Radical Laparoscopic Prostatectomy: Managing Localized Prostate

Radical Laparoscopic Prostatectomy: Managing Localized Prostate Cancer

Chase Wilson M1

S

Patient Presentation

S Difficulty urinating S Decreased force of urine flow S Blood in urine and/or semen

S Swelling in legs S Pelvic pain

Clinical Screening

S Digital Rectal Exam (DRE) S Abnormal size/texture of prostate

S PSA > 4.0 ng/mL

Diagnostic Tools and Stages of Prostate Cancer S Ultrasound S Prostate biopsy

(Gleason score) S CT Scan S MRI

S Stage I—not detectable on

DRE

S Stage II—detectable on

DRE, confined to prostate

S Stage III—spread to seminal

vesicles/nearby tissues

S Stage IV—complete

metastasis

Non-Surgical Treatment Options S Radiation Therapy S External radiation S Brachytherapy (radioactive seeds)

S Hormone therapy (decrease testosterone levels) S Medications S Orchiectomy

S Chemotherapy

Surgical Treatment Options

S Retropubic Surgery S Perineal Surgery S Laparoscopic Surgery

S Robotic Surgery

Advantages of Laparoscopic Approach S Better visualization of prostate anatomy S Reduced blood loss S Better nerve sparing

S Quicker post-operative recovery

Laparoscopic Prostatecomy: Operating Room Layout Video monitors

Assistants

Surgeon

Patient in 30° Trendelenburg

Standard Laparoscopic Instruments S 0° Laparoscope S Fine dissecting scissors S Ultrasonic dissectors S Fine grasping forceps

S Needle holder S Suction-irrigation device S Retrieval bag

S Grasping urinary catheter S 2.0 braided suture, 26 mm

needle S 3.0 absorbable,

monofilament suture, 26 mm needle

Trocar Placement A: Below umbilicus B: 2 cm medial to ASIS E: 2 cm medial to ASIS C: Between A & B D: Midline, between umbilicus and pubic symphysis

Instrument Placement Laparoscope

Grasper/s uction Forceps, grasper Grasper/suction, scissors Ultrasonic scissors, needle holder

Prostatectomy Procedure

1

Detach bladder from anterior abdominal wall (D1_:12)

2

Anterior and lateral dissection of prostate (:16-40)

3

Divide prostate and bladder neck (D2_:02-08)

4

Dissection of ductus deferens and seminal vesicles (:12)

5

Incise Denovillier’s fascia, dissect prostate from rectum (:22)

Prostatectomy Procedure

6

Carefully dissect neurovascular bundles from lateral prostate (:28)

7

Hemostasis and division of superficial dorsal vein (:46)

8

Divide prostate and urethra (:52)

9

Remove prostate, seminal vesicles, and ductus deferens (:57)

10 Vesicourethral anastomosis (D3)

Detach Bladder Anterior abdominal wall Bladder

Future Retzius’ space

Anterior/Lateral Dissection Location of superficial dorsal vein

Pelvic rim

Prostate

(Inside Retzius’s space)

Superficial Dorsal Vein Superficial dorsal vein

Pelvic rim

Pelvic floor (levator ani and endopelvic fascia) Prostate Location of nerve bundle

Divide Prostate and Bladder Neck Superior prostate

Urinary catheter

Bladder neck

Seminal Vesicles/Ductus Deferens

Seminal vesicle

Location of neurovascular bundle Ductus deferens

Denovillier’s Fascia Seminal vesicle Neurovascular bundle

Posterior prostate

Denovillier’s fascia

Rectum (deep to denovillier’s fascia)

Nerve Sparing Fine dissecting scissors

Scissors dissect between prostatic capsule and lateral prostatic fascia

Plexus of nerves

Neurovascular bundle

Division of Superficial Dorsal Vein Superficial dorsal vein

Anterior prostate

Division of Prostate and Urethra Urethra

Catheter

Prostate

Prostate Removal Pelvic rim

Lateral prostate

Superior prostate

Vesicourethral Anastomosis Urethra Catheter w/ grasper

Anchor stitch

Needle holder

Bladder neck

Time Lapse Anastomosis Urethra

Bladder neck

Post-Operative Care

S Infection control: S Antibiotics S Drain

S Urinary catheter (removed ~7 days post-op)

S Blood thinners S Little pain medication necessary

Operative Complications

S Infection S Incontinence S Erectile dysfunction

S Persistent cancer S Blood clots

References

S Images and Procedure: Dr. Strup’s Radical Laparoscopic

Prostatectomy Teaching DVD S Background information: S Piechaud T, Saussine C. Laparoscopic radical prostatectomy:

transperitoneal approach. Epublication: WeBSurg.com, Feb 2006; 6(2). URL: http://www.websurg.com/ref/doiot02en302.htm