Ckrogers
Contributor
50949 compared with 52332, 51999 compared with 51750, 38571, and 50820-62?18 French cystoscope placed in the bladder. The supra umbilical incision was created. The abdomen was insufflated using a Veress needle to satisfactory pressures using warmed CO2. 4 robotic 8 mm ports and a single 12 mm assistant port were placed in the standard template. The robot was docked. The abdomen was inspected. There was no evidence for gross metastatic disease. The sigmoid colon was mobilized along the line of Toldt. The left ureter was identified at the pelvic brim and tracked proximally to the bladder. A surgical clip was placed proximally and distally and the ureter was transected at the level of the distal ureter near the ureterovesical junction. The distal left ureter was then sampled and sent for pathologic section. There was no evidence for carcinoma on frozen section of the distal left ureter. The left ureter was dissected then proximally and a window posterior to the sigmoid mesentery over the sacral promontory was identified created and the left ureter was brought into the retroperitoneum on the right. Sigmoid colon was then retracted to the left side at the retroperitoneal window was opened to find the right ureter the right ureter was dissected with a large rim of normal tissue surrounding it to the level of the intravesical ureter. It was again clamped using surgical clips proximally and distally and transected. The distal portion of the left ureter was sent for pathologic examination. Frozen section revealed dysplasia. An additional 1 cm was resected and sent for inspection and this returned no evidence for carcinoma. The satisfactory length of the right ureter was noted in the right and left ureter were left in the right retroperitoneal space. Attention was then taken posteriorly to the bladder and prostate anterior to the rectum. The window was opened using Bovie electrocautery and the rectum was dissected off the posterior wall of the bladder and prostate to the level of the urethral plate. The urachus was identified ligated and brought proximally en bloc using with the bladder specimen. The space of Retzius was opened. The bladder was mobilized off the lateral portions of the pelvic sidewall bilaterally the anterior and posterior pedicles were identified. The superior vesicle artery was identified and visually and clipped twice proximally and singly distally initially on the left side not on the right. The endopelvic fascia was incised. The dorsal venous complex was surrounded ligated using 0 Vicryl suture. Attention to the pedicles of the bladder and posterior pedicles of the prostate were then entertained. Using the vessel sealing device the anterior and posterior pedicles on the right were taken subsequently the posterior neurovascular pedicle of the prostate were then taken using the vessel sealer entirely on the right side to mobilize the bladder and prostate. Subsidy on the left side the anterior and posterior pedicles were taken as well as the posterior lateral pedicle of the prostate taken to fully mobilize the prostate other than at the urethra. The dorsal venous complex was then transected. The urethra was then transected. The urethra was closed using a 0 Vicryl figure-of-eight suture. The specimen prostatic urethra was then closed also using a figure-of-eight suture. On the specimen to prevent spillage. The specimen was left in the pelvis until the end of the procedure.
Subsequently a complex extended pelvic lymph node dissection was then performed. This was a "post chemo dissection "with significant inflammatory change surrounding the vessels bilaterally but particularly on the right side. A full extended bilateral pelvic node dissection was performed. The limits were the aortic bifurcation proximally and the pubic distally. The genitofemoral nerve anteriorly and 1 cm posterior to the obturator nerve posteriorly were the limits. The pelvic sidewall laterally and the bladder wall medially. Excellent hemostasis was achieved.
Subsequent Dr. XXXXXX came to the room and isolated a terminal ileal segment for ileal conduit formation. This is dictated under separate cover.
Subsequently bilateral ureteral ileal anastomoses utilizing 3-0 Vicryl sutures in a single layer over a 6 x 22 JJ stent was created. A 0 Vicryl suture was then placed in the distal end of the conduit for later retrieval at the stoma site. A needlepoint suture device was placed through the Subin set stoma site area to tack the distal end of the ileal conduit to the abdominal wall for later retrieval. The robot was then undocked. A small Pfannenstiel incision was created through the skin and subcutaneous tissue the muscle was separated and the peritoneum was opened. The prostate and bladder were then removed from the abdomen sent for pathologic examination. The peritoneum was closed the muscular layer was reapproximated and the fascial layer was closed using running 0 PDS suture. Skin cutaneous tissue was closed using 3-0 Vicryl and the skin was closed using 4-0 Monocryl. Through a separate robotic port a drain was placed in the pelvis. This 10 French Jackson-Pratt drain was secured at the skin using 2-0 nylon suture. A circumferential incision was created at the skin level. A column of subcutaneous tissue and skin was removed over the fascia. A cruciate incision was made in the fascia the muscle was separated and the posterior fascia and peritoneum were opened. The butt end of the ileal conduit was brought to the skin level. Significant redundancy of the butt end of the conduit was identified. Approximately 5 cm were removed and healthy viable ileal tissue were noted. The posterior fascia was secured using 0 Vicryl suture to the fascia and conduit to prevent retraction. Subsequently using undyed 3-0 Vicryl sutures in a everting rosebud stoma was matured. The fascia of the 12 mm port was closed using 0 Vicryl suture using a UR 4 needle in a figure-of-eight type fashion. The ports were then removed infiltrated using Marcaine and then closed using 4-0 Monocryl. An ostomy device was then placed. The nephrostomy tubes were capped. At that point the procedure was terminated. The patient was in the supine position, he was awoken and taken recovery room in satisfactory condition. All needle sponge instrument counts are correct. There were no apparent complications. All needle sponge instrument counts were correct. He tolerated procedure well.