Diagnosis and Conservative Management of Ureteral Orifice Injury During Robotic Prostatectomy for a Large Prostate with a Prominent Median Lobe

Robot-assisted laparoscopic radical prostatectomy (RALRP) is now considered the standard treatment for localized prostate cancer. However, challenges may arise when dealing with large prostates with a prominent median lobe because the ureteral orifices may not always be visible during dissection and maybe injured in the process. We describe our experience on the diagnosis and conservative management of ureteral orifice injury in this situation. Case: A Gleason score 3 + 3 prostatic adenocarcinoma was detected during 12-quadrant prostate biopsy performed after measurement of a serum prostate specific antigen value of 8.1 ng/mL in a 65-year-old man presenting with lower urinary tract symptoms. The left ureter orifice was observed to have been injured by scissors at dissection of the neck of the bladder and enlarged median lobe at RALRP. An online video call was made to more experienced robotic surgeons for advice. Diagnosis and management of the ureteral injury are presented. Conclusion: Ureteral orifice injury during an RALRP may be managed conservatively with intraoperative ureteral stenting without the need for reimplantation nor conversion to open surgical techniques. Online video call with experienced robotic surgeons is helpful in the decision process.