wyatt313
New
The patient was placed in steep Trendelenburg and the robot docked. The sigmoid colon was then mobilized medially. The ureter was identified and traced caudad. Tissue planes around the ureter seen reasonably well defined considering that she had a previous balloon dilatation of the ureter with 2 double-J stents placed. Dissection was then carried down until the superior vesical artery was identified. The artery was preserved and the dissection then carried out below the superior vesical artery to the wall of the bladder. The bladder was then filled with saline. A 2-0 Vicryl suture was then placed approximately 1-1/2 cm superior to the insertion of the ureter and the bladder. Incision was then carried out just below the stay stitch into the bladder and a wide bladder cuff was then created using the double J stent to clearly identify the orifice. Once this had been completely circumscribed, the opening of the bladder was at least 4 cm in diameter. It should be noted that prior to this portion of the dissection, the ureter had been doubly clipped approximately 3 to 4 cm below the iliac vessels and a frozen section sent, which came back positive for transitiona cell carcinoma in the lamina propria. The ureter was again clipped and transected another centimeter and a half cephalad and the specimen sent. This also came back positive for transitional cell carcinoma. Another centimeter and a half up the ureter was doubly clipped and transected and this time, the frozen section margin returned negative. The ureter was dissected from it's few remaining attachments posteriorly. The mucosa of the bladder opening was then closed with running 4-0 Vicryl The muscularis layer was closed with running 2-0 Vicryl. The bladder was filled with water and no extravasation noted. Pelvic lymph node dissection was then performed on the left including obturator and external iliac nodes. Common iliac node dissection was also performed. The boundaries of the dissection were the genitofemoral nerve laterally, the circumflex iliac vein distally, the mid left common iliac artery proximally. Dissection was performed by split and roll technique with Hem-o-lok clips applied to lymphatic ridge tissue and in the femoral canal. The bladder was then completely mobilized from the right side and psoas hitch performed. The ureter was spatulated and sutures placed. These were run fro proximal to distal on the ureter until the anastomosis was complete. Bladder was again filled with saline and no extravasation noted. Should be mentioned that a 22 cm 6-French double-J stent was placed before completing the anastomotic closure.