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Different approaches for bladder neck dissection during robot-assisted radical prostatectomy: the Aalst technique

ABSTRACT

Introduction:

Bladder neck dissection is one of the most delicate surgical steps of robotic-assisted radical prostatectomy (RARP) [11 Martini A, Falagario UG, Villers A, Dell'Oglio P, Mazzone E, Autorino R, et al. Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy. Eur Urol. 2020;78:583-91., 22 Nunes-Silva I, Hidaka AK, Monti CR, Tobias-Machado M, Zampolli HC. Salvage Retzius sparing robotic assisted radical prostatectomy: the first brazilian experience. Int Braz J Urol. 2021;47:1279-80.], and it may affect surgical margins rate and functional outcomes [33 Ma X, Tang K, Yang C, Wu G, Xu N, Wang M, et al. Bladder neck preservation improves time to continence after radical prostatectomy: a systematic review and meta-analysis. Oncotarget. 2016;7:67463-75., 44 Capibaribe DM, Avilez ND, Sacomani CAR, Lucena ASPDN, Reis LO. Robotic approach to vesicourethral anastomotic stenosis and resection of remaining prostate after radical prostatectomy. Int Braz J Urol. 2023;49:158-60.]. Given the relationship between outcomes and surgical experience [55 Bravi CA, Tin A, Vertosick E, Mazzone E, Martini A, Dell'Oglio P, et al. The Impact of Experience on the Risk of Surgical Margins and Biochemical Recurrence after Robot-Assisted Radical Prostatectomy: A Learning Curve Study. J Urol. 2019;202:108-13.77 Bravi CA, Dell'Oglio P, Mazzone E, Moschovas MC, Falagario U, Piazza P, et al. The Surgical Learning Curve for Biochemical Recurrence After Robot-assisted Radical Prostatectomy. Eur Urol Oncol. 2022:S2588-9311(22)00113-4.], it is crucial to implement a step-by-step approach for each surgical step of the procedure, especially in the most challenging part of the intervention. In this video compilation, we described the techniques for bladder neck dissection utilized at OLV Hospital (Aalst, Belgium).

Surgical Technique:

We illustrated five different techniques for bladder neck dissection during RARP. The anterior technique tackles the bladder neck from above until the urethral catheter is visualized, and then the dissection is completed posteriorly. The lateral and postero-lateral approaches involve the identification of a weakness point at the prostate-vesical junction and aim to develop the posterior plane – virtually until the seminal vesicles – prior to the opening of the urethra anteriorly. Finally, we described our techniques for bladder neck dissection in more challenging cases such as in patients with bulky middle lobes and prior surgery for benign prostatic hyperplasia. All approaches follow anatomic landmarks to minimize positive surgical margins and aim to preserve the bladder neck in order to promote optimal functional recovery. All procedures were performed with DaVinci robotic platforms using a 3-instruments configuration (scissors, fenestrated bipolar, and needle driver). As standard protocol at our Institution, urinary catheter was removed on postoperative day two [88 Develtere D, Rosiello G, Piazza P, Bravi CA, Pandey A, Berquin C, et al. Early Catheter Removal on Postoperative Day 2 After Robot-assisted Radical Prostatectomy: Updated Real-life Experience with the Aalst Technique. Eur Urol Focus. 2022;8:922-5.].

Conclusions:

Five different approaches for bladder neck dissection during RARP were described in this video compilation. We believe that the technical details provided here might be of help for clinicians who are starting their practice with this surgical intervention.

REFERENCES

  • 1
    Martini A, Falagario UG, Villers A, Dell'Oglio P, Mazzone E, Autorino R, et al. Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy. Eur Urol. 2020;78:583-91.
  • 2
    Nunes-Silva I, Hidaka AK, Monti CR, Tobias-Machado M, Zampolli HC. Salvage Retzius sparing robotic assisted radical prostatectomy: the first brazilian experience. Int Braz J Urol. 2021;47:1279-80.
  • 3
    Ma X, Tang K, Yang C, Wu G, Xu N, Wang M, et al. Bladder neck preservation improves time to continence after radical prostatectomy: a systematic review and meta-analysis. Oncotarget. 2016;7:67463-75.
  • 4
    Capibaribe DM, Avilez ND, Sacomani CAR, Lucena ASPDN, Reis LO. Robotic approach to vesicourethral anastomotic stenosis and resection of remaining prostate after radical prostatectomy. Int Braz J Urol. 2023;49:158-60.
  • 5
    Bravi CA, Tin A, Vertosick E, Mazzone E, Martini A, Dell'Oglio P, et al. The Impact of Experience on the Risk of Surgical Margins and Biochemical Recurrence after Robot-Assisted Radical Prostatectomy: A Learning Curve Study. J Urol. 2019;202:108-13.
  • 6
    Mottrie A, Mazzone E, Wiklund P, Graefen M, Collins JW, De Groote R, et al. Objective assessment of intraoperative skills for robot-assisted radical prostatectomy (RARP): results from the ERUS Scientific and Educational Working Groups Metrics Initiative. BJU Int. 2021;128:103-11.
  • 7
    Bravi CA, Dell'Oglio P, Mazzone E, Moschovas MC, Falagario U, Piazza P, et al. The Surgical Learning Curve for Biochemical Recurrence After Robot-assisted Radical Prostatectomy. Eur Urol Oncol. 2022:S2588-9311(22)00113-4.
  • 8
    Develtere D, Rosiello G, Piazza P, Bravi CA, Pandey A, Berquin C, et al. Early Catheter Removal on Postoperative Day 2 After Robot-assisted Radical Prostatectomy: Updated Real-life Experience with the Aalst Technique. Eur Urol Focus. 2022;8:922-5.

Publication Dates

  • Publication in this collection
    14 Aug 2023
  • Date of issue
    Jul-Aug 2023

History

  • Received
    18 Jan 2023
  • Accepted
    26 Jan 2023
  • Published
    31 Mar 2023
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