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Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques
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Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques

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  • 1. Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques George Ferzli, MD, FACS Robert Cacchione, MD; Paul Sayad, MD Department of Laparoscopic Surgery Staten Island University Hospital
  • 2. Prostate 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
  • 3. Methods of Treating Localized Prostate Cancer
    • Surgery
      • Retropubic Prostatectomy
      • Perineal Prostatectomy
      • Laparoscopic Prostatectomy
    • Radiation Therapy
      • External Beam
      • Interstitial Seed Implantation
    • Watch and Wait
  • 4. Evolution of Laparoscopic Surgery for Prostate Cancer
    • Extraperitoneal Hernia Repair
    • Pelvic Lymph Node Dissection
    • Bladder Neck Suspension
    • Sigmoid and Rectal Resections
    • Prostatectomy
  • 5. Anatomy of the Prostate
    • Bladder
    • Ureter
    • Vas deferens
    • Seminal vesicle
    • Prostate
  • 6. Prostatectomy: Analogy to Fundoplication esophageal tumor - prostate stomach - bladder esophagus - urethra vagus – neurovasc. bundle
  • 7. Placement of Trocars
    • 4-5 trocars in line with the iliac crests
    • Camera is placed in the umbilicus
  • 8. Placement of Trocars (Totally Extraperitoneal Technique)
  • 9.
    • Intraperitoneal
      • Transperitoneal access to seminal vesicles
      • Dissection of prostatorectal space
    • Extraperitoneal
      • Dissection of retropubic space
      • Mobilization of prostatic block
    Steps of the Procedure
  • 10. Step 1: Transperitoneal Access to Seminal Vesicles
    • Transperitoneal approach to vas deferens
    • Total mobilization of seminal vesicles
  • 11. Step 1: Transperitoneal Access to Seminal Vesicles
    • Transperitoneal approach to vas deferens
    • Total mobilization of seminal vesicles
  • 12. Step 2: Dissection of the Prostatorectal Space
    • Incision of aponeurosis
    • Liberation of anterior rectal wall to prostatic apex
    • Lateral dissection of rectum
  • 13. Step 2: Lateral Dissection of Rectum vas deferens neurovascular bundle seminal vesicle urethra pubic bone ureter bladder rectum prostate dorsal vein
  • 14. 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
  • 15. Step 3: Dissection of the Anterior Pubic Space
  • 16. Step 3: Division of Dorsal Vein
  • 17. Step 3: Section of Urethra at Prostatic Apex
  • 18. Step 4: Mobilization of the Prostate
    • Sectioning of anterior bladder neck
    • Mobilization and removal of prostate
    • Ureterovesicle anatomosis
  • 19. Step 4: Sectioning of Anterior Bladder Neck
  • 20. Step 4: Ureterovesicle Anastomosis
  • 21. Laparoscopic 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
  • 22. Results of Laparoscopic Prostatectomy Schuessler. Urol. 50:854-57, 1997.
  • 23. Results of Laparoscopic Prostatectomy Raboy, Albert, Ferzli. Surg Endosc. 12:1264-67, 1998.
  • 24. The Last French Revolution
    • Laparoscopic Cholecystectomy
      • Mouret
      • Dubois
      • Perrissat
      • Mouiel
  • 25. The Next French Revolution
    • Laparoscopic Prostatectomy
      • Vallancien
      • Guillonneau
      • Abbou
      • Gaston
  • 26. Results of Laparoscopic Prostatectomy Guillonneau. J Urol 163:418-22, 2000.
  • 27. Results of Laparoscopic Prostatectomy Abbou. Urol. 55:630-633, 2000.
  • 28. Robotics in Urology
    • Jonas and Kramer of Frankfurt University Hospital recently completed 4 of a series of 30 cases using the da Vinci robotic system.
  • 29. Totally Extraperitoneal vs 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
  • 30. Conclusions
    • 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
  • 31. Conclusions
    • 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

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