Key elements to approaching difficult cases in robotic urologic surgery

Variations in prostate anatomy provide surgical challenges, the most common of which include the presence of large prostate, median lobes, post-transurethral prostate resection (TURP), prior abdominal surgery, and obese patients. Although it is wise, early in a surgeon’s experience, to select ideal candidates, these difficult cases are no longer contraindications to robotic-assisted laparoscopic radical prostatectomy (RALP). However, these variations in surgical anatomy significantly impact the learning curve and contribute to the potential for increased risk of complications. The key to avoiding problems is a standardized approach to recognition of the anatomy and dissection of the surgical planes. Identification of the bladder neck in large prostate and prior TURP is one of the most challenging aspects of the procedure; defining the bladder neck using the fat insertion line and the contour of the lateral prostate instead of traction of an inflated Foley catheter may provide a clue for this purpose. In case of a median lobe, elevating it using a robotic fourth arm will facilitate dissection of the bladder neck. If deemed necessary, reconstruction of the bladder neck should be performed burying the ureteral orifice out of the path of the anastomosis in cases of large median lobes. The operator should pay attention to inspect the ureteral orifice, as it often lies in close proximity to the borders of the prostate. The ability to recognize these anatomic variations and manage challenging intraoperative situations is an important aspect of RALP. The understanding of anatomic variations in these cases will allow for refinement of technique and the development of new techniques to optimize surgical outcomes. In this chapter, we will discuss the approach to various challenges encountered during RALP and provide advice based on our experience.