Transurethral marking incision of the bladder neck: a helpful technique in robot-assisted laparoscopic radical prostatectomy involving post-transurethral resection of the prostate and cancers protruding into the bladder neck
© Kurokawa et al.; licensee BioMed Central Ltd. 2013
Received: 16 May 2013
Accepted: 15 August 2013
Published: 17 August 2013
Bladder neck transection is one of the most difficult procedures for robot-assisted laparoscopic radical prostatectomy (RALP), particularly in patients who have undergone previous transurethral resection of the prostate (TUR-P), and in those with large median lobes or prostate cancer protruding into the bladder neck. To ensure negative surgical margins and safely preserve the ureteral orifices during bladder neck transection, we propose the use of the transurethral resectoscope for making the incision in the bladder neck before initiating RALP. Thus, we developed a technique for bladder neck transection to facilitate this operation in such patients.
Two Japanese men, aged 61 and 63 years, who were diagnosed with prostate cancer, received a transurethral marking incision of the bladder neck before starting RALP; prostate cancer developed in one patient after TUR-P and the other patient had cancer protruding into the bladder neck. A transurethral resectoscope was used to closely observe the ureteral orifices and bladder necks; the bladder necks were marked to indicate the depth from the mucosa to the muscular layer. During the RALP, the bladder necks were dissected to indicate the depth of the marking incision. The surgical margins were negative and perioperative complications did not occur. The Foley catheters were removed on postoperative day 6, according to the usual protocol. No urinary leakage from the anastomosis sites was observed.
This technique, involving the use of an ordinary transurethral resectoscope, may be an easy procedure to ensure negative surgical margins, safely preserve the ureteral orifices, avoid increasing the bladder neck diameter, and achieve a good quality vesicourethral anastomosis that prevents the risk of suture-related tissue tears.
KeywordsBladder neck Prostate cancer Robot-assisted laparoscopic radical prostatectomy Transurethral incision Transurethral resection of the prostate
Bladder neck transection is one of the most difficult procedures associated with robot-assisted laparoscopic radical prostatectomy (RALP), particularly in patients who have undergone previous transurethral resection of the prostate (TUR-P), and in those with large median lobes or prostate cancer protruding into the bladder neck. Among such patients, the rates of positive surgical margins and operative complications, such as ureteral orifice injury or obstruction, urinary leakage, or bladder neck contracture, are approximately twice as high as in other patients [1–4].
Certain techniques have been proposed for preserving the ureteral orifices during RALP procedures, including their enhanced identification in the robotic magnified view by the administration of intravenous furosemide and indigo carmine, and the insertion of ureteral stents [5, 6]. During such techniques, the surgeon has to sufficiently enlarge the diameter of the bladder neck to clearly observe the bilateral ureteral orifices, and the magnified view from the surgeon’s console may not be suitable for observing the ureteral orifices. Moreover the transurethral cystoscope is more suitable than the da Vinci’s laparoscope for observing ureteral orifices. In the present study, we propose the use of the TUR system to closely observe the ureteral orifices and for making a transurethral marking incision in the bladder neck before initiating RALP.
Case 1: A 61-year-old man presented with dysuria; his serum prostate-specific antigen (PSA) level was 2.2 ng/mL. TUR-P was performed, and an adenocarcinoma (Gleason score 4 + 3) was incidentally detected in 8% of the resected tissue. He was scheduled to undergo radical prostatectomy at 3 months after TUR-P described as a recommended duration in recent reports [7–9].
Both the patients provided informed consent, and the Institutional Review Board of Nagoya Tokushukai General Hospital approved the publication of these results (approval numbaer 2011-3).
In our experience, these 2 cases were the 69th and 93rd cases. At the early stage in the learning curve of robotic surgery, RALP would have been difficult to perform in both of these cases, including a case of cancer developing after TUR-P and a case of prostate cancer protruding into the bladder neck. Intuitive Surgical, manufacturers of the da Vinci system, indicates that any surgeon who has completed 20 robotic operations is a potential proctor. Recent reports indicate that the learning curve of functional and oncological outcomes begins to plateau at approximately 50–100 cases [10–12]. The described technique may be performed easily and safely as the surgeon’s experience nears the plateau of the learning curve. Before performing RALP, we gained experience with 579 cases of laparoscopic radical prostatectomy (LRP) . We experienced a smooth transition from LRP to RALP with a low complication rate, including a 0.3% rate of blood transfusions, no visceral injuries, and no conversions to open surgery as described in recent reports [14, 15]. Among the 579 cases of LRP, we have performed transurethral marking incisions of the bladder neck, preoperative insertion of ureteral stents, and both these procedures simultaneously in cases who underwent prior TUR-P. However, transurethral incision of the bladder neck is a safe and satisfactory procedure, compared with ureteral stenting alone or both procedures performed simultaneously.
The use of a transurethral marking incision in the bladder neck was shown to facilitate bladder neck transections during RALP, especially when the anatomy of the bladder neck is altered. This procedure can be easily and quickly performed using an ordinary TUR system. Thus, we believe that this technique may be useful for ensuring negative surgical margins, safely preserving the ureteral orifices, avoiding increases in bladder neck diameter, and achieving a good quality vesicourethral anastomosis that prevents the risk of suture-related tissue tears.
Written informed consent was obtained from the patients for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor of this journal.
Laparoscopic radical prostatectomy
Robot-assisted laparoscopic radical prostatectomy
Transurethral resection of the prostate.
