Video content presents a technique describing preservation of antero-lateral structures in Robotic Radical prostatectomy helps in achieving early continence.
The accompanying article provides a description of the novel “hood technique” for robotic-assisted radical prostatectomy (RARP). Download Article
Chapters (Click to go to chapter start) Introduction Midline “Tunnel” Bladder Drop Anterior Bladder Neck Transection Posterior Bladder Neck Transection Dissection of Seminal Vesicles Dissection of the posterior plane left and right lateral dissection, including bilateral nerve sparing technique “Hood” sparing and apical dissection Dorsal vein ligation Urethral transection Posterior bladder wall reconstruction Urethral anastomosis with completion of total anatomical reconstruction Surgical pathology For appointments or referrals, please call Dr. Tewari directly at 212-241-9955. Good morning ladies and gentlemen. This film demonstrates a robotic assisted radical prostatectomy. With the tunnel and hood technique by dr ashe to armor. The patient is a 74 year old man who presented with minimal, you know, prior surgery and a prostate biopsy showing gleason three plus four prostate cancer. Four calls on the right with up to 40% involvement. His MRI showed a 26cc prostate with a 1.4 centimeter Pirates four lesion in the right, mid peripheral zone and no extra counselor extension. This is a schematic of the M. R. I. Findings with the lesion shown in red Based on this using the in House Nama Graham predicting extra capsule extension. The risk of ec and SV. I on the right is 12 and 4% respectively and negligible on the left. With a proposed grade of nerve sparing of two on the right and one on the left. The tunnel and hood technique is a paris arosa will supervise cycle recess sparing approach that provides an endo pelvic fashionable window for entry into the neurovascular triangle and so allows early neurovascular bundle release. It is versatile in that it allows preservation of the bladder neck with dissection of any medium loans but at the same time taking care of the Euro Terrien or offices. It doesn't disturb the anatomy of the pouch of Douglas and preserves important structures contributing to the anterior hood, which we will discuss during the film. Later, the film starts after the truckers have been placed. Doctor to our begins his dissection, dividing the Eureka's to drop the bladder. But with the tunnel techniques staying in the midline in order to spare the lateral tissues. During this part of the procedure he uses fine sharp dissection and electro coagulation for homeostasis. The endo pelvic fascia is generally only incised when there is a large prostate or an aggressive cancer for the larger prostates, it gives more mobility and for the aggressive cancers, more vision during the lateral dissection. In keeping with the tunnel technique for this patient, the lateral tissues are spared and the end of pelvic fascia is preserved on both sides. For the bladder net transaction an incision is made in the anterior bladder wall, right above the prostate. Over cycle junction. The Foley Catheter is then lifted and held eventually using the 4th arm. In this case you can see a large median lobe and the dissection continues beneath it onto the posterior bladder wall. In a posterior recess bearing approach, the presence of a median lobe may be missed. An incision is made through the post area, bladder neck which takes you onto the retro trigo nor fibromyalgia secular layer overlying the seminal vesicles having dissected through the retro trig onal fibra muscular layer, the visa deferential and seminal vesicles are clearly visible. Following this both ways are dissected, lifted up and divided separately. In this case dr tiwari has chosen to dissect and divide the right vous and then dissect the entire right seminal vesicles before moving on to the left side. When dissecting the seminal vesicles, it is helpful to find the median a vascular plane between the body of the several vehicles and the surrounding fashion, which is nicely demonstrated here. This plane could also be traced approximately to identify arteries entering the seminal vesicles from below and laterally. Once the vase are sectioned, it is important to try and minimize dia thermic using clips for vascular control whenever possible to prevent pelvic plexus damage, especially lateral to the seminal vesicles and near the tips where the cell bodies of the pelvic plexus can be found as the dissection of the seminal vesicles continues. It's helpful to understand the neuro anatomy of the pelvic plexus. The pelvic plexus consists of the proximal neurovascular plate related to the tips of the seminal vesicles. The neurovascular bundle itself located in a poster or lateral groove on the side of the prostate and the accessory nerve pathways on the lateral surface of the prostate. After seminal vesicles dissection, the prostate is lifted with the fourth arm setting up the posterior dissection which starts with the incision of dental villiers fascia in the midline. The posterior dissection is completed at the prostatic apex on the pelvic floor and then extends laterally where three different tissue layers are encountered, allowing for different grades of nerve sparing For grade one nerves bearing dissection