Approach to the Bladder Neck During Robot-Assisted Radical Prostatectomy

Abstract

Introduction: Dissection of the bladder neck represents one of the most challenging steps of robot-assisted radical prostatectomy, particularly in the presence of difficult anatomic conditions. These can be natural, such as the presence of a median lobe, or due to previous surgery, as in the case of previous surgery for benign prostatic hyperplasia. Materials and Methods: A standardized approach to the bladder neck was applied to robot-assisted radical prostatectomy performed with the Da Vinci Surgical System. Results: A 30° camera is used during the bladder neck dissection. The line of dissection of the anterior bladder neck can be identified operating traction with the fourth arm, with a symmetric pressure of the robotic arms or pulling the catheter. The use of a low monopolar energy helps in maintaining the features of the tissue, thus distinguishing the muscular tissue of the detrusor from the glandular tissue of the prostate. The approach to the posterior bladder neck is based on two opposite tractions: that on the catheter superiorly and that on the bladder neck inferiorly. The incision begins on the lateral aspects of the detrusor. After releasing the lateral muscular fibers, and so transferring the traction on the midline, the bladder neck is dissected. A constant traction is made by means of the left arm; the scissors, with separate blades, develop the surgical plane, until the seminal vesicles are visible. The assistant can help providing downward traction with the sucker. In the presence of a median lobe, traction on the catheter can help identifying an eventual asymmetry of the lobes. The dissection of the anterior bladder neck begins again on the midline, until the catheter is identified and suspended. The lateral aspects of the detrusor are separated, while traction is exerted with the left arm. When the median lobe becomes evident, the point of traction is changed to the median lobe itself to improve exposition, while the assistant can help again providing downward traction. We do not use stitches on the median lobe for counter traction. Special attention should be given to the thickness of the posterior aspect of the bladder neck and to identification of the ureteral orifices. The bladder neck defect after transurethral resection of prostate (TURP) can create many difficulties in the dissection. The catheter is pulled cranially and superiorly, exposing the large defect of the bladder neck. Here is even more important to separate the lateral aspects before dissection of the posterior bladder neck. The presence of scar tissue can make it more difficult to distinguish the muscular from the glandular tissue. When the bladder neck results are large, we perform bilateral plication over the lateral aspects of the bladder using sutures of 3-0 poliglecaprone, 13 cm long, in an RB-1 needle, as described by Lin et al.1 Conclusions: A standardized approach to the bladder neck can be implied even in the presence of difficult anatomical conditions. No competing financial interests exist. Runtime of video: 7 mins