Download - Dr. J.L Hoepffner Clinique St Augustin, Bordeaux FRANCE Laparoscopic Radical Prostatectomy
Dr. J.L HoepffnerClinique St Augustin,
Bordeaux
FRANCE
Laparoscopic Radical Laparoscopic Radical ProstatectomyProstatectomy
HistoryHistory
Schuessler ‘94Raboy ‘97Gaston ‘97Guillonneau ‘982006: 50% prostatectomies laparoscopic
LAPAROSCOPIC APROACH LAPAROSCOPIC APROACH
TRANSFORMATION of the PROSTATECTOMY :– Mini invasive Surgery– Easier exposition, Magnification of the vision – Définition anatomic plans– Précision of the gestual , Miniaturisation of the sutures – Bloodless– Post-operative more simple
LAPAROSCOPIC APROACHLAPAROSCOPIC APROACH
IMPROVEMENT OPEN SURGERY
SAFETY ONCOLOGIC
REDUCTION OF FUNCTIONAL SEQUELLA
LAPAROSCOPIC APROACHLAPAROSCOPIC APROACH
LIMITS AND DISAVANTAGES : – Quality of the vision – Steadiness of the instrument– Difficulty of the access , – Limit of the angular dissection
– Discomfort of the surgeon
LAPAROSCOPIC APROACHLAPAROSCOPIC APROACH
NEW LIMITS FOR A DISSECTION PRESERVATIVE AND ATRAUMATIC OF THE PROSTATE
NEW LIMITS FOR PROGRESS IN ERECTILE PRESERVATION
ROBOT ASSISTED: ROBOT ASSISTED: ONE ANSWER ?ONE ANSWER ?
QUALITE OF OPERATIVE VISION +++ PRECISION OF THE ANATOMIC
DEFINITION REDUCTION TRAUMATIC DISSECTION DISAPPAERANCE OF THE LIMITS OF
THE DISSECTION COMFORT AND LOGICAL ERGONOMY
FOR THE SURGEON
ROBOT ASSISTED : ROBOT ASSISTED : A TECHNICAL ADVANTAGE?A TECHNICAL ADVANTAGE?
DEMONSTRATION :
Bladder neck dissection Bundle preservation Suturing
Curative T1 – T2T3 ?Gleason score / ageNerve Sparing ?Alternative : EBRT – brachytherapy
Opératoring IndicationsOpératoring Indications
Pre-operative StatusPre-operative Status
Cardiovasculary examRespiratory FonctionHemostasis blood testNo autologus transfusion8-10 weeks after biopsies
Obesity not excludeNo bowel préparation No specific contre-indications to the
laparoscopic surgery
Pré-opératorive StatePré-opératorive State
TechniqueTechnique
Patient in Trendelenburg positionOne surgeon, one assistant5 trocars: 1 x 10 mm , 4 x 5mm Video column between the legsLaparoscope 0°
Laparoscopic InstrumentsLaparoscopic Instruments
•Needle driver
•Monopolaire
•Bipolaire
•Grasp
•Thin grasp
LAPAROSCOPIC APROACHLAPAROSCOPIC APROACH
LAPAROSCOPIC APROACHLAPAROSCOPIC APROACH
THE ROBOT
Trocards PlacementTrocards Placement
Assistent Ports
Optic Ports
Robot Ports
The ‘Da Vinci’ Sytem The ‘Da Vinci’ Sytem
THE ROBOT
THE ROBOT
THE ROBOT
Laparoscopic Bladder Neck Laparoscopic Bladder Neck Dissection Dissection
Bladder Neck Robotic Bladder Neck Robotic Dissection Dissection
Seminales Vesicules Seminales Vesicules Laparoscopic DissectionLaparoscopic Dissection
Right Bundle Laparoscopic Right Bundle Laparoscopic DissectionDissection
Intrafasciale Robotic DissectionIntrafasciale Robotic Dissection
Apex Laparoscopic DissectionApex Laparoscopic Dissection
Apex Robotic Dissection (1)Apex Robotic Dissection (1)
Apex Robotic Dissection(2)Apex Robotic Dissection(2)
DVC SutureDVC Suture(running suture)(running suture)
Urétro-Vésicale Laparoscopic Urétro-Vésicale Laparoscopic Anastomosis Anastomosis
(running suture)(running suture)
Anastomose Robotique Anastomose Robotique urétro-vésicale urétro-vésicale
(running suture)(running suture)
Laparoscopic DataLaparoscopic Data
3000 patientsStudy of 1574 filesMean Psa 6,72Mean Gleason score 6,27Age 61,9 years old
Eur Urol. 2006 Feb;49(2):344-52
OUR DATA OUR DATA
OPERATIVE TIME 120 MNHOSPITALISATION 5.7 JOURS0 CONVERSION in 7 years
OUR DATAOUR DATA
COMPLICATIONS
HAEMORRHAGES 1.3%
ANASTOMOSIS FISTULA 0.3%
RECTAL INJURY 0.5%
URETERAL INJURY one case
ANASTOMOTIC STENOSIS <1%
EVENTRATION <1%
OUR DATAOUR DATA
PATHOLOGICAL RESULTS 1293
PT2A 10.2%
PT2B.C 57.8%
PT3A 28.2%
PT3B 3.8%
MARGINSMARGINS
TOTAL 22%
T2 14%
T3 36%
FUNCTIONAL RESULTSFUNCTIONAL RESULTS
CONTINENCE
ERECTION : THE CHALLENGE – better result ? – Better complete recovery? – reduce the delay of recovery ?
