Pre-op Diagnosis: Prostate cancer (CMS/HCC) [C61]
Post-op Diagnosis: Same as Pre-op
Procedure(s): RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION – Wound Class: Clean Contaminated
Proc. Description(s) & CPT Code(s): RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION:
Anesthesia: General
Estimated Blood Loss: less than 100 mL
Quantitative Blood Loss: No data recorded
Implants: * No implants in log *
Complications: None
Findings: Dictated
Technique: RADICAL PROSTATECTOMY ROBOTIC ASSISTED WITH BILATERAL PELVIC LYMPH NODE DISSECTION
Technique:
Drains: 1) 18 French Foley catheter, 2) 19 French JP drain
Procedures: 1) robotic-assisted laparoscopic radical prostatectomy with bilateral nerve sparing and bilateral obturator lymph node dissection
Indications for procedure: 72 y.o.male recently diagnosed with a clinical stage T1cNxMx Gleason 3+4 adenocarcinoma. He is felt to be a good candidate for robotic prostatectomy. Prior to proceeding with the operation, the risks, benefits, and alternatives were discussed with the patient. Possible complications explained, and all questions answered. The patient gave full consent for the procedure.
Procedure in detail: Patient was taken to the operative suite and placed on the OR table in the supine position. He was then placed under general anesthesia without complication. He was then positioned in the low lithotomy, his abdomen shaved free of her and then his abdomen and genital area prepped and draped in the normal sterile fashion.
Initially the abdominal cavity was entered at the level of the umbilicus using a Hassan method. A 12 mm balloon port was placed at this incision and pneumoperitoneum was established to 15 cm water pressure. Initial evaluation of the intra-abdominal contents revealed no evidence of injury. Patient was then placed in the steep Trendelenburg position to allow the abdominal contents to fall towards the head to expose the pelvis. 5 additional port sites were then placed, all under direct vision, with 3 robotic port sites and to assist in port sites placed in the standard fashion. The da Vinci robot system was then docked and dissection began.
Utilizing monopolar scissors and bipolar cautery, the intra-abdominal wall and peritoneum was incised in order to drop the bladder posteriorly. The space of Retzius was entered and dissection was carried out to the level of the pubic symphysis exposing the anterior bladder wall and the prostate. He leaves of the peritoneum were released from the midline down to the vas deferens bilaterally.
The external iliac vein was then identified and standard obturator lymph node dissection was performed. The node packet contained inferior to the external iliac vein, distally to the node of Cloquet, posteriorly to the obturator nerve and laterally to the pelvic sidewall was dissected out. The lymphatic channels were sealed with bipolar cautery. Particular care was utilized to avoid any injury to the obturator nerve. The nodal packet was then removed through one of the assistant port sites intact and sent for permanent pathology. This was performed bilaterally. There were no abnormal appearing lymph nodes identified grossly.
Moving along the lateral aspect of the prostate, the reflection of the endopelvic fascia over the prostate was released to expose the levator ani muscles. The fibers of the muscle were carefully released off the lateral and posterior aspects of the prostate from the prostatic base up to the apex. The puboprostatic ligaments were carefully released using electrocautery. The superficial dorsal vein of the prostate were sealed using bipolar cautery and transected to better expose the dorsal vein complex. The monopolar scissors and bipolar cautery then exchanged for needle drivers and a figure-of-eight suture was placed around the dorsal vein complex using a 0 Vicryl on a CT1 needle. The same suture was then utilized to punch the reflected edges of the endopelvic fascia over the midportion of the prostate such that the bladder neck could be better identified.
