Editing Robot-assisted Laparoscopic Prostatectomy (section)

== Special Scenarios ==

=== Median Lobe ===

* Large median lobe increases risk of[https://pubmed.ncbi.nlm.nih.gov/20858064/ §]
** Ureteral injury
** Buttonholing the bladder
**Positive surgical margins
** Postoperative urinary incontinence from an incompetent bladder neck
** Prolonged operative time
** Prolonged hospital say
** Need for bladder neck reconstruction
* If not known based on previous imaging, may be suggested intraoperatively through repeated traction on the catheter which can reveal displacement of the balloon to[https://pubmed.ncbi.nlm.nih.gov/20858064/ §]
** Either side or 
** Deep within the prostate
* '''Technique'''
** Identify the median lobe and location of ureteric orifices
** Grasp the median lobe and elevate it out of the bladder using the fourth arm and a robotic grasper (e.g. cobra grasper).[https://pubmed.ncbi.nlm.nih.gov/18455623/ §]
** If median lobe too large to be grasped,
*** Method 1: Make a transverse incision on the mucosa overlying the 
****Midportion of the median lobe[https://pubmed.ncbi.nlm.nih.gov/20858064/ §]
****Inferior portion of the median lobe[https://pubmed.ncbi.nlm.nih.gov/18455623/ §]
*** Method 2: Pass a 6-inch 0 polyglactin (Vicryl) suture on a CT-1 needle with a Hem-o-lok clip tied into the tail end of the suture through the prostate from distal to proximal, in a parasagittal plane, with a right hand robotic needle driver until the clip sits snugly against the distal aspect of the lobe. Grasp the suture and retract it anteriorly against the pubic bone using a Prograsp in the fourth arm. Retraction of the foley catheter is no longer needed.[https://pubmed.ncbi.nlm.nih.gov/23859125/ §]
****The number of stitches deployed depends on the prostate configuration.
*****One stitch is deployed per prostatic lobe; one stitch for median lobe, three stitches for median lobe and two lateral lobes
***Dissect down to the underlying prostatic tissue and develop the plane between the bladder mucosa and the median lobe using scissors and cautery.
*** Once the plane has begun to be established, ask assistant to place suction in the plane and on downward retraction on the bladder.
*** Gradually circumscribe the lobe along the surface until it is free.
** Frequent adjustment of the fourth arm maintains traction during the dissection and ensures that the size of the bladder neck is minimized
** The bladder often encroaches bilaterally on the median lobe, and caution must be taken when dissecting laterally to avoid widely opening the bladder.
** Inferiorly, care must be taken to continue the dissection along the plane between the prostate and bladder and not into the transition zone, as is performed in a simple suprapubic prostatectomy.
*** The floor of the bladder and lateral prostate should be used to orient the correct plane of dissection.
*Videos
**[https://www.youtube.com/watch?v=yCwlA1CAFvs Management of Median Lobe during RALP (Dr. Edward Schaeffer)]
**[https://www.youtube.com/watch?v=EOsSnKbhYmQ Management of Median Lobe during RALP (Dr. Ali Moinzadeh)]

=== Bladder Neck Reconstruction ===
* May be needed if a large defect is present, to narrow the diameter of the bladder neck opening to match the urethral diameter
* Technique[https://pubmed.ncbi.nlm.nih.gov/20858064/ §][https://pubmed.ncbi.nlm.nih.gov/18455623/ §][https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25 §]
**Equipment: 2-0 Vicryl suture on SH needle, cut to 15-20cm
**Method 1 (anterior tennis racket closure)[https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25 §]
***Proceed with the anastomosis as is usually performed, knowing that there will still be a substantial anterior bladder defect. Once the anastomotic sutures circumferentially complete the anastomosis, these sutures are tied together. 
***The anterior bladder neck defect is then closed in a side-to-side manner using 2-0 or 3-0 polyglactin sutures similar to bladder closures for other surgical procedures when the bladder has to be opened. This closure mimics a tennis racket and hence the name.
****See [https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25#Fig6 Figure]
**Method 2 (posterior tennis racket closure)
***Figure-of-eight stitches inferiorly in the bladder neck (ie, tennis racquet closure).[https://pubmed.ncbi.nlm.nih.gov/20858064/ §]
***'''This inverting approach moves the UOs away from the anastomosis, thus avoiding a leak or inadvertent injury.'''
***See [https://www.urotoday.com/conference-highlights/eau-robotic-urology-section/erus-2018/106782-erus-2018-how-to-manage-complications-during-prostate-surgery.html Figure]
**Method 3 (fish-mouth closure)
***Interrupted sutures 
****From the 2-o’clock to the 4-o’clock position and the 8-o’clock to the 10-o’clock position on the bladder neck, closing it in a ‘‘fish mouth’’ configuration or in a ‘‘reverse tennis racket’’ approach.[https://pubmed.ncbi.nlm.nih.gov/18455623/ §]
****At 3 and 9 o’clock on the bladder neck and run medially until the bladder neck is of a sufficient size[https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25][https://pubmed.ncbi.nlm.nih.gov/18455623/ §]
***** '''Caution: while feasible, this approach often involves placing sutures very close to the UOs.'''
*****See [https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25#Fig5 Figure]
***Once this has been accomplished, the remainder of the anastomosis is continued in a usual manner.
**Additional sutures placed medially may be needed to narrow the diameter of the bladder neck opening to match the urethral diameter
* Once the bladder neck is complete, a standard running vesicourethral anastomosis is performed.