has continued in a plain beneath the inconsistent loose layer of vascular Fashir onto the prostatic pseudo capsule itself, maximizing sparing of the accessory nerve pathways for gray to nerve sparing dissection is through the venus layer of fascia beneath the formal lateral prostatic fascia, which will conserve the majority of accessory nerve pathways. The grade three nerve sparing dissection is outside the lateral prostatic fashion, sparing the vato Fashir and conserving the predominant neurovascular bundle but not the accessory nerve pathways. Grade four nerve sparing or non nerve sparing is when the lateral prostatic fascia is excised and left on the prostate specimens. As discussed. When we show the schematic at the beginning of the film, this patient is having grade one nerve sparing on the left and grade two on the right. With the posterior dissection complete. The pericles will be clipped and divided before the dissection continues on towards the prostatic apex on the left. This will be directly on the pseudo capsule. In keeping with grade one nerve sparing and on the right, within the venus layer of fashion beneath the lateral prostatic fascia consistent with Grade two nerve sparing any perforating arteries entering the prostatic catchall that are encountered are cut sharply within the appropriate plane. Sometimes for the retro ethical dissection, the prostate is lifted. Anti really towards the pubic synthesis and the camera lens has changed to 30° optic with upward direction. Using blunt dissection with monopoly scissors and retracting the apex away from the urethra it's possible to gain 1 to 2 millimeters of member anus urethra length. Prior to transaction The camera lenses then changed back to 0° optic for the anterior dissection here you can see he is dissecting directly onto the prostatic pseudo capsule. As he moves towards the apex. With the nerve sparing complete, he dissected the detroiter apron off the anterior surface of the prostate from left and right sides and then from the midline. The dead trees. A Apron has three layers anterior, middle and posterior. The anterior layer passes posterior lee to the devastated pubic cockatiel fibers. Diffuses Antero inferior early and anchors onto the posterior surface of the pubic bone. The middle air is loose and joins the fashions sheath of the dorsal vein complex. Lastly, the posterior layer encloses and extends onto the prostate to form the anterior fiber muscular strom A. Of the prostate. The Detroit to open is a key part of the anterior fiber muscular Strama, a thick sheet of tissue over the entire anterior external surface of the prostate, devoid of any glandular tissue. It can safely be dissected off the surface of the prostate and preserved to maintain the continent's mechanism and limit dissection near the urethral sphincter. He then moves on to the a pickle dissection, another crucial part of radical prostatectomy with implications for both oncological and functional outcomes here. Part of the a pickle dissection is done and the urethra is seen emerging from the prostatic apex. The dorsal vein is then litigated before the a pickle dissection is completed. Positive surgical margins are more frequently reported at the prostatic apex and have been associated with a higher risk of recurrence but preservation of maximum urethral length is associated with improved postoperative continents. Here you can see the eureka has transacted a few millimeters from the prostatic apex to reduce the risk of positive surgical margins but also to maximize urethral stump length. In this case an extra piece of tissue is taken from the post area urethra margin for frozen section in summary preservation of the endo pelvic fascia that Patricia, apron nerve sparing and maintaining urethral stump length. All help to keep the urethral sphincter incontinence mechanism intact as much as possible to maximize earlier return of continence here you can see the post area urethral sections being placed before the visoko urethral anastomosis which he comes back to after doing the post area reconstruction. Once the urethra is transected, the specimen is bagged and then removed for neurosurgery procedure. The posterior bladder neck and donald villiers muscular fashion plate reconstruction represents the first step of the total anatomical reconstruction By reconstructing the post area plate. 1st we secure enough support to the posterior urethra, which also includes the retro trig onal layer of tissue and the Veysel stumped for extra support. The main purpose of this surgical step is to minimize urethra sphincter eric sliding to provide support to the vsco urethral anastomosis to bring the bladder neck close to the urethral stump and also to provide an adequate fulcrum of contraction for the rhabdo sphincter once the posterior muscular fashion plate has been reconstructed with denim villiers fashion reconstruction of the posterior bladder wall has begun with Velox futures. This is done in two layers. Once the second layer of the Postwar reconstruction is complete, the Vlach and vicryl sutures are tied approximately close to the opening of the bladder. With the posterior reconstruction finished, he retrieves the urethral suits as he placed earlier on and completes the visit co urethral anastomosis over the catheter.