Step-by-step Peritoneal Bladder Flap Bunching (PBFB) technique: an innovative approach following lymph node dissection in robotic radical prostatectomy

Gamal, Ahmed; Moschovas, Marcio Covas; Jaber, Abdel Rahman; Saikali, Shady; Reddy, Sumeet; Patel, Ela; Patel, Evan; Rogers, Travis; Patel, Vipul

doi:10.1590/S1677-5538.IBJU.2024.0278

ABSTRACT

Introduction:

Robot-assisted radical prostatectomy (RARP) has become a popular surgical approach for localized prostate cancer due to its favorable oncological and functional outcomes, as well as lower morbidity. In cases of intermediate- and high-risk prostate cancer, bilateral pelvic lymphadenectomy (PLND) is recommended as an adjunct to RARP (¹1 Sanda MG, Cadeddu JA, Kirkby E, Chen RC, Crispino T, Fontanarosa J, et al. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Part I: Risk Stratification, Shared Decision Making, and Care Options. J Urol. 2018;199:683-90. doi: 10.1016/j.juro.2017.11.095.
https://doi.org/10.1016/j.juro.2017.11.0... –³3 Alfano CG, Moschovas MC, Montagne V, Soto I, Porter J, Patel V, et al. Implementation and outcomes of Hugo(TM) RAS System in robotic-assisted radical prostatectomy. Int Braz J Urol. 2023;49:211-20. doi: 10.1590/S1677-5538.IBJU.2023.9902.
https://doi.org/10.1590/S1677-5538.IBJU.... ). Despite its benefits, PLND can lead to surgical complications, with postoperative lymphocele formation being the most common. Most postoperative lymphoceles are clinically insignificant with variable incidence, reaching up to 60% of cases 4. However, a small percentage of patients 2-8% may experience symptomatic lymphoceles (SL), which can cause significant morbidity (⁴4 Ploussard G, Briganti A, de la Taille A, Haese A, Heidenreich A, Menon M, et al. Pelvic lymph node dissection during robot-assisted radical prostatectomy: efficacy, limitations, and complications-a systematic review of the literature. Eur Urol. 2014;65:7-16. doi: 10.1016/j.eururo.2013.03.057.
https://doi.org/10.1016/j.eururo.2013.03... , ⁵5 Zorn KC, Katz MH, Bernstein A, Shikanov SA, Brendler CB, Zagaja GP, et al. Pelvic lymphadenectomy during robot-assisted radical prostatectomy: Assessing nodal yield, perioperative outcomes, and complications. Urology. 2009;74:296-302. doi: 10.1016/j.urology.2009.01.077.
https://doi.org/10.1016/j.urology.2009.0... ).

Surgical technique:

We perform our RARP technique with our standard approach in all patients (⁶6 Moschovas MC, Patel V. Nerve-sparing robotic-assisted radical prostatectomy: how I do it after 15.000 cases. Int Braz J Urol. 2022;48:369-70. doi: 10.1590/S1677-5538.IBJU.2022.99.03.
https://doi.org/10.1590/S1677-5538.IBJU.... ). After vesicourethral anastomosis a modified PF created to prevent symptomatic lymphocele. We start by suturing the peritoneal fold on the right side, medially to the vas deferens, followed by a similar stitch on the left side to approximate the edges in the midline. A running suture bunches the bladder peritoneum from both sides, passing through the pubic bone periosteum to secure it in place (⁷7 Gamal A, Moschovas MC, Jaber AR, Saikali S, Sandri M, Patel E, et al. Peritoneal Flap Following Lymph Node Dissection in Robotic Radical Prostatectomy: A Novel "Bunching" Technique. Cancers (Basel). 2024;16:1547. doi: 10.3390/cancers16081547.
https://doi.org/10.3390/cancers16081547... ). This approach keeps the lateral pelvic gutters open for lymphatic drainage, while allowing fluid drainage from the true pelvis into the abdomen. A pelvic ultrasound was done for all patients at 6 weeks post operative, and additional clinical follow-up was carried out at 3 months following surgery.

Considerations:

We have demonstrated a modified technique of peritoneal flap (PBFB) with an initial decrease in postoperative symptomatic lymphoceles, the technique is feasible, safe, does not add significant morbidity, and does not require a learning curve.