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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