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Management of a Large Median Lobe during Robot Assisted Radical Prostatectomy
Rian J. Dickstein, M.D., Aaron C. Weinberg, B.A., David S. Wang, M.D., Richard K. Babayan, M.D..
Boston Medical Center, Boston, MA, USA.

BACKGROUND: Robot Assisted Radical Prostatectomy (RARP) has become an accepted treatment option for patients with organ confined prostate cancer. Difficulty with a large median lobe during radical retropubic prostatectomy has been seldom described. However, median lobe difficulties more frequently arise during RARP. The literature indicates that large median lobes do not alter outcomes for urinary symptoms, continence, and surgical margin status after RARP. Yet, there are significantly longer operative and posterior bladder neck dissection times, a larger percentage of patients requiring bladder neck reconstruction, higher blood loss, and a longer hospital stay. We present a video describing this novel technique for successful management of a large median lobe during RARP without compromise in outcome.
METHODS: A 62 year old man with moderately bothersome urinary symptoms and adequate potency, and a PSA of 6.2 ng/mL was diagnosed with stage T2a, Gleason 3+3 prostate adenocarcinoma. A large, pedunculating median lobe was identified in a 59 cc gland. He underwent RARP during which a 0 Vicryl suture was used to elevate the median lobe and significantly aid in dissection (see video). The anastomosis was performed using a standard modified van Velthoven suturing technique, without the need for bladder neck reconstruction.
RESULTS: The operation was uncomplicated and yielded 300 cc of blood loss. Total operative time was 210 minutes, total robotic time 150 minutes, bladder neck dissection time 20 minutes, and anastomotic time 31 minutes. Pathology revealed bilateral, Gleason 3+3 cancer in 15% of the gland and was confined to the prostate with negative margins. He was discharged home on postoperative day (POD) 1. The urethral catheter was removed on POD 12 without evidence of leak. By two months postoperatively, his PSA was < 0.1 ng/mL, he was using only two pads daily for stress urinary incontinence, and he remained on penile rehabilitation for erectile function.
CONCLUSIONS: Early identification of and preparation for a large median lobe during RARP is essential. Surgeons must be aware of potential complications upon encountering a large median lobe. One technique to aid in dissection includes elevating the median lobe with either tissue graspers or, as described here, a retracting suture.


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