Miko24
Guru
Procedure:
1. Robot assisted laparoscopic cystectomy with bilateral lymphadenectomy
2. Ileal neobladder urinary diversion
Specimens:
1. Cystoprostatectomy specimen to pathology
2. Bilateral ureteral and urethral margins for frozen section
3. Right and left pelvic lymph nodes to pathology
4. Left internal iliac lymph node
Procedure
The robot was brought in and docked to the ports. The robotic instruments were inserted under direct visualization with the camera.
The sigmoid colon was mobilized sharply. An incision was made in the White Line of Toldt to mobilize the left colon partially. The left ureter was dissected in the retroperitoneum at the level of the iliac vessels. The ureter was sharply dissected distally to the level of the bladder. The superior vesicle artery was encountered and divided using the vessel sealer device. The ureter was dissected down to the bladder. The ureter was then doubly clipped with Wek clips. The ureter was divided and a margin was sent for frozen section. The ureter was then mobilized cephalad from the iliac vessels as much as possible.
Attention was then turned to the right side of the pelvis. The terminal ileum and the appendix were visualized. The right colon was mobilized sharply by incising the White Line. Small bowel was retracted out of the retroperitoneum. The retroperitoneum was incised overlying the iliac vessels. The ureter was identified and sharply dissected. The ureter was dissected down to the bladder similarly to the left side. The superior vesical artery was divided using the vessel sealer. The ureter was doubly clipped at the level of the bladder. The ureter was divided and a margin was obtained and sent to pathology.
The posterior peritoneum was incised in the space of Douglas. The vasa were dissected down to the SVs. The SVs were mobilized sharply. I created a plane posterior to the SVs and the prostate. The plane was developed down to the prostatic apex.
Starting on the left side, the bladder was retracted anteriorly. The bladder pedicles were identified and divided using the vessel sealer. I was careful to stay posterior to the ureter and the SVs. Eventually the pedicles were divided down to the level of the endopelvic fascia. I then opened the anterior peritoneum lateral to the obliterated umbilical artery on the left side. The peritoneal incision was carried down lateral to the bladder. The vas deferens was divided using the vessel sealer device.
The bladder pedicles were divided on the right side in a similar fashion using the vessel sealer device. I created a plane below the bladder and SVs until the prostate pedicles could now be visualized. I opened the endopelvic fascia on both sides using sharp dissection. The endopelvic fascia was opened as far towards the prostate apex as feasible. The prostate pedicles were then divided using the vessel sealer. The prostate was then free up to the apex.
I then used the 30 degree lens upward to visualize the Urachus. This was dissected just caudally from the umbilicus and divided using the vessel sealer device. I then proceeded to dissect the anterior peritoneum off of the anterior abdominal wall and enter the space of Retzius. Eventually the bladder was mobilized and the pubic bone was encountered. The anterior prostate was then visualized. Fat was removed from the anterior surface of the prostate. The endopelvic fascia was visualized and opened on both sides of the prostate. The prostate was dissected off of the pelvic floor muscles on both sides. The dorsal vein complex was identified. This was ligated with an 0 PDS suture. The dorsal vein complex was divided using electrocautery.
The bladder neck was identified and opened anteriorly. The Foley catheter was visualized and used as traction on the prostate. The foley was pulled through the incision and a Wek clip was placed. The foley was cut downstream from the Wek clip. The posterior bladder neck was divided. The rhabdosphincter was divided. The cystoprostatectomy specimen was freed at this point. The specimen was pushed into the upper abdomen. The pedicles were examined and there appeared to be excellent hemostasis.
A pelvic lymph node dissection was performed on the left side. The internal iliac vein was identified. The node packet was dissected off the medial aspect of the vein and then dissected back to the pelvic sidewall. The node packet was dissected distally to Cooper's ligament. The vessel sealer device was used to divide the node packet distally. Inferiorly, the obturator nerve is identified. The node packet is dissected proximally off the obturator nerve. The packet is dissected back to the bifurcation of the internal and external iliacs. The packet is divided at this point using the vessel sealer. The lymph node packet is then mobilized off of the external iliac artery. This is mobilized back to the bifurcation of the external/internal iliac artery. The packet is divided using the vessel sealer device. The packet is then removed with a spoon tip grasper and labeled for pathology. A prominent lymph node was encountered along the internal iliac artery just distal to the bifurcation. This is likely the lymph node that was seen on the patient's recent PET Scan. Care was taken to dissect this out and send as a separate sample.