– OBLIGATION of an EVALUATION
!!How can we improve functional result ? How can we improve functional result ?
Better knowledge of the prostate anatomy Better knowledge of the prostate anatomy
??
High incision of pelvic fasciaHigh incision of pelvic fascia
From Eichelberg C,
European urology, 2006
Principles of Principles of preservationpreservation
During radical prostatectomy, innervation of the trigone, neobladder neck, and posterior urethra may become disrupted, because the surgical procedure involves anatomic dissection around the prostate, posterior aspects of the bladder base, and seminal vesicles.
afferent innervation of the trigone posterior urethra may lead to alterations in
posterior urethral sensation
indirectly contribute to outlet incompetence
From Hubet John
UROLOGY 55: 820–824, 2000.
96,3%96,3%
62,7%62,7%
45%45%
85,7%85,7%
The percentage continence rates at a4 weeks and 12 The percentage continence rates at a4 weeks and 12 months after surgery. months after surgery.
From Peter Albers
Level of Evidence 1b
BJU Int 1 0 0 , 10 5 0 – 10 5 4, 2007
Antegrade dissectionAntegrade dissection Traction on Seminal vesiclesTraction on Seminal vesicles
Injury to the nervesInjury to the nerves
From Stolzemburg
European Urology 51 ( 2 0 0 7 ) 629–639
Detrusor apronDetrusor apron
Detrusor apron (arrowheads) in Masson
trichrome-stained sagittal section through
adult cadaveric prostate. Detrusor apron ends
in tuft (arrow) that is transected end of
pubovesical (puboprostatic) ligament. Tuft
contains fibrous tissue (blue) and smooth
muscle fibers (red) that curve and course
anteriorly to the large venous sinus. s,
sphincter; u, urethra; P-pz, prostate-peripheral
zone; Bu, bulb of penis; R, rectum.
Inset, magnified tuft. Note, smooth muscle
fibers beneath leftmost arrowhead stained
poorly.
From Robert P. MyersUROLOGY 59: 472– 479, 2002
FUNCTIONAL RESULTSFUNCTIONAL RESULTS
QUESTIONNAIRE ICS CONTINENCE
NO PADS AT 6 MONTHS 87%
FUNCTIONAL RESULTSFUNCTIONAL RESULTS
AUTOQUESTIONNAIRE IEFF 5 FOR THE SEXUALITY
57% AT ONE AYEAR
LAPAROSCOPYLAPAROSCOPY
REVOLUTION IN THE SURGICALTECHNIQUE
RESULTS THE SAME THAN OPEN
GREAT DEVELOPPEMENT
LAPAROSCOPYLAPAROSCOPY
DIFFICULTY OF THE FIRST CASES
LEARNING CURVE
PUBLICITY OF A NEW TECHNIQUE
LAPAROSCOPYLAPAROSCOPY
THE ROBOT ?
ROBOTIC DATAROBOTIC DATA
230 PATIENTS 2005 2 CONVERSIONS IN CLASSICAL LAP TRANSFUSION 2% OPERATVE TIME 150MN
Positive MarginsPositive Margins
LaparoscopyLaparoscopy
30,75
69,25
18,49%
81,50%
SexualitySexuality
58,5 %41,5 %
80 ,3%
19,7%
ContinenceContinence
Laparoscopy at 1 YearLaparoscopy at 1 Year
5%
95 %
Robotic at 4 months Robotic at 4 months
7,60 %
92,40 %
ROBOTIC DATAROBOTIC DATA
HOSPITALISATION 4.6 DAYS
FOR 100CAS
CONTINENCE AT 3 MONTHS 72%
ERECTION +- viagra 66.9%
CONCLUSIONS CONCLUSIONS
ROBOTIC ASSISTED :
………..MAKE EASIER THE RADICAL PROSTATECTOMY
Quality of the vision Miniaturization of the dissection Preservation of the anatomical structures
…….IMPROVE FUNCTIONNALS RESULTS
CONCLUSIONS CONCLUSIONS
ROBOTIC ASSISTED ………THE LIMITS :
– ECONOMIC COST
– TIME IN THE THEATER MORE LONGER – LEARNING CURVE
CONCLUSIONS CONCLUSIONS
ROBOTIC ASSISTED :
A HIGH LEVEL OF OPERATIVE QUALITY
EXCELLENT FOR RADICAL PROSTATECTOMY
LOGICAL AFTER OR AT THE SAME TIME FOR A LAP CENTER
CONCLUSIONSCONCLUSIONS
Radical prostatectomy: treatment of choice
Laparoscopic prostatectomy: excellent approach
Robotic prostatectomy: The future or the present??
But…But…
…we are still far away from the comprehension of the prostate’s anatomy, and we are confident that the robotic technique will give us a great help……