Bladder neck dissection is now performed by the authors using the Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH), although the endoshears with bipolar coagulation may also be used. The plane of dissection between the base of the prostate and the bladder neck is identified by the margin of the perivesical fatty tissue (Fig. 37.7). Also the distinction of the floppy bladder wall and the solid prostatic surface can be visualized by gently tapping on the anterior surface of the bladder wall with a laparoscopic instrument. The relative movement, between the prostate and the bladder wall when the metal bougie is moved, also provides a visual queue to identification of the plane of dissection. The dissection of the bladder neck is then performed. Dissection can be carried out on both sides of the midline exposing the vertical fibers of the bladder neck in the midline (Fig. 37.8). With tactile feedback afforded by the metal bougie, the anterior bladder neck is incised in the midline with the endoshears. Coagulation is not used during this maneuver for the potential for coagulating the urethra in the presence of the metal bougie within the urethra. After the anterior bladder neck is divided, the metal bougie is brought out through this opening and the base of prostate is rotated anteriorly. The posterior wall of the bladder neck is divided and is then held with a laparoscopic grasper. The plane between the posterior bladder neck and the base of the prostate is identified. It is essential to proceed vertically in order to avoid
Fig. 37.6. Ligation of the dorsal venous complex. After the endopelvic fascia is incised and the puboprostatic ligaments divided, the dorsal venous complex is ligated.
dissection into the prostate. In the presence of a large median lobe, the median lobe is retracted anteriorly to identify the posterior bladder neck.
Dissection in the proper plane posteriorly will result in exposure of the Denonvilliers' fascia that was previously opened during dissection of the seminal vesicle (Fig. 37.9). The seminal vesicles and the vasa deferentia are then visualized through this opening and held up with a locking atraumatic grasper by the assistant. The metal bougie at this stage can be removed.
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