The obturator nerve is inspected and free of any injury. No significant bleeding is noted. The same procedure is performed on the patient's right side.
At this point, there appears to be excellent hemostasis. The patient is repositioned supine. The robotic instruments are removed. The robot is backed away from the table. The pneumoperitoneum was left intact. A low midline incision is mapped out on the skin using a marker. The incision is injected with Exparel. A scalpel was used to incise the skin and a Bovie is used to divide the underlying connective tissue down to the level of the fascia. Fascia is opened sharply. The rectus sheath is encountered and the midline is identified and opened. The underlying abdominal contents are identified.
The Omni retractor is placed. The cystoprostatectomy specimen is identified and removed from the abdomen. The remnant of the Foley catheter is intact within the specimen. This is passed off for pathology.
The frozen sections from the ureters are negative. Dr. B is present at this point and proceeds to divide the mesentery of the terminal ileum to harvest the bowel for the neobladder. Please see his note for details.
All of the bowel is retracted into the upper abdomen. The urethra is identified. 2-0 Monocryl sutures are placed interrupted into the urethra. Sutures are placed at 12:00, 2:00, 4:00, 6:00, 8:00, and 10:00 positions
Using stay stitches and Babcock clamps, the bowel loops are brought together in such a way to form a Hauptman ileal neobladder. The antimesenteric aspect of the bowel is opened over 60 cm using cautery. The bowel is then irrigated to remove gross succus. The back walls of the neobladder are then sutured using a combination of interrupted 2-0 Vicryl suture as well as running 2-0 Vicryl suture. The inferior portion of the neobladder is brought together with a combination of interrupted and running 2-0 Vicryl suture. The location for the urethral anastomosis is selected at the most dependent portion of the neobladder. An incision is made in the bowel aspect of the neobladder using a Bovie. The mucosa is everted using interrupted 4-0 chromic sutures.
The urethral anastomotic sutures are then placed at corresponding locations on the urethral aspect of the neobladder using free needles. A 20 French Foley catheter was placed through the penis and into the pelvis. The catheter was placed through the anastomosis and the balloon is inflated with 20 cc of normal saline. Gentle traction is then placed on the balloon to bring the neobladder down to the urethra. The posterior sutures are ligated first followed by the lateral sutures and then finally the anterior sutures.
The chimney of the neobladder is identified. The left ureter is freshened and spatulated. A 5 mm incision is made on the left side of the chimney. 4-0 Monocryl suture is used to join the apex of the ureter to the bowel incision. 1 sutures placed on each side and ligated. A 7 French by 28 cm stent is placed over a guidewire into the left kidney. The guidewire was removed and there is a curl noted. The curl is placed into the chimney of the neobladder. Each side of the anastomosis is then closed with a running 4-0 Monocryl suture. Saline is injected into the chimney to confirm that the anastomosis is watertight. The same procedure was then used to anastomose the right ureter to the right side of the chimney.
A 5 mm stab incision is made on the right side of the abdomen. A clamp is placed through the abdomen and out the incision. An 18 French Foley catheter is brought through the incision using the clamp. A small incision is then made in the right lateral side of the neobladder. The Foley catheter is then passed into the neobladder. This will serve as an SP tube. A 3-0 chromic suture is used to place a pursestring around the SP tube at the opening into the neobladder. A 3-0 chromic suture is then also used to suture the SP tube at the level of the skin. The balloon is inflated with 10 cc of normal saline. The Foley catheter balloon is taken down to 15 cc of normal saline.
The remainder of the anterior neobladder incision is closed with a combination of interrupted 2-0 Vicryl and running 2-0 Vicryl sutures. The neobladder is then irrigated through the Foley catheter. No obvious leaks are observed.
A 15 French Blake drain was placed through the abdominal wall in the left lower quadrant. The drain is sutured to the skin with a 2-O nylon suture.
