In the minimally invasive radical prostatectomy, dissections are antegrade and bladder neck division became an early step of the operation. Meanwhile, either laparoscopic or robotic it is not possible to palpate the anatomical structures and the surgeon generally relies on visual cues. Furthermore, negative effects of the previous biopsy or biopsies might also contribute to the challenges of this step of the operation.
I wanted to present a case (https://www.youtube.com/watch?v=RahciXj8K24), that I could not find the correct planes and made a button-hole injury at the bladder neck. In the first section of the video you will see the dissection of the anterior portion of the bladder neck. The bladder is retracted to help tent up the prostato-vesical junction and with the aid of the balloon of the Foley catheter, the exact incision plane was identified.
When the bladder is entered,
Foley catheter is deflated and brought through the opening and grasped with the
third arm of the robot. At this time, as the second section of the video, you will see the posterior bladder neck. This case
has no middle lobe and we performed posterior dissection initially for the
release of vas deferentia and seminal vesicles.
In many cases, keeping the veins
untouched at the two sides of the bladder neck, narrows the dissection plane
and lead to a smaller space to work in for finding the seminal vesicles. On the
other hand, touching these veins sometimes makes annoying bleedings that you
have to handle during this critical step of the operation.
Behind the bladder there should
be a thin areolar tissue to orient myself. But I could not find it. During the
dissection, I suddenly saw a tissue as you are going to see, that looks mucosal
and made me nervous for a few moment because it might be rectum at the worst
scenario or low inserting pouch of Douglas or bladder itself. At this step it
might be more accurate to grasp the posterior layers at the specimen side for
widening the dissection plane. Another issue is that, is some cases a variant
anatomy is seen such as jutting of the bladder neck to the prostate plane
instead of straight funneling. In this case, somehow, I identified the seminal
vesicles and after this crucial step, prostatectomy was pretty straightforward.
The third section of the video is related with the repair of the button hole injury, By looking and manipulating
inside of the bladder, I felt that there is defect at the posterior bladder
neck and from the outside I managed to see it. In general button hole injuries
are on dependent bladder wall that is not part of the trigone. However, one should
be sure that the ureteral orifices are intact. And now you see the repair of
the bladder neck with 3:0 V-lock suture in two layers such as mucosa and
detrusor. After the repair of the injury, I inspected inside of the bladder saw
that the ureteral orifices are intact.
Lessons learned from this
case:
1-Divide the veins travelling at
the two sides of the prostate to widely see the dissection planes of the
bladder neck
2-Stay not too closed to the
prostate. There is a risk of being anterior of the vas deferens and the seminal
vesicles. If needed, widely open the bladder neck. Try to understand the
anatomy.
3-Beware of the variant anatomy
of the bladder neck.
