title: Management of an enlarged median lobe with ureteral orifices at the margin of bladder neck during robotic-assisted laparoscopic prostatectomy.
abstract: OBJECTIVE
  To present our technique for the management of an enlarged median lobe when the ureteral orifices are close to the bladder neck during robotic-assisted radical prostatectomy.
  
  
  METHODS
  From January 2005 to January 2007, we performed over 600 robotic assisted radical prostatectomies. We had 63 patients (10%) with enlarged medium lobes. Of these patients, two (5.7%) had their ureteral orifices in close proximity to the bladder neck. An additional patient, without a median lobe, had his orifices very close to the bladder neck. To aid in the management of their median lobes, all three patients had bilateral placement of ureteral catheters manually by the daVinci robot. We present our technique of robotic-assisted catheter insertion during robotic prostatectomy to protect the ureteral orifice from damage, precluding the use of a cystoscope.
  
  
  RESULTS
  All three patients, underwent successful robotic-assisted radical prostatectomy (RALP) aided by intraoperative placement of either a double J ureteral catheters or open ended ureteral catheters that were removed after completion of the anastamosis. All three had normal cystograms before Foley catheter removal. All three patients were continent with follow up PSAs < 0.1. The presence of a median lobe slightly increased the operative time required for bladder neck dissection or anastomosis (including reconstruction). There was no difference in complications such as urine leaks and bladder neck contractures. Continence after RALP was not significantly different in men with large median lobes.
  
  
  CONCLUSIONS
  Management of ureteral orifices that are too close to the bladder neck with or without large medium lobes can be successfully performed with the uses of ureteral catheters placed robotically with the da Vinci robot. The presence of a median lobe does not alter outcomes in patients who undergo robot-assisted laparoscopic prostatectomy.
authors.affiliation: Department of Urology, SUNY-Stony Brook University Health Sciences Center, School of Medicine, Stony Brook, New York 11794-8093, USA.
authors.forename: Jamil
authors.initials: J
authors.lastname: Rehman
authors.forename: Bilal
authors.initials: B
authors.lastname: Chughtai
authors.forename: Khurshid
authors.initials: K
authors.lastname: Guru
authors.forename: Ridwan
authors.initials: R
authors.lastname: Shabsigh
authors.forename: David B
authors.initials: DB
authors.lastname: Samadi
mesh_terms: D000368:Aged; D006801:Humans; D010535:Laparoscopy; D008297:Male; D011468:Prostatectomy / Q000379:methods*; D011471:Prostatic Neoplasms / Q000473:pathology* / Q000601:surgery*; D012371:Robotics; D014513:Ureter / Q000002:abnormalities*