Emmy Posted Thu 12th of March, 2020 15:21:56 PM
REQUIRE DX AND CPT CODES FOR ALL PHYSICIANS BESIDE PA: BAUER MD
RESIDENT ASSISTING: WHITE, MD
FELLOW: SPERRY, MD
PREOPERATIVE DIAGNOSIS: Localized prostate cancer
POSTOPERATIVE DIAGNOSIS: Localized prostate cancer
PROCEDURE: Robotic assisted radical prostatectomy with bilateral pelvic lymphadenectomy with nerve sparing
FINDINGS: No grossly positive disease, wide margin on the posterior aspect near the tumor. Excellent nerve sparing on the left, partial nerve sparing on the right, preservation of accessory pudendal artery on the right, watertight urethrovesical anastomosis.
SPECIMENS: Prostate, bilateral pelvic lymph nodes and periprosthetic fat.
ATTESTATION: I was present for all portions of this procedure.
POSTOPERATIVE PLAN: The patient was admitted to the urology service. He will follow up in one week for catheter removal, voiding trial and discussion of pathology.
INDICATIONS: The patient is a healthy 59-year-old male who was diagnosed with prostate cancer after he had a PSA elevation of 4. He underwent a 12-core biopsy on August 17th, 2018, which revealed 7 positive cores out of 12, two of these cores had 3 + 4 prostate cancer. No further staging has been performed other than an MRI of the prostate on November 7th, 2018 which revealed a PI-RADS version 2 score 3 lesion at the right apex, right paramedian mid gland, and right paramedian mid gland anterior transition zone. The prostate was 41 mL evidence of prostatitis. No bone scan is performed, nor is it indicated. He does have a family history of prostate cancer. His dad died at the age of 96 of prostate cancer. No family history of breast cancer, endometrial cancer, lymphoma, or leukemia. He reports moderate lower urinary tract symptoms. AUA symptom score is 8. He is not on medications for this. With respect to erectile function, he reports a fairly significant erectile dysfunction.
DESCRIPTION OF PROCEDURE: Patient was brought to the operating room. He was confirmed by name, date of birth. He was placed on the operating room table. Appropriate lines replaced. General anesthesia was induced. Hair was removed using clippers. He was placed in the supine split leg position. He was appropriately padded and secured. He was prepped and draped in the standard sterile fashion. Time out was performed. Foley catheter was inserted sterily on the field. Pneumoperitoneum was established with the veress needle. We entered the abdomen under direct visualization with the visiport. The abdomen was surveyed. No it's of diffuse metastases were identified. The two other robotic ports in 12mm assist ports are placed in the standard configuration under direct visualization. The robot was docked. We commenced with the posterior approach. The peritoneum was divided between the perirectal fat pads, dropping the rectum. We identified the left vas deferens, grasped this and we dissected off the perivasal adventitial tissue. We divided the vas at the elbow with electrocautery. We put traction on the vas, identified the pedicle to the seminal vesicle, divided this with the electrocautery and then we released our seminal vesicle down to the level of the base of the prostate. This set of maneuvers were repeated on the left-hand side as well. The vas and SV's were held on tension, the posterior peritoneum was held posteriorly and denovilliers fascia was incised right on to the level of the rectum, dropping the rectum and leaving the strip of denovilliers fascia on the posterior aspect of the prostate where the tumor was. Once we dissected as much as we could posterior to the prostate, given the size of the prostate, we proceeded with our lymph node dissection. On the right-hand side, the ureter was identified. Distal to the ureter, we split the peritoneum over the iliac artery and vein. We began our lymph node dissection by releasing all the lymphatic tissue off of the right external iliac and common iliac veins until we were lateral to the sidewalls. We did this proximally and distally for the entire duration of the vein and posteriorly until we were beyond the obturator nerve into the hypogastric fossa. We separated the lymphatic tissue off of the bladder. We took Hem-o-lok clips and clipped the lymphatic trunks at the bifurcation of the iliac vein where the obturator nerve exits and then again at Coopers ligament. The right pelvic lymph nodes were marked with a Hem-o-lok stitch and then we preceded to the left side. The exact same set of nerves were identified. Once we were happy with our lymph node dissection and inspected for hemostasis, we dropped the bladder on the right-hand side and proceeded to the left. The bladder was put on stretch. The prostate was defatted. This was dissected along it’s entirety and released laterally. Once the prostate was defatted, we incised the endopelvic fascia bilaterally very close to the prostate, preserving an arch o f aponeurosis to provide a scaffolding for the levator musculature. We next commenced with nerve release beginning on the left hand side. At the apex, we were able to get a high release in an avascular plane and extend this from the apex back to the base of the prostate. This was repeated on the right. Nevertheless, we were able to identify a bundle and drop it. We next proceeded with our bladder neck incision. There was a fairly readily identifiable plane that we followed until we entered the bladder. It appeared that we had an approximately 1 cm bladder neck. Both the trigonal ridges were identified. Then, we left of the midline mucosa intact as we dropped the lateral sides of the bladder and we cut the mucosa coldly and took down the remainder of the detrusor muscle with electrocautery. We entered the space where the vas deferens and the seminal vesicles were identified. These were delivered through our posterior bladder neck incision and then held on traction. We began on the patients left hand side taking the pedicles using clips and cold dissection. We were able to trace back the nerves and release them off of the prostate relatively easily. The rectal attachments were divided sharply as well. This was repeated on the right. Once we were at the apex bilaterally, the catheter was placed, the DVC was divided primarily using cold scissors and the specimen was handed off. We then oversewed the DVC with a running V-loc suture in parallel with the nerve fibers. At this point, we irrigated the wound and spent approximately 15 minutes in hemostasis. Once we were happy with the hemostasis, we put surgicel on bilateral pelvic lymph node basins and then began our anastomosis using interlocked V-loc sutures. We ran this around both sides. We placed our final catheter. We checked for a leak and there was none, so we decided not to leave a drain. We placed a piece of surgicel over the anastomosis. We dropped the pressure to 5 and inspected one more time for hemostasis. We delivered the specimen through the midline trocar and then removed all ports under visualization. The fascia was closed with #1 PDS meeting at both apices. Subcutaneous tissues were reapproximated with 3-0 vicryl and the skin was closed with 4-0 monocryl. All wounds were dressed with dermabond. The patient was extubated and taken to PACU in good condition.