CPT codes: 55866 38571 and 50825
1. Robot assisted laparoscopic cystectomy with bilateral lymphadenectomy
2. Ileal neobladder urinary diversion
Specimens:
1. Cystoprostatectomy specimen to pathology
2. Bilateral ureteral and urethral margins for frozen section
3. Right and left pelvic lymph nodes to pathology
4. Left internal iliac lymph node
Procedure
The robot was brought in and docked to the ports. The robotic instruments were inserted under direct visualization with the camera.
The sigmoid colon was mobilized sharply. An incision was made in the White Line of Toldt to mobilize the left colon partially. The left ureter was dissected in the retroperitoneum at the level of the iliac vessels. The ureter was sharply dissected distally to the level of the bladder. The superior vesicle artery was encountered and divided using the vessel sealer device. The ureter was dissected down to the bladder. The ureter was then doubly clipped with Wek clips. The ureter was divided and a margin was sent for frozen section. The ureter was then mobilized cephalad from the iliac vessels as much as possible.
Attention was then turned to the right side of the pelvis. The terminal ileum and the appendix were visualized. The right colon was mobilized sharply by incising the White Line. Small bowel was retracted out of the retroperitoneum. The retroperitoneum was incised overlying the iliac vessels. The ureter was identified and sharply dissected. The ureter was dissected down to the bladder similarly to the left side. The superior vesical artery was divided using the vessel sealer. The ureter was doubly clipped at the level of the bladder. The ureter was divided and a margin was obtained and sent to pathology.
The posterior peritoneum was incised in the space of Douglas. The vasa were dissected down to the SVs. The SVs were mobilized sharply. I created a plane posterior to the SVs and the prostate. The plane was developed down to the prostatic apex.
Starting on the left side, the bladder was retracted anteriorly. The bladder pedicles were identified and divided using the vessel sealer. I was careful to stay posterior to the ureter and the SVs. Eventually the pedicles were divided down to the level of the endopelvic fascia. I then opened the anterior peritoneum lateral to the obliterated umbilical artery on the left side. The peritoneal incision was carried down lateral to the bladder. The vas deferens was divided using the vessel sealer device.
The bladder pedicles were divided on the right side in a similar fashion using the vessel sealer device. I created a plane below the bladder and SVs until the prostate pedicles could now be visualized. I opened the endopelvic fascia on both sides using sharp dissection. The endopelvic fascia was opened as far towards the prostate apex as feasible. The prostate pedicles were then divided using the vessel sealer. The prostate was then free up to the apex.
I then used the 30 degree lens upward to visualize the Urachus. This was dissected just caudally from the umbilicus and divided using the vessel sealer device. I then proceeded to dissect the anterior peritoneum off of the anterior abdominal wall and enter the space of Retzius. Eventually the bladder was mobilized and the pubic bone was encountered. The anterior prostate was then visualized. Fat was removed from the anterior surface of the prostate. The endopelvic fascia was visualized and opened on both sides of the prostate. The prostate was dissected off of the pelvic floor muscles on both sides. The dorsal vein complex was identified. This was ligated with an 0 PDS suture. The dorsal vein complex was divided using electrocautery.
The bladder neck was identified and opened anteriorly. The Foley catheter was visualized and used as traction on the prostate. The foley was pulled through the incision and a Wek clip was placed. The foley was cut downstream from the Wek clip. The posterior bladder neck was divided. The rhabdosphincter was divided. The cystoprostatectomy specimen was freed at this point. The specimen was pushed into the upper abdomen. The pedicles were examined and there appeared to be excellent hemostasis.
A pelvic lymph node dissection was performed on the left side. The internal iliac vein was identified. The node packet was dissected off the medial aspect of the vein and then dissected back to the pelvic sidewall. The node packet was dissected distally to Cooper's ligament. The vessel sealer device was used to divide the node packet distally. Inferiorly, the obturator nerve is identified. The node packet is dissected proximally off the obturator nerve. The packet is dissected back to the bifurcation of the internal and external iliacs. The packet is divided at this point using the vessel sealer. The lymph node packet is then mobilized off of the external iliac artery. This is mobilized back to the bifurcation of the external/internal iliac artery. The packet is divided using the vessel sealer device. The packet is then removed with a spoon tip grasper and labeled for pathology. A prominent lymph node was encountered along the internal iliac artery just distal to the bifurcation. This is likely the lymph node that was seen on the patient's recent PET Scan. Care was taken to dissect this out and send as a separate sample.
