Robot-Assisted Laparoscopic Prostatectomy and Urethral Pull Through of Membranous Urethra to Bladder

Clinical History: In this video, we report a unique case of a 71-year-old man with a urologic history of prostate cancer in 2010 treated with high-intensity focused ultrasound. After biochemical recurrence in 2013, he underwent salvage external beam radiation therapy complicated by a severe bulbar urethral stricture. In addition, the patient underwent a transurethral resection of the prostate and placement of an inflatable penile prosthesis. His prostate-specific antigen slowly rose after EBRT from 1.3 in 2019 to 2.7 in 2021. Prostate biopsy showed 1/14 cores positive for Gleason score 4 + 4 = 8 prostate cancer. The patient proceeded with a robot-assisted laparoscopic prostatectomy with a urethral pull through and bilateral pelvic lymph node dissection. Intervention: The procedure began with the XI Da Vinci robot side docked, and the patient was placed in high lithotomy position. The robotic ports were placed in their standard configuration with a 12 mm Airseal assistant port. The urethral dissection was carried out through a midline perineal incision back to the membranous stricture and the perineal body was divided. The bulbar arteries were nonexistent from prior radiation therapy. The video begins with dissection of the prostatic apex to entirely free up and remove the prostate. Once the prostate is separated from the urethra, the old bulbar urethral scar is completely removed. This is accomplished with the help of a perineal counter incision. The remnant urethra is then passed through from below into the pelvic cavity. The anastomosis is performed in a running manner. We then proceeded with a bilateral pelvic lymphadenectomy using the synchroseal device that obviates the need for any clips. The patient's inflatable prosthesis reservoir makes the right side more challenging, however, it is feasible with careful dissection. Follow-Up: The patient was discharged on postoperative day 1 with all drains removed and his postoperative course remained uncomplicated. The surgical pathology analysis revealed Gleason score 4 + 4 = 8 prostate cancer, pT2, and N0 with negative margins and negative lymph nodes. PSA was undetectable at 8 months postoperatively. Owing to continued incontinence, the patient underwent an artificial urethral sphincter at 4 months postoperatively. The patient's incontinence resolved with no further complications. Patient Consent Statement: Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. No conflicts of interest or author disclosures exist. Runtime of video: 5 mins 45 secs