Name:
Transvesical robotic bladder neck reconstruction for posterior urethral stenosis following HoLEP - surgical technique and case presentation
Description:
Transvesical robotic bladder neck reconstruction for posterior urethral stenosis following HoLEP - surgical technique and case presentation
Thumbnail URL:
https://cadmoremediastorage.blob.core.windows.net/f45bface-bc99-4c20-ba9e-fb784ae21cd2/videoscrubberimages/Scrubber_1.jpg?sv=2019-02-02&sr=c&sig=1RRCfGhfTs1tW5GmQLxq30OmXPWGcsOzam45IIHaD1U%3D&st=2026-03-09T17%3A06%3A29Z&se=2026-03-09T21%3A11%3A29Z&sp=r
Duration:
T00H05M55S
Embed URL:
https://stream.cadmore.media/player/f45bface-bc99-4c20-ba9e-fb784ae21cd2
Content URL:
https://cadmoreoriginalmedia.blob.core.windows.net/f45bface-bc99-4c20-ba9e-fb784ae21cd2/470941789-PUSfollowingHo-LEPVideourologymp4.mp4?sv=2019-02-02&sr=c&sig=CI488TgrQ6b3qByiGj1kgbSbIv0fNEhq92ZYrk7XesI%3D&st=2026-03-09T17%3A06%3A29Z&se=2026-03-09T19%3A11%3A29Z&sp=r
Upload Date:
2024-04-03T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
SPEAKER: This video discusses the case and surgical technique for a transvesicle robotic bladder neck reconstruction for posterior urethral stenosis following HoLEP. This case presents a 51-year-old male with BPH who underwent a Holmium Laser Enucleation of the Prostate or a HoLEP procedure in July of 2022 for worsening lower urinary tract symptoms. Six months later, he presented for worsening weakened stream and dribbling.
SPEAKER: At the time, cystoscopy showed an obliterative scar of the posterior urethra. He subsequently had a suprapubic tube placed and was referred to us. In March of 2023, retrograde cystoscopy revealed that the obliterative scar was proximal to the sphincter, while antegrade cystoscopy showed evidence of a stenosed bladder neck. The decision was then made to proceed with the transvesicle robotic bladder neck reconstruction for posterior urethral stenosis.
SPEAKER: Posterior urethral stenosis has been identified in roughly 1% to 5% of patients after a HoLEP procedure. Urethral stenosis can result in lower urinary tract symptoms, including difficulty urinating, weakened stream, frequent urination, urinary retention, and urinary tract infections. Several retrospective studies have identified risk factors, including longer operative time, small prostatic volume, prior history of prostatitis, and prior history of TURP.
SPEAKER: Treatment options for urethral stenosis have included endoscopic interventions such as urethral dilation, direct internal visual urethrotomy, bladder neck incision, or reconstructive surgical interventions. Currently, there is no standardized surgical treatment for posterior urethral stenosis following HoLEP. This image is the preoperative retrograde urethrogram and cystogram showing the patient's prostatic urethral stenosis.
SPEAKER: The surgery began with the cystoscopy where a blind end was seen approximately 1 centimeter proximal to the veru. [MUSIC PLAYING] The bladder was then scoped anterograde. And a 5 French opening was seen in the bladder neck, but it could not be cannulated. After standard entry into the abdomen, the procedure started by performing a lysis of adhesions of the sigmoid of the sidewall of the pelvis to allow improved access to the dome of the bladder.
SPEAKER: Next, we performed a 4-centimeter vertical cystotomy of the bladder, initially incising the detrusor followed by the mucosa. The bladder had been previously filled with saline by the cystoscope. [MUSIC PLAYING] Next, four 2-0 Prolene Keith needle stitches were used as traction stay sutures.
SPEAKER: The needles were passed from the abdominal wall, and then the full thickness through the bladder, and then back up through the anterior abdominal wall and placed on tension. This allowed optimal transvesicle exposure of the bladder neck. [MUSIC PLAYING] Next, we perform the robotic transvesicle reconstruction.
SPEAKER: The ureteral orifices were prospectively identified and marked with cautery. Next, a circumscribing incision around the bladder neck was marked out. Using monopolar scissors and electrocautery, the bladder neck was incised. This was carried out circumferentially around. [MUSIC PLAYING] The assistant then passed the flexible cystoscope up to the level of the scar above the veru.
SPEAKER: Firefly was then used to visualize the scope light. The dissection was continued around the bladder neck and into the residual prostate, ensuring the removal of all scar tissue. The proximal urethra was then seen with the scope in it. A cold cutting dissection was performed at this point as we got closer to mucosa. The mucosa appeared vascular and healthy. [MUSIC PLAYING] The bladder neck contracture specimen was then sent off for pathologic evaluation.
SPEAKER: The cystoscope was now easily passed through the previously obliterated urethra, ensuring its patency. A partial subtotal prostatectomy was then performed by removing some additional prostate tissue that was encroaching on the urethra. The specimen was dissected off and also sent for pathologic evaluation. A bladder neck advancement flap was created by undermining circumferentially around the bladder neck and into the prostate.
SPEAKER: This allowed some release of the bladder mucosa to be advanced. Next, a Rocco stitch was used with a 2-0 Vicryl to pull the posterior bladder muscularis distally to the prostate apex prior to the anastomosis. This was done three times and allowed for a more tension-free anastomosis. [MUSIC PLAYING] Using 9-inch 3-0 V-Loc suture we performed a running anastomosis in a clockwise fashion starting from the 12 o'clock position until the 6 o'clock position on the right side.
SPEAKER: This right clockwise stitch ran from mucosa on the bladder to the mucosa of the posterior urethra. Tensioning was done throughout to allow the mucosal surface to oppose together. This same technique was performed on the contralateral side in a counterclockwise fashion. The final Foley catheter was placed without difficulty and was inflated with 15 CC. Finally, the bladder holding stitches were removed and the cystorrhaphy was then completed in two layers.
SPEAKER: The patient's post-operative course was uncomplicated. He was discharged home on postoperative day one with a Foley catheter in place. At his two-week outpatient follow-up visit a voiding cystourethrogram showed a well-healed anastomosis without evidence of contrast extravasation. Also, at three-month follow up cystoscopy showed a patent anastomosis.
SPEAKER: In conclusion, this case presents posterior urethral stenosis, which is a rare complication of the HoLEP procedure. In this case, we validate the usefulness of a conventional robot-assisted system for a transvesicle bladder neck reconstruction to repair posterior urethral stenosis following HoLEP, highlighting the surgical technique in its potential clinical utility.
SPEAKER: [MUSIC PLAYING]
