Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques

Laparoscopic ProstatectomyIntra- and Extraperitoneal Techniques

George Ferzli, MD, FACSRobert Cacchione, MD; Paul Sayad, MD

Department of Laparoscopic SurgeryStaten Island University Hospital

Prostate Cancer StatisticsProstate Cancer Statistics

• 96,000 men diagnosed in the US 1987

• 26,000 cancer deaths 1987











Methods of Treating Localized Prostate Cancer

Methods of Treating Localized Prostate Cancer

• Surgery– Retropubic Prostatectomy– Perineal Prostatectomy– Laparoscopic Prostatectomy

• Radiation Therapy– External Beam– Interstitial Seed Implantation

• Watch and Wait

• Surgery– Retropubic Prostatectomy– Perineal Prostatectomy– Laparoscopic Prostatectomy

• Radiation Therapy– External Beam– Interstitial Seed Implantation

• Watch and Wait

Evolution of Laparoscopic Surgery for Prostate CancerEvolution of Laparoscopic Surgery for Prostate Cancer

• Extraperitoneal Hernia Repair

• Pelvic Lymph Node Dissection

• Bladder Neck Suspension

• Sigmoid and Rectal Resections

• Prostatectomy

• Extraperitoneal Hernia Repair

• Pelvic Lymph Node Dissection

• Bladder Neck Suspension

• Sigmoid and Rectal Resections

• Prostatectomy

Anatomy of the ProstateAnatomy of the Prostate

• Bladder• Ureter• Vas deferens• Seminal vesicle• Prostate

• Bladder• Ureter• Vas deferens• Seminal vesicle• Prostate

Prostatectomy: Analogy to Fundoplication

Prostatectomy: Analogy to Fundoplication

esophageal tumor - prostate esophageal tumor - prostate

stomach - bladder stomach - bladder

esophagus - urethra esophagus - urethra

vagus – neurovasc. bundle vagus – neurovasc. bundle

Placement of TrocarsPlacement of Trocars

• 4-5 trocars in line with the iliac crests

• Camera is placed in the umbilicus

• 4-5 trocars in line with the iliac crests

• Camera is placed in the umbilicus

Placement of Trocars(Totally Extraperitoneal Technique)

Placement of Trocars(Totally Extraperitoneal Technique)

• Intraperitoneal– Transperitoneal

access to seminal vesicles

– Dissection of prostatorectal space

• Extraperitoneal– Dissection of

retropubic space– Mobilization of

prostatic block

• Intraperitoneal– Transperitoneal

access to seminal vesicles

– Dissection of prostatorectal space

• Extraperitoneal– Dissection of

retropubic space– Mobilization of

prostatic block

Steps of the ProcedureSteps of the Procedure

Step 1: Transperitoneal Access to Seminal Vesicles


• Transperitoneal approach to vas deferens• Total mobilization of seminal vesicles






Step 2: Dissection of the Prostatorectal Space

Step 2: Dissection of the Prostatorectal Space

• Incision of aponeurosis• Liberation of anterior rectal wall to prostatic apex• Lateral dissection of rectum

• Incision of aponeurosis• Liberation of anterior rectal wall to prostatic apex• Lateral dissection of rectum

Step 2: Lateral Dissection of Rectum

Step 2: Lateral Dissection of Rectum

vas

deferens vas

deferens

neurovascular

bundle neurovascular

bundle

seminal

vesicle seminal

vesicle

urethra urethra

pubic bone pubic bone

ureter ureter

bladder bladder

rectum rectum

prostate prostate

dorsal vein dorsal vein

Step 3: Dissection of the Anterior Pubic Space


• Extraperitoneal dissection of prevesical fascia

• Dissection of retropubic space and endopelvic fascia laterally

• Division of dorsal vein complex

• Section of urethra at prostatic apex

• Extraperitoneal dissection of prevesical fascia

• Dissection of retropubic space and endopelvic fascia laterally

• Division of dorsal vein complex

• Section of urethra at prostatic apex



Step 3: Division of Dorsal VeinStep 3: Division of Dorsal Vein

Step 3: Section of Urethra at Prostatic Apex

Step 3: Section of Urethra at Prostatic Apex

Step 4: Mobilization of the Prostate

Step 4: Mobilization of the Prostate

• Sectioning of anterior bladder neck

• Mobilization and removal of prostate

• Ureterovesicle anatomosis

• Sectioning of anterior bladder neck

• Mobilization and removal of prostate

• Ureterovesicle anatomosis

Step 4: Sectioning of Anterior Bladder Neck

Step 4: Sectioning of Anterior Bladder Neck

Step 4: Ureterovesicle Anastomosis

Step 4: Ureterovesicle Anastomosis

Laparoscopic ProstatectomyLaparoscopic Prostatectomy• Transabdominal

– Schuessler, et al. J Urol 147:246A, 1992

– Schuessler, et al. Urology 50:854, 1997

– Guillonneau, et al. Eur Urol 36:14, 1999

– Guillonneau, et al. Prostate 39:71, 1999

– Guillonneau, et al. J Urol 163:418, 2000

– Abbou, et al. Urology 55:630-33, 2000

• Extraperitoneal– Raboy, Ferzli. Urology 50:849, 1997– Raboy, Ferzli. Surg Endosc 12:1264, 1998

• Transabdominal– Schuessler, et al. J Urol 147:246A, 1992

– Schuessler, et al. Urology 50:854, 1997

– Guillonneau, et al. Eur Urol 36:14, 1999

– Guillonneau, et al. Prostate 39:71, 1999

– Guillonneau, et al. J Urol 163:418, 2000

– Abbou, et al. Urology 55:630-33, 2000

• Extraperitoneal– Raboy, Ferzli. Urology 50:849, 1997– Raboy, Ferzli. Surg Endosc 12:1264, 1998

Results of Laparoscopic Prostatectomy


Schuessler. Urol. 50:854-57, 1997.

