Delivery of the Median Lobe: A novel way to perform one of the most difficult parts of the dvP

This is my first technique that I will be adding to a new section of the blog.
After watching many videos and trying different ways to approach an intravesical median lobe, I found a new way to take care of it.
The following video was uploaded to google video and shows the dissection of a median lobe.

In simple terms: The bladder holds the urine and then the urine passes through the prostate on its way out. The prostate needs to be removed completely in prostate cancer surgery. The prostate is separated from the bladder routinely during the operation.
The median lobe is the part of the prostate that sometimes pushes into the bladder. This is the main reason why some urologists elect to place scopes into peoples bladders prior to surgery. This is one of the most difficult parts of the operation for beginners and experienced surgeons. The video shows the prostate (yellow) being separated from the bladder (green). The stitch is placed into part of the prostate to lift it off of the bladder.
Instruments used: PK dissector (bipolar), hot shears (monopolar- setting coag only 30), 2 needle drivers
Suture: 2’0 vicryl on an SH needle. (I have used 0’vicryl on a CT-1 for larger median lobes)
Color scheme- Yellow- Prostate; Green bladder and bladder opening; Orange arrrow- foley


Key points:
1) Approach anterior bladder neck as you prefer. Hints that there may be a median lobe are difficulty in appreciating the catheter or the balloon being off of midline. Preoperative cystoscopy or prostate ultrasound often shows this as well.
2) Once the median lobe is seen, the mucosa from the lateral lobes should be taken down until the median lobe is near.
3) The suture can be placed multiple times until the entire median lobe is out of the bladder.
4) Indigo carmine can be given IV if there is any doubt of the ureteral orifices.
5) The median lobe is done first in this video, but the lateral lobes can be done part way if the median lobe is very big.
Ease in learning the technique: Easy
Projected use is for all urologists. I believe this is the most efficient way to tackle an intravesical lobe and allows the best bladder neck sparing with the least amount of cautery needed.
How I developed it: I was trying to develop a better way to expose the median lobe during a robotic simple prostatectomy for BPH and tried suturing the median lobe. To my surprise, a very large median lobe was lifted out of the bladder and I had an excellent view of the posterior bladder neck.
Editors note: I thought long and hard about new techniques that I was developing and how to introduce them. I had planned on publishing this work to a journal, but I did not have the time (or didn’t want to put in the time) to make a journal submission. I also thought the interactivity of the blog would help to spread the word quicker and allow others to modify or add to my technique.
I have decided to introduce some of my new techniques through the robotic surgery blog and have it stored on google video for ease in viewing.
I apologize to any surgeons who may feel that this is not the best way to introduce new work.
If any other urologists (or other specilaties) would like to contribute their work, I will be glad to link to it if you add it to google video or blog about it if it is on another site.

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