Investig Clin Urol.  2016 Dec;57(Suppl 2):S165-S171. 10.4111/icu.2016.57.S2.S165.

Standardized 4-step technique of bladder neck dissection during robot-assisted radical prostatectomy

• Alnazari M
• Zanaty M
• Rajih E
• El-Hakim A
• Zorn KC

• KMID: 2361682
• DOI: http://doi.org/10.4111/icu.2016.57.S2.S165

Abstract

Bladder neck (BN) dissection is considered one of the most challenging steps during robot-assisted radical prostatectomy. Better understanding of the BN anatomy, coupled with a standardized approach may facilitate dissection while minimizing complications. We describe in this article the 4 anatomic spaces during standardized BN dissection, as well other technical maneuvers of managing difficult scenarios including treatment of a large median lobe or patients with previous transurethral resection of the prostate. The first step involves the proper identification of the BN followed by slow horizontal dissection of the first layer (the dorsal venous complex and perivesicle fat). The second step proceeds with reconfirming the location of the BN followed by midline dissection of the second anatomical layer (the anterior bladder muscle and mucosa) using the tip of the monopolar scissor until the catheter is identified. The deflated catheter is then grasped by the assistant to apply upward traction on the prostate from 2 directions along with downward traction on the posterior bladder wall by the tip of the suction instrument. This triangulation allows easier, and safer visual, layer by layer, dissection of the third BN layer (the posterior bladder mucosa and muscle wall). The forth step is next performed by blunt puncture of the fourth layer (the retrotrigonal fascia) aiming to enter into the previously dissected seminal vesical space. Finally, both vas deferens and seminal vesicles are pulled through the open BN and handed to the assistant for upper traction to initiate Denovillier's dissection and prostate pedicle/neurovascular bundle control.

Keyword

Prostate neoplasms; Prostatectomy; Robot assisted radical prostatectomy; Robotics

MeSH Terms

Catheters
Hand
Hand Strength
Humans
Mucous Membrane
Neck Dissection*
Neck*
Prostate
Prostatectomy*
Prostatic Neoplasms
Punctures
Robotics
Seminal Vesicles
Suction
Traction
Urinary Bladder*
Vas Deferens

Figure

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  Fig. 1 Transverse-section of the bladder neck representing the 4 anatomical layers. DVC, dorsal venous complex. Adapted from Stolzenburg et al. Eur Urol 2007;51:629-39, with permission of Elsevier B.V. [12].

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  Fig. 2 (A) The lateral branches of dorsal venous complex, (B) the bipolar forceps is used to separate the first layer from underlying bladder muscle, and clips are applied to control bleeding from dorsal venous complex branches. Scan this QR code to see the accompanying video, or visit www.icurology.org or https://youtu.be/0Q2DONLN5DE.

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  Fig. 3 The anterior bladder muscle is dissected (blue arrow) and Foley catheter is identified. Scan this QR code to see the accompanying video, or visit www.icurology.org or https://youtu.be/r7dqChGbDbI.

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  Fig. 4 (A) Upward traction of the prostate by holding the Foley catheter tip (upward large blue arrow) and down ward traction of the bladder neck by the tip of suction devise (downward large blue arrow) with cauterization marking of the line posterior dissection. (B) Dissected posterior bladder muscle layer with intact prostate and bladder trigone. Scan this QR code to see the accompanying video, or visit www.icurology.org or https://youtu.be/dd0BBcKnGDs.

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  Fig. 5 (A) The retrotrigonal fascia is exposed (blue arrow) after dissecting the posterior bladder muscle layer. (B) after the retrotrigonal fascia is opened the vas deferences and the seminal vesicles are brought through the opening and handled to the assistant for upward traction. Scan this QR code to see the accompanying video, or visit www.icurology.org or https://youtu.be/y2rELbTI-wc.

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  Fig. 6 The median lobe is lifted upward by the assistant using the preplaced VLoc suture along with downward traction on the trigone by the assistant which helps in obtaining clear visualization of the posterior bladder neck and ureteric offices allowing for posterior dissecting of the bladder neck at safe distance from the ureteric offices with better control of the prostate. Scan this QR code to see the accompanying video, or visit www.icurology.org or https://youtu.be/1UcwfE8hwrY.

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  Fig. 7 Bladder neck dissection during robot-assisted radical prostatectomy in patient with previous transurethral resection of the prostate demonstrating the proximity of left ureteric orifice to the bladder neck.

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