Robotic-assisted vesicourethral leakage repair with omentum-flap interposition after a robotic-assisted radical prostatectomy

Objective: To present a step-by-step video of a robotic-assisted vesicourethral leakage repair with an omentum-flap interposition after a radical prostatectomy. Patient and surgical procedure: A 64-years-old male diagnosed with a high-risk prostate cancer underwent robotic-assisted radical prostatectomy and extended pelvic lymph node dissection. Bladder neck reconstruction was performed with a run 4-0 monocryl® suture on lateral sides of bladder neck (“fish-mouth” reconstruction). Postoperative period was uneventful and bladder catheter was removed on day 7 after surgery. Immediately after bladder catheter removal, the patient presented with lower continuous abdominal and flank pain. Computed tomographic cystography revealed a right-sided VUA leakage. The attempt of a conservative approach with prolonged bladder catheterization was unsuccessful and surgical approach was decided. Intraoperatively, access to VUA was difficulted by fibrin adherences. It was confirmed the leak being caused by solely a dehiscence of the right-sided bladder neck reconstruction with the major part of the urethral reconstructing intact. The right ureteral orifice was identified and the defect was corrected with a, double layer, running 2-0 barbed suture. Subsequently, an omentum-flap was fixed over the sutured bladder defect. Results: Bladder catheter was removed 2-weeks post-operatively with a previous cystography showing no VUA leakage. Patient turned to be continent and asymptomatic with undetectable PSA on the second month of follow up. Conclusions: There is no strong evidence regarding the best timing to surgical intervention. However, after 3 weeks of catherization, it is unlikely that conservative approach will be successful. Robotic approach allowed selective suturing of the bladder neck dehiscence with preservation of vesicourethral anastomosis and omentum inlay. Thus, minimizing the morbidity of re-intervention