PREOPERATIVE DIAGNOSIS: Clinically localized prostate cancer.
POSTOPERATIVE DIAGNOSIS: Clinically localized prostate cancer.
OPERATIONS PERFORMED:
1. Robotic-assisted laparoscopic radical prostatectomy, difficult.
2. Insertion of Foley catheter.
SURGEON: John Doe , MD
ASSISTANTS:
1. Jane Doe , MD
2. Bradford Doe, MD
ANESTHESIA: General anesthesia.
SPECIMENS REMOVED: Radical prostatectomy specimen.
ESTIMATED BLOOD LOSS: 500 mL.
COMPLICATIONS: None.
INDICATION FOR OPERATION: The patient is a (XX)-year-old gentleman who presented with an elevated PSA at a level of 7.1. He had a prostate needle biopsy performed, which revealed Gleason 3+3=6 adenocarcinoma of the prostate involving 20% of one of the specimens on the left base. The patient’s metastatic workup has been negative. All of the different management options have been discussed with the patient and he elected to proceed with robotic-assisted laparoscopic prostatectomy.
DESCRIPTION OF OPERATION: The patient was given preoperative antibiotics as well as preoperative subcutaneous heparin. He was taken back to the operative suite and moved onto the table in the supine position. General anesthesia was induced. His position was then changed to the lithotomy position and all bony prominences and pressure points were appropriately padded. The abdominal and perineal regions were prepped and draped in the typical fashion. A Foley catheter was inserted into the bladder with return of clear urine. A midline supraumbilical incision was made with a #15 blade, approximately 2 cm in length. This was deepened sharply to the rectus fascia. Stay sutures were placed on either side of the rectus fascia. A Veress needle was inserted into the peritoneal cavity. The position of the needle was confirmed after injecting and aspirating saline. Pneumoperitoneum was created.
The Veress needle was then replaced with a 12 mm trocar. The camera was introduced through this trocar and the peritoneal cavity was inspected. There were some intraperitoneal adhesions that were visualized. These were mainly in the right upper quadrant at an area where the patient had had a previous open cholecystectomy. There were also some adhesions in the right lower quadrant where the patient had previous appendectomy. The left robotic trocar was inserted and laparoscopic scissors was then used through this trocar in order to take down the adhesions in the right upper quadrant. The fourth arm trocar was then inserted under direct vision followed by the right robotic trocar. We then placed a 12 mm trocar in the right upper quadrant under direct vision and a 5 mm trocar medial to this. All of these were inserted under direct laparoscopic vision. The da Vinci robot was then docked to the robotic trocars.
The procedure started by reflecting the bladder off the anterior abdominal wall. The space of Retzius was dissected. The prostate was identified and cleaned off. Starting on the patient's right side, the endopelvic fascia was carefully dissected and opened in order to dissect the space between the prostate and the levator ani muscle. This was repeated on the patient's left side. The dorsal vein was identified and a stitch was applied to the dorsal vein in order to tie it off. After the dorsal vein had been completely tied off, the dissection was returned to the region of the bladder neck. The anterior bladder neck was divided at the prostatovesical junction. The Foley catheter was identified within the bladder. The bladder neck dissection was continued posteriorly after the Foley was removed. The posterior bladder neck was divided carefully and the dissection was carried through the posterior layers of the bladder wall. The vas deferens and seminal vesicles were then identified on either side and carefully dissected free. Denonvilliers' fascia was then divided at the plane between the posterior surface of the prostate and the rectum could be developed. This was developed using a combination of blunt and sharp dissection. The left prostatic pedicle was then divided using a combination of blunt and sharp dissection and Hem-o-lok clips.
We then turned our attention to the right prostatic pedicle, which was taken down in a similar fashion. We then approached the apex of the prostate. The dorsal vein complex and the apex of the prostate were divided carefully and then the rectourethralis muscle was divided sharply. The prostate specimen was completely freed and placed in an Endocatch bag. The site was then examined for hemostasis, which was found to be adequate. The bladder neck was visualized and there was no need for further bladder neck reconstruction. The anastomosis between the urethra and the bladder neck was completed using two continuous 2-0 Monocryl sutures tied to each other. Each of the sutures was 16 cm in length. The anastomosis was secured intermittently with laparoscopic tie absorbable clips. A Foley catheter was placed without difficulty into the bladder after the anastomosis was completed. The bladder was distended with 120 mL of normal saline and there was no evidence of extravasation confirming a watertight anastomosis. Again, hemostasis was examined and found to be adequate. The JP drain was then inserted through the exit of the fourth robotic trocar site. The drain was secured to the skin with a silk suture.
The robot was then undocked from the patient. The patient was moved out of Trendelenburg position and the laparoscopic sites were closed under laparoscopic vision using a port closure device and 0 PDS interrupted suture. The midline incision was then extended in order to remove the large specimen. The midline incision was closed with interrupted 0 PDS sutures. The skin was closed with 4-0 Vicryl sutures followed by Dermabond. The specimen was sent for pathologic analysis. The patient was awakened from the procedure, extubated, and transferred to the postanesthesia care unit in stable condition.
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