Patients 9Mean age 65.6 yrsMean PSA 14.9 ng/mLMean Gleason Score 5.7Conversion rate 0%OR time 9.4 hrsMean blood loss 583 mLTransfusion rate NADeaths 0Mean hospital stay 7.3 daysNegative margains 89%Mean follow-up 26 monthsPSA> 0.1ng/mL NA




Raboy, Albert, Ferzli. Surg Endosc. 12:1264-67, 1998.



The Last French RevolutionThe Last French Revolution

• Laparoscopic Cholecystectomy

– Mouret

– Dubois

– Perrissat– Mouiel

• Laparoscopic Cholecystectomy

– Mouret

– Dubois

– Perrissat– Mouiel

The Next French RevolutionThe Next French Revolution

• Laparoscopic Prostatectomy

– Vallancien

– Guillonneau

– Abbou

– Gaston

• Laparoscopic Prostatectomy

– Vallancien

– Guillonneau

– Abbou

– Gaston



Guillonneau. J Urol 163:418-22, 2000.

Patients 120Mean age 64 yrs (±5.8)Mean PSA 10.8 ng/mL (±6.7)Mean Gleason Score 6 (±1)Conversion rate 5.8%OR time 239 min (±59)Mean blood loss 402 mL (±293)Transfusion rate 10%Deaths 0Mean hospital stay 6 days (±3.3)Negative margains 85%Mean follow-up 2.2 monthsPSA> 0.1ng/mL 94.7%

Patients 120Mean age 64 yrs (±5.8)Mean PSA 10.8 ng/mL (±6.7)Mean Gleason Score 6 (±1)Conversion rate 5.8%OR time 239 min (±59)Mean blood loss 402 mL (±293)Transfusion rate 10%Deaths 0Mean hospital stay 6 days (±3.3)Negative margains 85%Mean follow-up 2.2 monthsPSA> 0.1ng/mL 94.7%



Abbou. Urol. 55:630-633, 2000.

Patients 43Mean age 64.4 yrs (±6.1)Mean PSA 9.6 ng/mL (±6.2)Mean Gleason Score 5.9 (±1.1)Conversion rate 0%OR time 5.3 hrsMean blood loss NATransfusion rate 4.7%Deaths 0Mean hospital stay 5.9 daysNegative margains 72.1%Mean follow-up 6.3 monthsContinence rate 84%PSA> 0.1ng/mL 100%

Patients 43Mean age 64.4 yrs (±6.1)Mean PSA 9.6 ng/mL (±6.2)Mean Gleason Score 5.9 (±1.1)Conversion rate 0%OR time 5.3 hrsMean blood loss NATransfusion rate 4.7%Deaths 0Mean hospital stay 5.9 daysNegative margains 72.1%Mean follow-up 6.3 monthsContinence rate 84%PSA> 0.1ng/mL 100%

Robotics in UrologyRobotics in Urology

• Jonas and Kramer of Frankfurt University Hospital recently completed 4 of a series of 30 cases using the da Vinci robotic system.

• Jonas and Kramer of Frankfurt University Hospital recently completed 4 of a series of 30 cases using the da Vinci robotic system.

Totally Extraperitonealvs

Transabdominal

Totally Extraperitonealvs

Transabdominal• A proposed study to compare the two routes

of access was abandoned because the transabdominal method was judged superior– more room for dissection– less trouble maintaining pneumoperitoneum– easier to dissect the seminal vesicles– difficult to apply the totally extraperitoneal

method to patients with large prostates

• A proposed study to compare the two routes of access was abandoned because the transabdominal method was judged superior– more room for dissection– less trouble maintaining pneumoperitoneum– easier to dissect the seminal vesicles– difficult to apply the totally extraperitoneal

method to patients with large prostates

ConclusionsConclusions

• Oncologic results of laparoscopic prostatectomy appear similar to the open procedure given the available early data

• Functional results of laparoscopic prostatectomy are encouraging but patient numbers are as yet too few to make conclusions on potency and continence

• Oncologic results of laparoscopic prostatectomy appear similar to the open procedure given the available early data

• Functional results of laparoscopic prostatectomy are encouraging but patient numbers are as yet too few to make conclusions on potency and continence

ConclusionsConclusions

• Although it can be performed totally extraperitoneally, we recommend the transperitoneal route– provides larger working space avoids excluding

patients based on prostate size– easier to maintain pneumoperitoneum– better visualization posteriorly means safer

dissection of the seminal vesicles and rectum

• Although it can be performed totally extraperitoneally, we recommend the transperitoneal route– provides larger working space avoids excluding

patients based on prostate size– easier to maintain pneumoperitoneum– better visualization posteriorly means safer

dissection of the seminal vesicles and rectum

Date post:	15-Jun-2015
Category:	Health & Medicine
Upload:	george-s-ferzli
View:	1,464 times
Download:	3 times

Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques

Health & Medicine