221 Surgical Technique International Braz J Urol Official Journal of the Brazilian Society of Urology Vol. 30 (3): 221-226, May - June, 2004 LAPAROSCOPIC RADICAL PROSTATECTOMY BY EXTRAPERITONEAL ACCESS WITH DUPLICATION OF THE OPEN TECHNIQUE M. TOBIAS-MACHADO, PEDRO FORSETO JR., JIMMY A. MEDINA, MARCELO WATANABE, ROBERTO V. JULIANO, ERIC R. WROCLAWSKI Discipline of Urology, Medicine School of ABC, Santo André, São Paulo, Brazil ABSTRACT Introduction: The laparoscopic radical prostatectomy is a continually developing technique. Transperitoneal access has been preferred by the majority of centers that employ this technique. En- doscopic extraperitoneal access is used by a few groups, nevertheless it is currently receiving a higher acceptance. In general, the antegrade technique is used, with dissection from the bladder neck to the prostate apex. The objective of the present paper is to describe the extraperitoneal technique with repro- duction of the open surgery’s surgical steps. Surgical Technique: With this technique, the dissection of the prostate apex is performed and, following the section of the urethra while preserving the sphincteric apparatus, the Foley catheter is externally tied and internally recovered, which allows cranial traction, similarly to the way it is performed in conventional surgery. The retroprostatic space is posteriorly dissected and the seminal vesicles are identified by anterior and posterior approach, obtaining with this method an optimal exposure of the posterolateral pedicles and the prostate contour. The initial impression is that this technique does not present higher bleeding rate or difficulty level when compared with antegrade surgery. Potential advantages of this technique would be the greater familiarity with surgical steps, isolated extraperitoneal drainage of urine and secretions and a good definition of prostate limits and lateral pedicles, which are critical factors for preserving the neurovascular bundles and avoiding positive surgical margins. A higher number of cases and a long-term follow-up will demonstrate its actual value as a technical option for endoscopic access to the prostate. Key words: prostatic neoplasms; prostatectomy; laparoscopy Int Braz J Urol. 2004; 30: 221-6 INTRODUCTION Laparoscopic radical prostatectomy has be- come an option for treatment of localized prostate cancer in some centers. The majority of laparoscopists prefer the transperitoneal technique that was standard- ized by Guilleneau & Vallencien (1). The endoscopic extraperitoneal technique performed by some groups promotes antegrade dissection, from the bladder neck to the prostate apex (2-4). Our objective was to describe the extraperitoneal technique that was initiated in our institution in 2002 with duplication of open surgery’s surgical steps, discussing potential advantages and initial impressions obtained after its use in 25 pa- tients. SURGICAL TECHNIQUE 1. Patient is positioned in horizontal dorsal decubi- tus, with Y-shaped abduction of lower limbs on the table;
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LAPAROSCOPIC RADICAL PROSTATECTOMYSurgical TechniqueInternational Braz J UrolOfficial Journal of the Brazilian Society of Urology
Vol. 30 (3): 221-226, May - June, 2004
LAPAROSCOPIC RADICAL PROSTATECTOMY BY EXTRAPERITONEALACCESS WITH DUPLICATION OF THE OPEN TECHNIQUE
M. TOBIAS-MACHADO, PEDRO FORSETO JR., JIMMY A. MEDINA, MARCELOWATANABE, ROBERTO V. JULIANO, ERIC R. WROCLAWSKI
Discipline of Urology, Medicine School of ABC, Santo André, São Paulo, Brazil
ABSTRACT
Introduction: The laparoscopic radical prostatectomy is a continually developing technique.Transperitoneal access has been preferred by the majority of centers that employ this technique. En-doscopic extraperitoneal access is used by a few groups, nevertheless it is currently receiving a higheracceptance. In general, the antegrade technique is used, with dissection from the bladder neck to theprostate apex.
The objective of the present paper is to describe the extraperitoneal technique with repro-duction of the open surgery’s surgical steps.
Surgical Technique: With this technique, the dissection of the prostate apex is performedand, following the section of the urethra while preserving the sphincteric apparatus, the Foley catheteris externally tied and internally recovered, which allows cranial traction, similarly to the way it isperformed in conventional surgery. The retroprostatic space is posteriorly dissected and the seminalvesicles are identified by anterior and posterior approach, obtaining with this method an optimalexposure of the posterolateral pedicles and the prostate contour. The initial impression is that thistechnique does not present higher bleeding rate or difficulty level when compared with antegradesurgery. Potential advantages of this technique would be the greater familiarity with surgical steps,isolated extraperitoneal drainage of urine and secretions and a good definition of prostate limits andlateral pedicles, which are critical factors for preserving the neurovascular bundles and avoidingpositive surgical margins. A higher number of cases and a long-term follow-up will demonstrate itsactual value as a technical option for endoscopic access to the prostate.
Laparoscopic radical prostatectomy has be-come an option for treatment of localized prostatecancer in some centers. The majority of laparoscopistsprefer the transperitoneal technique that was standard-ized by Guilleneau & Vallencien (1).
