Cutting Edge Urology

T his PDF belongs to matthew.hooson@springer.co ROBOTIC SIMPLE PROSTATECTOMY • 11  Fig. 10: Bladder mucosa incision. With traction stitch retracted with fourth arm, bladder mucosa is incised between median lobe and bladder trigone. After a plane of dissection has been established posteriorly, the surgeon progresses both lat- erally and distally using a combination of blunt and sharp dissection (Fig. 11a). Bleeding vessels are coagulated concurrently using monopolar electrocautery. Once the posterior aspect of the adenoma has been separated from the compressed peripheral zone and prostate capsule, the dis- section proceeds along the lateral surface of the prostate adenoma, mobilizing the lateral aspect of the adenoma (Fig. 11b). The plane of dissection should hug the pearly white surface of the adenoma. Care should be taken to avoid transgressing the compressed peripheral zone and the prostate capsule. Once enough of the adenoma has been freed up, the previously placed stay suture in the median lobe is removed and the adenoma is grasped with a robotic tenaculum forceps brought in under vision through the fourth robotic arm. The tenaculum provides an excellent grip on the adenoma, and allows excellent traction and countertraction to aid in the dissection of the adenoma. During dissection of the adenoma, we maintain a ProGrasp™ in the left arm and the monopolar scissors in the right arm. As the dissection of the lateral aspect of the adenoma progresses distally, the previously made posterior mucosal incision is carried laterally in a circum- ferential fashion. The lateral aspect of the adenoma is mobilized down towards the apical tissue where the l ateral shoulders of the adenoma start tapering medially towards the membranous urethra. The anterior aspect of the adenoma mobilization is done last and the anterior bladder neck mucosa is i ncised with hot scissors at the 12 o’clock position and the dissection progresses distally along the an terio r surface of the adenoma (Fig. 11c, d). The dissection continues distally to the point the urethra is visualized (Fig. 12). The urethra is then sharply transected using cold scissors. The adenoma is completely released from the prostate and then placed in a 10-mm specimen entrapment bag. The prostate fossa is examined for any residual adenoma, which can be excised separately and removed with a laparoscopic spoon forceps. Cutting EDGE_Urology(SUN)_final.indd 11 27-Mar-18 10:00:27 AM