16 Mayıs 2020 Cumartesi

Button hole injury and its repair during robotic prostatectomy

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.