V1858: Prostate-sparing radical cystectomy with prostatic capsule and vasa deferentia sparing by means of Millin prostatectomy.
VideoIntroduction and Objectives
Radical cystectomy (RC) is a major surgery with risks including incontinence, erectile dysfunction and loss of ejaculations. There are various approach how to improve functional results. One of the proposed methods is prostate sparing by various techniques. The objective is to present the technique of prostate-sparing RC (PSRC) with prostatic capsule and vasa deferentia sparing by means of Millin prostatectomy.
To describe the technique we present a case of 63 year healthy male with T2 N0 M0 urothelial bladder cancer located at the posterior bladder wall. His erectile function was normal and he strongly wished to maintain ejaculation. Following a discussion on management options a PSRC was chosen. His PSA was 1,67 and due to the type of treatment 12-core prostate biopsy was performed with negative result. He underwent 2 courses of neoadjuvant chemotherapy and robot-assisted PSRC was performed.
We use transperitoneal approach in Trendelenburg position. Bilateral extended pelvic lymph node dissection was performed initially with care not to divide vasa deferentia. Once completed posterior peritoneum is open above the tips of seminal vesicles a dissection is done laterally to isolate vas deference and ureters. Distal ureteral margins were sent for frozen section. Dissection continues posteriorly between vasa and seminal vesicles to identify the base of prostate. Then anterior incision of prostatic capsule is done and enucleation of adenoma is started. At the level of uretra catheter is clipped and divided. Afterwards the bladder is detached laterally to identify the sides of prostate. Opening of prostatic capsule is done posteriorly, extended ventrally on both sides and enucleation of adenoma is completed. The whole specimen is removed in the bag via small midline incision, which is also used for extracorporeal ileal neobladder formation with uretero-neobladder anastomosis as usually. Pouch is placed back to pelvis, laparotomy closed and robotic system redocked. Anastomosis of neobladder to the prostatic capsule is done with running 3/0 V-loc stitches and 2 Redon drains are placed. Final histology was pT0 pN0 (26/0) for bladder and no cancer in the prostate. Three weeks later the patients was continent and had penile tumescence.
PSRC is an alternative for highly selected patients who wish to maintain erectile function and/or ejaculation.Robotic–assistance may be beneficial for patient and surgeon. The surgeon needs to be familiar with the technique and adenoma enucleation may be more difficult in small prostates.