Replacing the monopolar scissors and bipolar cautery the anterior bladder neck was transected using electrocautery. Identifying the location of the bladder neck was assisted by placing traction on the Foley catheter that had been placed at the beginning of the procedure. Dissection was carried out through the anterior bladder neck, the Foley balloon was dropped and the Foley catheter tip was brought out through the defect in the anterior bladder neck and placed on traction utilizing the fourth robotic arm. Dissection was then carried out through the posterior bladder neck, taking particular care to avoid entry into the prostate tissue. Eventually the bladder was released from the prostate and the ampulla of vas deferens came into view. The ampulla of vas were sequentially isolated, lifted, sealed with the bipolar cautery and then transected sharply. Placing the anterior and cephalad traction on the transected ampulla, the seminal vesicles came into view. Each seminal vesicle was carefully dissected out, releasing the tissue lateral to the seminal vesicle with blunt and sharp dissection and without the use of cautery. The deferential vessels were identified and selectively sealed using the bipolar cautery. Eventually both seminal vesicles were lifted to expose an obvious fashion at the posterior surface of the prostate. An obvious was then opened sharply to expose the perirectal fat plane, dissection was carried out posterior the prostate up to the rectourethralis muscle.
The prostate was then placed on lateral traction, and the lateral prostatic fascia was really sharply such that the nerve sparing procedure could be performed. The neurovascular bundle was carefully released from the lateral and posterolateral aspects of the prostate. After the neurovascular bundle had been sufficiently released away from the prostate particularly in the mid and apical sections, the prostate was lifted by the base of the seminal vesicle and then the lateral prostatic pedicles were isolated and secured using hemoclips. The lateral pedicles of the prostate were then released cutting on the prostate side away from the clip. The neurovascular bundle was then fully released from the posterior lateral aspect of the prostate all the way to the apex. This procedure was performed bilaterally.
The prostate was completely released from surrounding tissue with the exception of the dorsal vein complex and the urethra at this time. Prostate was placed on posterior cephalad traction and the dorsal vein complex was then transected at the apex of the prostate using electrocautery. The urethra was transected sharply at the apex of the prostate. Any remaining attachments of the rectourethralis were then released thereby completely freeing the prostate which was then moved into a separate area of the abdomen for later removal. The prostate fossa was carefully evaluated for any areas of active bleeding which were subsequently controlled with bipolar cautery. The neurovascular bundles were well-preserved.
The needle drivers were then replaced and a running vesicourethral anastomosis was performed utilizing a double-armed Stratofix 3-0 Monocryl suture on RB1 needle. Once the anastomosis had been completely closed, a final 20 French Foley catheter was advanced into the bladder. The bladder was irrigated with 180 mL of saline via catheter to check the patency of the anastomosis, no leakage was noted. The da Vinci robotic system was then undocked from the ports. The camera is placed through the right lateral assistant port site and the prostatic specimen placed into an Endo Catch bag through the umbilical port. A 19 French JP drain was placed via the left lateral quadrant port site and positioned into the pelvis. All ports were then removed from the abdomen and pneumoperitoneum released. The JP drain was secured to the skin using a 2-0 nylon suture. The umbilical incision was enlarged sufficiently to accommodate removal of the prostate intact within the Endo Catch bag, which was then sent for permanent pathology. The umbilical port site was closed in 3 layers, reapproximating the abdominal fascia using a 0 Vicryl in a running fashion followed by 3-0 Vicryl repeat approximate the subcutaneous tissues and finally the skin was reapproximated using a 4-0 Vicryl in a subcuticular fashion. All the port sites were closed at the level of the skin using a 4-0 Vicryl in a subcuticular fashion. Patient’s abdomen was cleaned and dried and sterile dressings applied. All needle and sponge counts were correct at the end of the case. Patient was taken out of the low lithotomy position and extubated without complication. He tolerated the procedure well, there were no complications
CPT and ICD 10 code:
55866 LAPAROSCOPY, SURGICAL PROSTATECTOMY, RETROPUBIC RADICAL, INCLUDING NERVE SPARING, INCLUDES ROBOTIC ASSISTANCE, WHEN PERFORMED
38571 Laparoscopy, surgical; with bilateral total pelvic lymphadenectomy
C61 – Prostate cancer