The endoscopic extraperitoneal techniqueperformed by some groups promotes antegradedissection, from the bladder neck to the prostateapex (2-4). Our objective was to describe the
extraperitoneal technique that was initiated in ourinstitution in 2002 with duplication of open surgery’ssurgical steps, discussing potential advantages andinitial impressions obtained after its use in 25 pa-tients.
SURGICAL TECHNIQUE
1. Patient is positioned in horizontal dorsal decubi-tus, with Y-shaped abduction of lower limbs onthe table;
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2. Display of the surgical team. The surgeon oper-ates on the left side, the camera is positioned atthe upper end of the table, and the assistant standat the patient’s right side. During suture, for im-proved comfort, the surgeon and the cameraswitch places;
3. Umbilical incision measuring 1.5 cm up to theRetzius space;
4. Creation of extraperitoneal space through digitaldissection and modified balloon dilator (handi-craft);
5. Hasson trocar (10 mm) through the umbilical in-cision for the 0-grade optics;
6. Installation of pneumoretroperitonium with CO2
tension of 15 mmHg;7. Introduction of another 4 working trocars (2
pararectal external measuring 10 mm, and 2 iniliac fossa measuring 5 mm) under direct view,in an arciform shape, taking care in order to avoidperitoneal lesion (Figure-1);
8. Exeresis of pre-prostatic fat with monopolar cau-tery for proper identification of prostate, bladderand puboprostatic ligaments;
9. Bilateral opening of endopelvic fascia with scis-sors, following previous contralateral traction ofthe prostate (Figure-2);
10. Identification and sectioning of puboprostaticligaments (Figure-3);
11. Vascular control of dorsal vein complex of thepenis with a X-stitch using 2-0 polyglactine su-ture with CT-1 needle (Figure-4) and control ofthe retrograde blood flow with harmonic or bi-polar scalpel, or polymer clip (Hem-o-lock®)(Figure 5). Applying the clip makes the subse-quent identification of the bladder neck easier forreconstruction, a surgical step that is often ardu-ous when we choose to preserve the bladder neck;
Figure 1 – Display of trocars in arciform shape. The 0-gradeoptics is placed in the umbilical trocar. Two pararectal 10-mmports and another 2 5-mm ones in iliac fossa complete the ac-cess. O = 5-mm trocar, X = 10-mm trocar
Figure 3 – Sectioning of the puboprostatic ligament (PPL) withharmonic scalpel.
Figure 2 – Opening of endopelvic fascia (EF). The assistantpulls the prostate to the contralateral side and the surgeon sec-tions the endopelvic fascia with scissors.
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12. Apical dissection with preservation of the sphinc-teric apparatus;
13. Sectioning of the dorsal vein complex of the pe-nis with electrocautery or harmonic scalpel, un-til the urethra is viewed (Figure-5);
14. Opening of the urethral anterior wall with scis-sors (Figure-6). Section is performed after per-fectly identifying the limits of the prostate apexand urethra, thus avoiding positive margins;
15. The catheter balloon is filled with 20 mL of dis-tilled water. The Foley catheter is externally pulledfor subsequent knot application with 0-cotton su-ture including drainage and balloon routes;
16. Sectioning of the catheter close to the previouslyapplied knot;
17. Recovery of the remaining stump of the Foleycatheter, through endoscopic view in theextraperitoneal space (Figure-7);
18. Posterior section of the urethra and recto-urethralmuscle following cranial traction of the stent bythe assistant;
19. Blunt retroprostatic dissection up to the mostproximal point as feasible;
20. Identification and opening of the posterior layerof the Denovilliers fascia (Figure-8). At this timeit is possible to identify the pre-rectal fat. Ana-logically to open surgery, we know that the neu-
Figure 4 – Vascular control of the dorsal vein complex (DVC).
Figure 5 – Sectioning of dorsal vein complex with harmonicscalpel. Ligation of dorsal vein complex (DVC) with suture.
Figure 6 – Opening of the urethral anterior wall. Observe theFoley catheter (F) and the prostate apex, clearly identified. Thepath of the nervi erigentes (N), schematically identified with yel-low lines, is located laterally to the sectioning area in the ure-thra (U).
Figure 7 – Dissection of retroprostatic space. U = urethra (yel-low circle), RE = retroprostatic space, N = projection of nervierigentes (yellow line).
