The first step of Dr. Hu’s robotic assisted laparoscopic radical prostatectomy is to dissect out the seminal vesicles and the vas deferens on both sides. Aggressive cancers can invade these structures which store and transmit ejaculate to the prostatic urethra. After dividing the vas deferens, which results in a functional vasectomy, Dr. Hu also opens Denonviller’s fascia and dissect the prostate off of the rectum posteriorly.
Next, Dr. Hu dissects the bladder away from the anterior abdominal wall to enter the retropubic space by incising the peritoneum lateral to the medical umbilical ligaments on both sides and then dividing the medical umbilical ligaments and the urachus. He uses the pubic bone as a landmark and follows the natural tissue planes anatomically.
The prostate is invested by a connective tissue known as the endopelvic fascia and pelvic floor muscle fibers. Dr. Hu opens this fascia and gently sweeps the pelvic floor muscle fibers away from the prostate.
Dr. Hu continues to sweep off the pelvic floor muscles off of the apex or distal tip of the prostate, using as little thermal energy as possible to preserve continence. He then divides the puboprostatic ligaments, which fix the prostate to the pubic bone.
Dr. Hu dissects the bladder off of the prostate, anatomically preserving the small caliber of the bladder neck. The catheter is pulled back into the prostatic urethra before dividing the posterior bladder neck. Division of the posterior bladder neck allows Dr. Hu to dissect into the space he created in the 1st step or the posterior dissection.
The neurovascular bundles lie posterior and lateral to the prostate on both sides. Dr. Hu has incised the thin layer of connective tissue overlying the prostate to peel the neurovascular bundles away from the prostate on both sides. The decreased blood loss and magnification of robotic assisted laparoscopic prostatectomy aid greatly with nerve sparing to preserve erectile function. Dr. Hu uses the bipolar forceps in his left robotic arm, which precisely controls bleeding on the prostate; however, he avoids any energy on the neurovascular bundles to prevent thermal damage.
Dr. Hu dissects the neurovascular bundles off of the urethra before he divides the urethra. The catheter is pulled back prior to dividing the posterior urethra, and the prostate is freed entirely. Dr. Hu then begins the reconstruction, suturing the small, anatomic bladder neck down to the urethral stump.
Dr. Hu continues the anastomosis, or reconstruction of the bladder neck to the urethra. He has placed bio-degradeable material behind the bladder, which stimulates the clotting cascade. The wrist-like movement of the robotic instruments aids precise needle placement. Dr. Hu fills the bladder to ensure that there is no leakage from his repair.
For men with moderate and high risk characteristics, Dr. Hu performs a lymph node dissection that is identical to his technique for open surgery. First, he identifies the external iliac vein and dissects underneath it to the pelvic side wall, teasing off the lymph node packet. Next, he identifies and preserves the obturator nerve and vessels before dissecting out the lymph node completely, which is removed through a 12 mm laparoscopic port.
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