Abstract
Variations in prostate anatomy provide surgical challenges, the most common of which include the presence of large prostate, median lobes, post-transurethral prostate resection (TURP), prior abdominal surgery, and obese patients. Although it is wise, early in a surgeon’s experience, to select ideal candidates, these difficult cases are no longer contraindications to robotic-assisted laparoscopic radical prostatectomy (RALP). However, these variations in surgical anatomy significantly impact the learning curve and contribute to the potential for increased risk of complications. The key to avoiding problems is a standardized approach to recognition of the anatomy and dissection of the surgical planes. Identification of the bladder neck in large prostate and prior TURP is one of the most challenging aspects of the procedure; defining the bladder neck using the fat insertion line and the contour of the lateral prostate instead of traction of an inflated Foley catheter may provide a clue for this purpose. In case of a median lobe, elevating it using a robotic fourth arm will facilitate dissection of the bladder neck. If deemed necessary, reconstruction of the bladder neck should be performed burying the ureteral orifice out of the path of the anastomosis in cases of large median lobes. The operator should pay attention to inspect the ureteral orifice, as it often lies in close proximity to the borders of the prostate. The ability to recognize these anatomic variations and manage challenging intraoperative situations is an important aspect of RALP. The understanding of anatomic variations in these cases will allow for refinement of technique and the development of new techniques to optimize surgical outcomes. In this chapter, we will discuss the approach to various challenges encountered during RALP and provide advice based on our experience.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Sarle RC, Guru K, Peabody JO. Training in robotic-assisted laparoscopic radical prostatectomy: the Vattikuti Urology Institute program. In: Smith JA, Tewary AK, eds. Robotics in Urologic Surgery. 1st ed. Philadelphia: Saunders Elsevier; 2008:15-25.
Myers RP. Practical surgical anatomy for radical prostatectomy. Urol Clin North Am. 2001;28:473-490.
Patel VR, Coelho RF, Palmer KJ, et al. Periurethral suspension stitch during robot-assisted laparoscopic radical prostatectomy: description of the technique and continence outcomes. Eur Urol. 2009;56(3):472-478. Epub 2009 Jun 16.
Jenkins LC, Nogueira M, Wilding GE, et al. Median lobe in robot-assisted radical prostatectomy: evaluation and management. Urology. 2008;71(5):810-813.
Lin VC, Coughlin G, Savamedi S, et al. Modified transverse plication for bladder neck reconstruction during robotic-assisted laparoscopic prostatectomy. BJU Int. 2009;104:878-881.
Coughlin G, Dangle PP, Patil NN, et al. Surgery illustrated – focus on details. Modified posterior reconstruction of the rhabdosphincter: application to robotic-assisted laparoscopic prostatectomy. BJU Int. 2008;102(10):1482-1485.
Patel VR. Clinical pearls: the approach to the management of difficult anatomy and common operative and postoperative problems. In: Patel VR, ed. Robotic Urologic Surgery. 1st ed. London: Springer; 2007:91-100.
Madi R, Daignault S, Wood DP. Extraperitoneal v intraperitoneal robotic prostatectomy: analysis of operative outcomes. J Endourol. 2007;21:1553-1557.
Kopelman PG. Obesity as a medical problem. Nature. 2000;404:635-643.
Mikhail AA, Stockton BR, Orvieto MA, et al. Robotic-assisted laparoscopic prostatectomy in overweight and obese patients. Urology. 2006;67:774-779.
Van Velthoven RF, Ahlering TE, Peltier A, et al. Technique for laparoscopic running urethrovesical anastomosis: the single knot method. Urology. 2003;61:699-702.
Mulhall JP, Secin FP, Guillonneau SB. Artery sparing radical prostatectomy – myth or reality? J Urol. 2008;179:827-831.
Rogers CG, Trock BP, Walsh PC. Preservation of accessory pudendal arteries during radical retropubic prostatectomy: surgical technique and results. Urology. 2004;64:148-151.
Mulhall JP, Slovick R, Hotaling J, et al. Erectile dysfunction after radical prostatectomy: hemodynamic profiles and their correlation with the recovery of erectile function. J Urol. 2002;167:1371-1375.
Author information
Authors and Affiliations
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2011 Springer-Verlag London Limited
About this chapter
Cite this chapter
Cheon, J., Orvieto, M.A., Patel, V.R. (2011). Key Elements to Approaching Difficult Cases in Robotic Urologic Surgery. In: Patel, V. (eds) Robotic Urologic Surgery. Springer, London. https://doi.org/10.1007/978-1-84882-800-1_13
Download citation
DOI: https://doi.org/10.1007/978-1-84882-800-1_13
Published:
Publisher Name: Springer, London
Print ISBN: 978-1-84882-799-8
Online ISBN: 978-1-84882-800-1
eBook Packages: MedicineMedicine (R0)