Cutting Edge Urology

T his PDF belongs to matthew.hooson@springer.co ROBOTIC SIMPLE PROSTATECTOMY • 13  Step 4: Hemostasis (Table 4) The key to excellent hemostasis is being in the correct plane during enucleation of the adenoma and obtaining concurrent hemostasis while the adenoma is being enucleated. This will signifi- cantly decrease the amount of time spent in obtaining hemostasis after the adenoma has been anchored laterally to the abdominal wall, then pulled and secured with a Hem-o-lok to expose the bladder and keep open the operative space enucleated. Post-enucleation hemostasis is obtained using a combination of electrocautery and sutures. Discrete arterial bleeders can be point coagu- lated with the monopolar scissors while venous bleeding is best secured with sutures. We use either 2-0 V-loc™ sutures or figure-of-eight, 2-0 Polyglactin sutures for hemostatic suturing in the prostatic fossa (Fig. 13a–d). Small bleeders near the sphincter are suture ligated with 4-0 Polyglactin sutures. The suturing is done with robotic needle drivers in the left and right robotic arm. The fossa is thoroughly irrigated to ensure excellent hemostasis. Step 5: Retrigonization We do not routinely retrigonize the prostatic fossa. If retrigonization is considered appropriate, we do this after carefully obtaining perfect hemostasis and a clean prostatic fossa. This is accom- plished using a 2-0 V-loc™ suture on a GS-21 needle placed at the 6 o’clock position in the bladder neck mucosa and advancing it into the prostatic fossa at a convenient location, usually in the midfossa. The stitch is then advanced along the left side of the bladder neck to advance the lateral mucosa down into the prostatic fossa. An additional 2-0 V-loc™ suture on a GS-21 needle is used for the advancement of the right-sided bladder neck mucosa. The goal of retrigonization is to cover the ra w surface of the prost atic fossa and theoretically decrease the risk of postoperative hemorrhage and irritative symp toms. Retrigonization is done with robotic needle drivers in the left and right rob otic arm. Step 6: Bladder Closure (Table 5) A 22-French 3-way hematuria catheter is inserted into the bladder via the urethra and 30 mL of sterile water is used to inflate the balloon. The previously placed stay sutures are now cut and removed. The Hem-o-lok clips on the stay sutures, on the bladder wall and the abdominal wall, Table 4: Instrumentation required for step 4: hemostasis. Surgeon instrumentation Assistant instrumentation Left arm Right arm Fourth arm • Laparoscopic suction irrigator • Laparoscopic needle driver • Needle driver • Needle driver • ProGrasp™ forceps • Monopolar scissors (for pinpoint coagulation) • Endoscope lens: 0° Cutting EDGE_Urology(SUN)_final.indd 13 27-Mar-18 10:00:28 AM