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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 Placement
A: 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 Placement
Laparoscope
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 deferens (:57)
10 Vesicourethral anastomosis (D3)
Detach Bladder
Anterior abdominal
wall Bladder
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 Fascia
Seminal
vesicle
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
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