diagnosis of extravesical ureterocele. UOs too close to the BN pose a high risk for ureteral injury. This case presented to our clinic with anuria 2 days after RALP performed at an outside hospital. Review of his intraoperative video showed bilateral ureteral ligation during vesicourethral (VU) anastomosis. UOs were noted to be in close proximity to the BN before posterior resection. During reoperation, we performed midline anterior cystotomy to access the VU anastomosis, used iv. dye to identify the UOs, and placed bilateral ureteral stents following take-down of previous anastomotic sutures. Our re-do VU anastomosis provided a successful outcome. We have noted proton beam radiation as one of the most difficult to handle in salvage RALP. In such cases, anterior BN and the small prostate are fused anteriorly to pubic tubercle. Following BN dissection and prostate resection, it is challenging to perform VU anastomosis due to extensive pelvic fibrosis. We release the posterior BN attachments for further bladder mobilization. If tension-free anastomosis is still not provided, sufficient extra-length can be 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.