The obturator nerve is inspected and free of any injury. No significant bleeding is noted. The same procedure is performed on the patient's right side.
At this point, there appears to be excellent hemostasis. The patient is repositioned supine. The robotic instruments are removed. The robot is backed away from the table. The pneumoperitoneum was left intact. A low midline incision is mapped out on the skin using a marker. The incision is injected with Exparel. A scalpel was used to incise the skin and a Bovie is used to divide the underlying connective tissue down to the level of the fascia. Fascia is opened sharply. The rectus sheath is encountered and the midline is identified and opened. The underlying abdominal contents are identified.
The Omni retractor is placed. The cystoprostatectomy specimen is identified and removed from the abdomen. The remnant of the Foley catheter is intact within the specimen. This is passed off for pathology.
The frozen sections from the ureters are negative. Dr. B is present at this point and proceeds to divide the mesentery of the terminal ileum to harvest the bowel for the neobladder. Please see his note for details.
All of the bowel is retracted into the upper abdomen. The urethra is identified. 2-0 Monocryl sutures are placed interrupted into the urethra. Sutures are placed at 12:00, 2:00, 4:00, 6:00, 8:00, and 10:00 positions
Using stay stitches and Babcock clamps, the bowel loops are brought together in such a way to form a Hauptman ileal neobladder. The antimesenteric aspect of the bowel is opened over 60 cm using cautery. The bowel is then irrigated to remove gross succus. The back walls of the neobladder are then sutured using a combination of interrupted 2-0 Vicryl suture as well as running 2-0 Vicryl suture. The inferior portion of the neobladder is brought together with a combination of interrupted and running 2-0 Vicryl suture. The location for the urethral anastomosis is selected at the most dependent portion of the neobladder. An incision is made in the bowel aspect of the neobladder using a Bovie. The mucosa is everted using interrupted 4-0 chromic sutures.
The urethral anastomotic sutures are then placed at corresponding locations on the urethral aspect of the neobladder using free needles. A 20 French Foley catheter was placed through the penis and into the pelvis. The catheter was placed through the anastomosis and the balloon is inflated with 20 cc of normal saline. Gentle traction is then placed on the balloon to bring the neobladder down to the urethra. The posterior sutures are ligated first followed by the lateral sutures and then finally the anterior sutures.
The chimney of the neobladder is identified. The left ureter is freshened and spatulated. A 5 mm incision is made on the left side of the chimney. 4-0 Monocryl suture is used to join the apex of the ureter to the bowel incision. 1 sutures placed on each side and ligated. A 7 French by 28 cm stent is placed over a guidewire into the left kidney. The guidewire was removed and there is a curl noted. The curl is placed into the chimney of the neobladder. Each side of the anastomosis is then closed with a running 4-0 Monocryl suture. Saline is injected into the chimney to confirm that the anastomosis is watertight. The same procedure was then used to anastomose the right ureter to the right side of the chimney.
A 5 mm stab incision is made on the right side of the abdomen. A clamp is placed through the abdomen and out the incision. An 18 French Foley catheter is brought through the incision using the clamp. A small incision is then made in the right lateral side of the neobladder. The Foley catheter is then passed into the neobladder. This will serve as an SP tube. A 3-0 chromic suture is used to place a pursestring around the SP tube at the opening into the neobladder. A 3-0 chromic suture is then also used to suture the SP tube at the level of the skin. The balloon is inflated with 10 cc of normal saline. The Foley catheter balloon is taken down to 15 cc of normal saline.
The remainder of the anterior neobladder incision is closed with a combination of interrupted 2-0 Vicryl and running 2-0 Vicryl sutures. The neobladder is then irrigated through the Foley catheter. No obvious leaks are observed.
A 15 French Blake drain was placed through the abdominal wall in the left lower quadrant. The drain is sutured to the skin with a 2-O nylon suture.
CPT codes: 55866 38571 and 50825
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