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rovascular bundle lies laterally and under the fas-cia, which makes nervous preservation easierduring ligation of the prostatic pedicle, which isperformed by posterior access;
21. Sectioning of the bladder neck, with preserva-tion of muscular fibers whenever possible. Thedissection is started with harmonic or bipolar scal-pel and upon reaching the urethral mucosa, it issectioned with scissors (Figure-9);
22. Identification and opening of the anterior layerof Denovilliers’ fascia, posterior to the prostatewith visualization of vasa deferentia;
23. Identification and sectioning of vasa deferentiawith harmonic or monopolar scalpel;
24. Superior traction of the vasa deferentia by theassistant in order to release the seminal vesicles.At this time, we preferred to use harmonic or bi-polar scalpel in order to avoid dissipation of ther-mal energy that could damage the nervi erigentes;
25. The assistant performs the lateral and superiortraction of previously mobilized (released) pros-tate, enabling the clear identification of the pros-tatic pedicles and the prostate capsular limits. Thecontrol of the prostatic pedicles is performed withharmonic or bipolar scalpel. Alternatively poly-mer clips (Hem-o-lock®) can be used (Figure-10);
26. Exeresis and entrapment of the specimen that islocated in right iliac fossa;
27. Vesicoureteral anastomosis is initiated with thepatient in Trendelemburg position in order toimprove the visualization of the urethra. The sur-geon works with the pararectal 10-mm trocars atthe upper end of the table. We perform a continu-ous 3-0 polyglecaprone (monocryl®) suture withSH needle. We use two 13-cm sutures, one color-less and the other one violet, externally tied bythe distal end. Suture begins at 6 o’clock posi-tion in the bladder directed inwards and each ofthe sutures rises toward 12 o’clock position,where a single internal knot is made (5);
28. Drainage with Penrose though one of the 5-mmports;
Figure 8 – Sectioning of bladder neck with harmonic scalpelpreserving muscular fibers. As a result, we obtained a small di-ameter neck (dotted line), which makes future vesicourethral anas-tomosis easier. BN = bladder neck, SM = muscle fibers.
Figure 9 – Identification and opening of the anterior layer ofDenovilliers’ fascia posterior to the prostate with viewing ofvasa deferentia. P= prostate, DF= Denovilliers’ fascia, VD=vas deferens.
Figure 10 – The prostatic pedicles are identified and clipped.P = prostate. C = polymer clip. Observe the path of the nervierigentes (dotted lines). SV = seminal vesicle.
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29. Removal of the specimen by enlargement of theumbilical port and closure of the incisions;
COMMENTS
Laparoscopic radical prostatectomy is a la-borious procedure with a long learning curve. Themost significant series in literature, where it was pos-sible to standardize and systemize the technique, usetransperitoneal access (1).
The endoscopic extraperitoneal techniquewas initially described by Raboy et al. where, aftercreating the space and ligating the dorsal vein com-plex, the dissection was performed from the bladderneck to the prostate apex (antegrade). The author re-ported that this technical option resulted from thehigher possibility of bleeding and technical difficultyif the early sectioning of the complex was performed(2). This observation is contrary to the results obtainedin our initial series of 25 patients, where none requiredhemotransfusion or conversion to open surgery.
In our setting, Andreoni et al. were the firstauthors to report laparoscopic radical prostatectomyusing the antegrade technique (3). Potential advan-tages of the extraperitoneal access are the non-ma-nipulation of abdominal viscera, reducing the riskof direct or distant lesions, keeping the drainage ofsecretions isolated from the peritoneal cavity, greaterfamiliarity with local anatomy, with the Trendelemburgexaggerated position being unnecessary (frequentlyrequired in the transperitoneal technique). As dis-advantages it presents a working space with lowergas content, requiring greater adaptation for instru-ment movements and aspiration of secretions andsmoke. If the space is not properly developed in itslateral area, according to previous descriptions, ahigher tension in the vesicoureteral anastomosis canoccur. Peritoneal perforation hampers, but does notprevent the surgery from being completed. If the pro-gression in dissection is hard, it is possible to operateby transperitoneal approach following wide perito-neal opening (2-4).
Our initial impression is that transperitonealand extraperitoneal techniques are equivalentconcerning surgical time, blood loss, complica-tions and post-operative recovery. However, in the
extraperitoneal technique, the presence of urinary fis-tula shows a better outcome, since there is no urinedrainage to the peritoneal cavity, thus avoiding pro-longed paralytic ileus.
As original modifications, in addition to theretrograde dissection as described in the open tech-nique, we used a polymer clip in order to avoid venousreflux from the dorsal complex, which aids in thesubsequent identification of the bladder neck duringsuture. The external handling and sectioning of theFoley catheter enabled the internal and superior trac-tion by the assistant, similarly to the open techniquefor accessing the posterior aspect of the prostate. Suchdissection makes the identification of lateral prostaticpedicles quite easier following the dissection of thebladder neck. The accurate identification of the pros-tate limits is fundamental for a proper preservationon the neurovascular bundles and to avoid the occur-rence of positive margins.
Recently, Dubernard et al. (2003) describedthe first series of 143 patients using retrogradelaparoscopic extraperitoneal technique. The authorsconclude that in spite of presenting only preliminaryfunctional results, the technique is promising and canpotentially become the method of choice forlaparoscopic radical prostatectomy (5).
From this initial work, we concluded thatextraperitoneal access is feasible, being possible topractically duplicate surgical steps of the open sur-gery. The actual role and advantages of this surgerywhen compared with laparoscopic transperitonealtechnique waits for future assessments in prospec-tive studies with a higher number of cases.