- Goldstraw MA, Challacombe BJ, Patil K, Amoroso P, Dasgupta P, Kirby RS: Overcoming the challenges of robot-assisted radical prostatectomy. Prostate Cancer Prostatic Dis. 2012, 15: 1-7. 10.1038/pcan.2011.37.View ArticlePubMedGoogle Scholar
- Link BA, Nelson R, Josephson DY, Yoshida JS, Crocitto LE, Kawachi MH, Wilson TG: The impact of prostate gland weight in robot assisted laparoscopic radical prostatectomy. J Urol. 2008, 180: 928-932. 10.1016/j.juro.2008.05.029.View ArticlePubMedGoogle Scholar
- Rehman J, Chughtai B, Guru K, Shabsigh R, Samadi DB: Management of an enlarged median lobe with ureteral orifices at the margin of bladder neck during robotic-assisted laparoscopic prostatectomy. Can J Urol. 2009, 16: 4490-4494.PubMedGoogle Scholar
- Stolzenburg JU, Rabenalt R, Do M, Kallidonis P, Liatsikos EN: Endoscopic extraperitoneal radical prostatectomy: the University of Leipzig experience of 2000 cases. J Endourol. 2008, 22: 2319-2325. 10.1089/end.2008.9714.View ArticlePubMedGoogle Scholar
- El Douaihy Y, Tan GY, Dorsey PJ, Jhaveri JK, Tewari AK: Double-pigtail stenting of the ureters: technique for securing the ureteral orifices during robot-assisted radical prostatectomy for large median lobes. J Endourol. 2009, 23: 1975-1977. 10.1089/end.2009.0133.View ArticlePubMedGoogle Scholar
- Katz MH, Eng MK, Deklaj T, Zorn KC: Technique for ureteral stent placement during robot-assisted radical prostatectomy: safety measure during vesicourethral anastomosis when ureteral orifices are too close for comfort. J Endourol. 2009, 23: 827-829. 10.1089/end.2008.0579.View ArticlePubMedGoogle Scholar
- Do M, Haefner T, Liatsikos E, Kalliodonis P, Hicks J, Dietel A, Horn LC, Rabenalt R, Stolzenburg JU: Endoscopic extraperitoneal radical prostatectomy after previous transurethral resection of prostate: oncologic and functional outcomes of 100 cases. Urology. 2010, 75: 1348-1352. 10.1016/j.urology.2009.09.009.View ArticlePubMedGoogle Scholar
- Menard J, de la Taille A, Hoznek A, Allory Y, Vordos D, Yiou R, Abbou CC, Salomon L: Laparoscopic radical prostatectomy after transurethral resection of the prostate: surgical and functional outcomes. Urology. 2008, 72: 593-597. 10.1016/j.urology.2008.03.019.View ArticlePubMedGoogle Scholar
- Hampton L, Nelson RA, Satterthwaite R, Wilson T, Crocitto L: Patients with prior TURP undergoing robot-assisted larparoscopic radical prostatectomy have higher positive surgical margin rates. J Robotic Surg. 2008, 2: 213-216. 10.1007/s11701-008-0121-7.View ArticleGoogle Scholar
- Murphy DG, Bjartell A, Ficarra V, Graefen M, Haese A, Montironi R, Montorsi F, Moul JW, Novara G, Sauter G, Sulser T, van der Poel H: Downsides of robot-assisted laparoscopic radical prostatectomy: limitations and complications. Eur Urol. 2010, 57: 735-746. 10.1016/j.eururo.2009.12.021.View ArticlePubMedGoogle Scholar
- Hashimoto T, Yoshioka K, Gondo T, Kamoda N, Ozu C, Horiguchi Y, Namiki K, Nakashima J, Tachibana M: Learning curve and perioperative outcomes of robot assisted radical prostatectomy in 200 initial Japanese cases by a single surgeon. J Endourol. 2013, in pressGoogle Scholar
- Doumerc N, Yuen C, Savdie R, Rahman MB, Rasiah KK, Pe Benito R, Delprado W, Matthews J, Haynes AM, Stricker PD: Should experienced open prostatic surgeons convert to robotic surgery? The real learning curve for one surgeon over 3 years. BJU Int. 2010, 106: 378-384. 10.1111/j.1464-410X.2009.09158.x.View ArticlePubMedGoogle Scholar
- Akita H, Okamura T, Ando R, Nagata D, Naruyama H, Yamada Y, Naiki T, Yasui T, Tozawa K, Kohri K: Implications of greater short-term PSA recurrence with laparoscopic as compared to retropubic radical prostatectomy for Japanese clinically localized prostate carcinomas. Asian Pac J Cancer Prev. 2011, 12: 909-913.PubMedGoogle Scholar
- Stolzenburg JU, Qazi HA, Holze S, Mende M, Nicolaus M, Franz T, Ho Thi P, Dietel A, Liatsikos E, Do M: Evaluating the learning curve of experienced laparoscopic surgeons in robot-assisted radical prostatectomy. J Endourol. 2013, 27: 80-85. 10.1089/end.2012.0262.View ArticlePubMedGoogle Scholar
- Wolanski P, Chabert C, Jones L, Mullavey T, Walsh S, Gianduzzo T: Preliminary results of robot-assisted laparoscopic radical prostatectomy (RALP) after fellowship training and experience in laparoscopic radical prostatectomy (LRP). BJU Int. 2012, 110: 64-70.View ArticlePubMedGoogle Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2490/13/40/prepub
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