DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Prostate cancer.
POSTOPERATIVE DIAGNOSIS: Prostate cancer.
OPERATION PERFORMED: Robotic prostatectomy with bilateral nerve sparing and bilateral lymph node dissection.
SURGEON: John Doe, MD
ANESTHESIA: General with local.
INDICATIONS FOR OPERATION: This (XX)-year-old patient was identified with rising PSA, and at time of presentation to Urology, this was 10 and a biopsy revealed 5 cores of prostate cancer, Gleason grade 6. We discussed options and the patient settled on robotic removal with nerve sparing.
DESCRIPTION OF OPERATION: With the patient under general anesthetic in lithotomy position, after suitable preparation and draping, a Foley catheter was inserted. A supraumbilical midline incision was made and peritoneum entered under direct vision. The balloon trocar was introduced, pneumoperitoneum established and 0 degree laparoscopy confirmed suitable anatomy for continued laparoscopy. The patient was placed in Trendelenburg and robotic ports were inserted; two 8 mm on the left, one 8 mm, one 5 x 12 mm, and one 5 mm on the right, all under direct vision with no vascular incident. The robot was then docked and the remainder of the procedure was performed on the console. The instruments were used to take down peritoneum from left internal ring to right internal ring transecting urachus and obliterated umbilical bilaterally. Fourth arm was used for cephalad traction of the urachus. Preprostatic fat was cleared.
Endopelvic fascia was incised bilaterally and puboprostatic sharply divided. Dorsal venous complex was well exposed and was secured with a 3.5 vascular load with good effect. The transition between bladder neck and base of the prostate was identified and opened transversely. Catheter was identified, deflated and withdrawn into the prostate. The inspection of the anterior of the bladder revealed a modest median lobe. This was carefully circumscribed without entering the prostate tissue and posterior bladder neck separated from the base of the prostate. Ureteral orifices were well away from the resected margin. The fourth arm was then used for anterior traction of the median lobe, allowing development of posterior prostate. Lateral pedicles at this point were still bladder based and were controlled with bipolar cautery. After identifying seminal vesicles and mobilizing these to the apex bilaterally and securing apical vessels with bipolar, the seminal vesicles and ampulla of vas were used for anterior traction.
At this point, the lateral pedicles were no longer controlled with cautery, and after thinning them out appropriately alongside the prostate capsule, these were clipped with robotic arm Weck clips. No thermal energy was used at this point. Lateral prostatic fascia was opened prior to this maneuver and neurovascular bundles swapped laterally and posteriorly. Denonvilliers fascia was opened transversely behind the seminal vesicles and this was swept laterally to facilitate lateral neurovascular bundle release. Some venous oozing was tolerated at this point to avoid any cautery. The lateral pedicles with neurovascular bundle sparing continued satisfactory towards the apex. The lateral fascia was opened up to the urethra avoiding any transaction of the neurovascular bundle. There did not appear to be any obvious involvement beyond the capsule. At this point, all that remained was the urethra. This was sharply incised without cautery anteriorly and catheter retrieved into the penile urethra and posterior urethra divided. The prostate was liberated. The area was inspected and venous oozing had stopped at this point. The same instruments were then used for node dissection.
The prostate was placed in the left lower quadrant for later retrieval. First, the left pelvic dissection was performed and then the right. Limits of dissection were noted of Cloquet caudad, bifurcation cephalad, inguinal ligament anterior and internal iliac posteriorly. Obturator nerve was identified and spared at all times. Lymphatic and vessels were sealed with cautery. The specimens were retrieved through the 5 x 12 port. Instruments were then exchanged for the needle drivers and a double-armed 3-0 Monocryl was used for a continuous bladder neck to urethra anastomosis starting outside-in at 6 o’clock at bladder neck and continuing sequentially through the urethra and bladder neck. A fresh Foley catheter was placed under direct vision before closure. The sutures were tensioned up and tied to themselves at 12 o’clock across the anastomosis. The bladder was irrigated and was free of any leak and free of any bleeding. The robot was then removed and the specimen was retrieved through the midline port with an endosac and a #19 Blake drain brought out through the left lower quadrant 8 mm port. Fascia was enlarged with cautery and specimen delivered. Fascia was closed with interrupted figure-of-eight Vicryl and skin edges approximated with Monocryl and dressings applied. The patient tolerated the procedure well and no complications were encountered during the case. The patient was transferred to the recovery room in satisfactory condition. Sponge, needle and instrument counts were correct. Estimated blood loss was approximately 100 mL.
