laparoscopic prostatectomy intra- and extraperitoneal techniques
TRANSCRIPT
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
• 122,000 men diagnosed in the US 1991
• 32,000 cancer deaths 1991
• 200,000 men diagnosed in the US 1998
• 40,000 cancer deaths 1998
• 96,000 men diagnosed in the US 1987
• 26,000 cancer deaths 1987
• 122,000 men diagnosed in the US 1991
• 32,000 cancer deaths 1991
• 200,000 men diagnosed in the US 1998
• 40,000 cancer deaths 1998
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
Step 1: Transperitoneal Access to Seminal Vesicles
• Transperitoneal approach to vas deferens• Total mobilization of seminal vesicles
• Transperitoneal approach to vas deferens• Total mobilization of seminal vesicles
Step 1: Transperitoneal Access to Seminal Vesicles
Step 1: Transperitoneal Access to Seminal Vesicles
• Transperitoneal approach to vas deferens• Total mobilization of 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
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: Dissection of the Anterior Pubic Space
Step 3: Dissection of the Anterior Pubic Space
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
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
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
Results of Laparoscopic Prostatectomy
Results of Laparoscopic Prostatectomy
Raboy, Albert, Ferzli. Surg Endosc. 12:1264-67, 1998.
Patients 2Mean age 60.5 yrsMean PSA 7.3 ng/mLMean Gleason Score 6.5Conversion rate 0%OR time 4.9 hrsMean blood loss 500 mLTransfusion rate NADeaths 0Mean hospital stay 2.5 daysNegative margains 100%Mean follow-up 24 monthsPSA> 0.1ng/mL NA
Patients 2Mean age 60.5 yrsMean PSA 7.3 ng/mLMean Gleason Score 6.5Conversion rate 0%OR time 4.9 hrsMean blood loss 500 mLTransfusion rate NADeaths 0Mean hospital stay 2.5 daysNegative margains 100%Mean follow-up 24 monthsPSA> 0.1ng/mL NA
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
Results of Laparoscopic Prostatectomy
Results of Laparoscopic Prostatectomy
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%
Results of Laparoscopic Prostatectomy
Results of Laparoscopic Prostatectomy
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