Cutting Edge Urology

T his PDF belongs to matthew.hooson@springer.co 16 • CUTTING EDGE - UROLOGY To confirm a watertight closure, the bladder is now distended with 300 mL of saline and con- tinuous bladder irrigation (CBI) is now commenced after irrigating out any clots. CBI is titrated to ensure a clear return of irrigant. Hemostasis is now confirmed in the peritoneal cavity and a 19-French Jackson–Pratt (JP) drain is placed in the retrovesical space and brought out through the right lateral 8-mm trocar site and affixed to the skin using 2-0 Nylon. Robotic instruments are now removed under vision and the robot is undocked. The midline camera trocar incision is now enlarged as needed to allow extraction of the adenoma specimen within the specimen entrapment bag. The fascia of the extraction site is closed using 0 PDS figure-of-eight stitches. The 12-mm assistant trocar site is closed using the Carter- Thomason Port Closure System® and 0 Polyglactin sutures. Subcutaneous tissue is reapproximated using 3-0 Polyglactin suture and the skin is closed using 4-0 Monocryl® in subcuticular fashion. Dermabond® is applied over the incisions. The patient is then extubated and transferred to recovery room. Special Considerations Potential Bladder Tumor To rule out a potential bladder tumor in smokers or patients with a history of hematuria, a flexible cystoscopy is performed either at the time of preoperative office visit or at the start of the case. The presence of a bladder tumor is a contraindication to opening the bladder. Previous Open Abdominal Surgery In a patient with a prior midline abdominal incision from an open procedure, pneumoperito- neum is obtained either with a Veress needle away from the incision, or with the open (Hasson) technique. The cavity is carefully inspected, and adhesions, if present, are taken down laparoscopi- cally prior to docking the robot. Bladder Diverticulum A bladder d iverticulectomy can b e performed at the same time as a RSP. We prefer to place a JJ stent on th e side of the diver ticulum to protect the ipsilateral ureter during dissection of the diverticulum. Al so the verti cal cystotomy is moved slightly off center away from the side of the diverticulum to avoi d ha ving the two suture lines very close together. Bladder Calculi Bladder calculi can be easily and expeditiously removed at the time of RSP since the bladder is wide open. Cutting EDGE_Urology(SUN)_final.indd 16 27-Mar-18 10:00:28 AM