Impact Of Prostate Median Lobe Anatomy On Robotic-Assisted Laparoscopic Prostatectomy

Main Category: Prostate / Prostate Cancer
Also Included In: Urology / Nephrology
Article Date: 19 Jan 2009 - 3:00 PDT

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UroToday.com - The idea to investigate the challenges associated with operating on men with a significant median lobe came when we were performing a RALP on a patient with an extremely large median lobe. We began to think about how the RALP was different from standard RRP.

No one had described the difficulty with performing a RRP on a man with a large median lobe because the approach is completely different. When a surgeon is performing a RALP from an anterior approach, the median lobe can really distort the normal anatomy as the ureteral orifices can be very close to the prostate (see figure, arrow). This has a lot to do with how the location of the laparoscope in relation to the median lobe. When a median lobe is identified, it can be really daunting. One of the most important things is identifying the median lobe early in the operation. One can predict the presence of a median lobe before surgery by a higher AUA symptom score (5.5 vs. 16, p=0.018). At the time of RALP, the catheter balloon is deviated latterly when the bladder is entered. Once the median lobe is identified, the use of upward traction, either from the third laparoscopic arm or from a Carter-thomason device can really help to elevate the prostate and get it out of your way to improve the management of the posterior bladder neck.

Overall, when we evaluated our series of RALPs we found an 18% prevalence of men with significant median lobe. We found that men who had a large median lobe required significantly longer to perform the RALP (349 min vs. 287 min., p=0.0058). This was due to the time required for dissection of the posterior bladder neck (13 vs. 19 min, p=0.007) and seminal vesicles (30 vs. 39 minutes, p=0.014) in men with a large median lobe compared to those without a significant median lobe. Additionally, a much larger percentage of men with a median lobe required reconstruction of the bladder neck during the vesicourethral anastomosis (40% vs. 14%, p=0.00009). The good news is that margin rates, bladder neck contractures and continence were statistically equivalent between men with a large median lobe and those without a median lobe. Although, we did find that men with large median lobes had a higher estimated blood volume (464 ml vs. 380 ml, p=0.05) and hospital stay (2.6 d vs. 1.7 d, p=0.02).

Overall, I think this data is reassuring that when a surgeon finds a median lobe during RALP, the patient can have a good outcome, although the operation may require a longer time. We hope some of the techniques we describe will hope other surgeons in the future when they encounter a large median lobe during RALP.

Written by Joshua J. Meeks, MD, PhD, as part of Beyond the Abstract on UroToday.com.

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