Radical Laparoscopic Prostatectomy:
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Transcript of Radical Laparoscopic Prostatectomy:
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Radical Laparoscopic Prostatectomy:
Managing Localized Prostate Cancer
Chase Wilson M1
Patient Presentation
Difficulty urinating Decreased force of urine flow Blood in urine and/or semen Swelling in legs Pelvic pain
Clinical Screening
Digital Rectal Exam (DRE) Abnormal size/texture of prostate
PSA > 4.0 ng/mL
Diagnostic Tools and Stages of Prostate Cancer
Ultrasound Prostate
biopsy (Gleason score)
CT Scan MRI
Stage I—not detectable on DRE
Stage II—detectable on DRE, confined to prostate
Stage III—spread to seminal vesicles/nearby tissues
Stage IV—complete metastasis
Non-Surgical Treatment Options
Radiation Therapy External radiation Brachytherapy (radioactive seeds)
Hormone therapy (decrease testosterone levels) Medications Orchiectomy
Chemotherapy
Surgical Treatment Options
Retropubic Surgery Perineal Surgery Laparoscopic Surgery Robotic Surgery
Advantages of Laparoscopic Approach
Better visualization of prostate anatomy Reduced blood loss Better nerve sparing Quicker post-operative recovery
Laparoscopic Prostatecomy: Operating
Room Layout
Surgeon
Patient in 30° Trendelenburg
Assistants
Video monitors
Standard Laparoscopic Instruments
0° Laparoscope Fine dissecting scissors Ultrasonic dissectors Fine grasping forceps Needle holder Suction-irrigation device Retrieval bag
Grasping urinary catheter
2.0 braided suture, 26 mm needle
3.0 absorbable, monofilament suture, 26 mm needle
Trocar PlacementA: Below umbilicus
B: 2 cm medial to ASIS
C: Between A & B
D: Midline, between umbilicus and pubic symphysis
E: 2 cm medial to ASIS
Instrument PlacementLaparoscope
Grasper/suction
Grasper/suction, scissors
Ultrasonic scissors, needle holder
Forceps, grasper
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 deferen
s (:57)10 Vesicourethral anastomosis (D3)
Detach BladderAnterior
abdominal wall Bladd
er
Future Retzius’ space
Anterior/Lateral Dissection
Pelvic rim
Prostate
Location of superficial dorsal vein
(Inside Retzius’s space)
Superficial Dorsal Vein
Superficial dorsal vein
Prostate
Pelvic rim
Pelvic floor (levator ani and endopelvic fascia)
Location of nerve bundle
Divide Prostate and Bladder Neck
Superior prostate
Urinary catheter
Bladder neck
Seminal Vesicles/Ductus Deferens
Location of neurovascular bundle
Ductus deferens
Seminal
vesicle
Denovillier’s FasciaSemin
al vesicl
e
Denovillier’s fascia
Neurovascular bundle
Rectum (deep to
denovillier’s fascia)
Posterior prostate
Nerve Sparing
Neurovascular bundle
Fine dissectin
g scissors
Plexus of nerves
Scissors dissect between prostatic capsule and lateral prostatic fascia
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
Infection control: Antibiotics Drain
Urinary catheter (removed ~7 days post-op) Blood thinners Little pain medication necessary
Operative Complications
Infection Incontinence Erectile dysfunction Persistent cancer Blood clots
References
Images and Procedure: Dr. Strup’s Radical Laparoscopic Prostatectomy Teaching DVD
Background information: Piechaud T, Saussine C. Laparoscopic radical
prostatectomy: transperitoneal approach. Epublication: WeBSurg.com, Feb 2006; 6(2). URL: http://www.websurg.com/ref/doi-ot02en302.htm