V474 “ANATOMIC RETRO-APICAL TECHNIQUE” FOR SYNCHRONOUS POSTERO-ANTERIOR APPROACH TO APICAL TRANSECTION DURING ROBOTIC RADICAL PROSTATECTOMY

You have accessJournal of UrologyProstate Oncology1 Apr 2010V474 “ANATOMIC RETRO-APICAL TECHNIQUE” FOR SYNCHRONOUS POSTERO-ANTERIOR APPROACH TO APICAL TRANSECTION DURING ROBOTIC RADICAL PROSTATECTOMY Ashutosh Tewari, Abhishek Srivastava, Denny Mui, Robert Leung, Kumaran Mudaliar, Sonal Grover, Youssef El Douaihy, David Peters, James Wysock, Rajiv Yadav, Sara Muir, Vanessa Dudley, Gerald Tan, Jason Fung, DaWei Ye, Amanda Lawlor, Christian Thom, Geoff Strasser, Amir Hussain, Adam Torres, Alexis Te, Maria Shevchuck, and Darracott Vaughan Ashutosh TewariAshutosh Tewari More articles by this author , Abhishek SrivastavaAbhishek Srivastava More articles by this author , Denny MuiDenny Mui More articles by this author , Robert LeungRobert Leung More articles by this author , Kumaran MudaliarKumaran Mudaliar More articles by this author , Sonal GroverSonal Grover More articles by this author , Youssef El DouaihyYoussef El Douaihy More articles by this author , David PetersDavid Peters More articles by this author , James WysockJames Wysock More articles by this author , Rajiv YadavRajiv Yadav More articles by this author , Sara MuirSara Muir More articles by this author , Vanessa DudleyVanessa Dudley More articles by this author , Gerald TanGerald Tan More articles by this author , Jason FungJason Fung More articles by this author , DaWei YeDaWei Ye More articles by this author , Amanda LawlorAmanda Lawlor More articles by this author , Christian ThomChristian Thom More articles by this author , Geoff StrasserGeoff Strasser More articles by this author , Amir HussainAmir Hussain More articles by this author , Adam TorresAdam Torres More articles by this author , Alexis TeAlexis Te More articles by this author , Maria ShevchuckMaria Shevchuck More articles by this author , and Darracott VaughanDarracott Vaughan More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.548AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The rate of positive margins in large robotic prostatectomy series is 18.5%. The vast majority of these positive margins occur at the apex. While several modifications have been made to prostate cancer surgery, positive apical margins continue to be a troublesome setback. We describe a novel technique where we approach prostate-urethra junction from the posterior aspect of the urethra. Posteriorly, the urethra is only covered by Denonvillier's fascia and the rectourethralis muscle, so this is a clear path to the apex. METHODS The Anatomic Retro-apical Technique begins after the prostate has been completely dissection postero-laterally; the left side assistant lifts the prostate towards the anterior abdominal wall, exposing the space posterior to the apex and urethra. A 30° upward-facing lens affords an optimal view of this space. Dissection begins with sharp dissection of the superficial layers of Denonvillier's fascia using sharp, curved scissors, thus exposing the precise prostate-urethral junction. Next, the posterior wall of the urethra is sharply incised 1 mm distal to the apex. The catheter is exposed and withdrawn through the posterior urethral opening. This also exposes the anterior wall of the urethral mucosa and the muscular wall. Using blunt and sharp dissections, the urethra is divided circumferentially. At this point only Dorso Venous Complex(DVC) is left attached to the anterior surface of the prostate. Management of the DVC now depends upon the width and thickness of the anterior tissue. If it is broad and thick, we will place a DVC stitch; if the remaining tissue is thin we increase the pneumo peritoneum to over 15 mm of water column pressure and a Foley catheter balloon is inflated to 20-30 cc behind the prostate. We then switch to a 0° lens and proceed with anterior dissection under a raised pneumoperitoneum. This novel approach was used in 209 patients and was compared with historical controls. The primary outcomes and apical positive margins were studied in these 209 patients. RESULTS After introduction of retro-apical dissection of the prostato-urethral junction, total positive margin rates decreased from 9.8% in the control group to 5.3% in retro-apical group. Positive apical margin rates decreased from 4.4% in the control group to 1.3% in the retro-apical group. CONCLUSIONS Retro-apical dissection is a novel approach to dissection of the prostato-urethral junction. It allows for better visualization of the prostatic apex and leads to both decreased total positive margin rates and decreased apical margin rates. New York, NY© 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e187 Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Ashutosh Tewari More articles by this author Abhishek Srivastava More articles by this author Denny Mui More articles by this author Robert Leung More articles by this author Kumaran Mudaliar More articles by this author Sonal Grover More articles by this author Youssef El Douaihy More articles by this author David Peters More articles by this author James Wysock More articles by this author Rajiv Yadav More articles by this author Sara Muir More articles by this author Vanessa Dudley More articles by this author Gerald Tan More articles by this author Jason Fung More articles by this author DaWei Ye More articles by this author Amanda Lawlor More articles by this author Christian Thom More articles by this author Geoff Strasser More articles by this author Amir Hussain More articles by this author Adam Torres More articles by this author Alexis Te More articles by this author Maria Shevchuck More articles by this author Darracott Vaughan More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...