Robotic-Assisted Laparoscopic Radical Prostatectomy (RALP) has become a common approach for treating clinically-localized prostate cancer. As experience with this technique increases, urologists are performing this operation on patients with less straightforward anatomy. One potential intraoperative challenge is the presence of a hypertplastic median lobe. We present a video that highlights surgical techniques aimed at facilitating the successful dissection of an enlarged median lobe.

We retrospectively reviewed our experience with RALP and identified three cases demonstrating successful management of an enlarged median lobe. Highlights of these cases are presented for the purpose of demonstrating key dissection principles.

Three patients undergoing RALP for clinically-localized prostate cancer presented with hypertrophied median lobes. Post-operative pathologic analysis demonstrated excellent oncologic outcomes in each case. Review of the operative recordings revealed several key steps that facilitated a successful dissection, including 1) identification of the junction between bladder neck and prostatic base, 2) wide anterior dissection of the prostate off the bladder neck with early entry into the bladder, 3) detection of the ureteral orifices, 4) posterolateral dissection that defines the borders of the median lobe, 5) full-thickness release of the median lobe from the posterior bladder neck and 6) reconstruction of the bladder neck when necessary.

The presence of an enlarged median lobe during RALP can represent a difficult surgical challenge. By adhering to the steps demonstrated in our video, this challenge can be overcome and excellent surgical outcomes can be achieved.