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Apical dissection athens 2011

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  • 1. Apicalanatomy & dissection
    Mottrie
    A. Gallina
    O.L.V. RoboticSurgeryInstitute (ORSI)
    Aalst
    Belgium
  • 2. Robot-assistedsurgeryindications
    Major indication :
    radicalprostatectomy
    Surgery is in constant motion
    Lookingforperfection to reach the “TRIFECTA”
    Curethe patient from his cancer
    Obtainingearlycontinence
    Preserving erectilefunction
  • 3. Robot-assistedsurgeryindications
    Major indication :
    radicalprostatectomy
    Surgery is in constant motion
    Lookingforperfection to reach the “TRIFECTA”
    Cure the patientfromhiscancer
    Obtainingearlycontinence
    Preserving erectilefunction
  • 4. Robotic-assisted surgery
    How to achieve the ideal outcome?
    • Accurate patient selection (age, comorbidity, oncological risk group)
    • 5. Good knowledge of anatomy
    • 6. Surgical steps for ideal outcome
    • 7. Preservation of puboprostatic ligaments & muscle fibers
    • 8. Preservation of membranous urethra
    • 9. Anterior fixation
    • 10. Restoration of posterior aspect of rhabdosphincter
    (Rocco ‘s stitch)
    • Bladder neck preservation
    • 11. Preservation of neurovascular bundles and “continence nerves”
  • Knowledge of Anatomy
    Prostate is well covered
    by Pubovesical Complex
    • Detrusor apron
    • 12. Puboprostatic ligaments
    • 13. Dorsal Vein Complex
    Myers RP Urology 2002; 59 (4): 472-9
  • 14. Robot-assistedsurgeryApicaldissection
    DILEMMA
    Preserve tissue/anatomy
    Vs.
  • Intrafascial Radical Prostatectomy
    Preservation of puboprostatic ligaments
    Montorsi F et al Eur Urol 2005; 48: 938-945
  • 16. Division of puboprostatic ligaments
    Pubourethral
    component
  • 17. Knowledge of Anatomy:
    Puboprostatic ligaments
    Steiner MS The puboprostatic ligament and the male urethral suspensory mechanism:
    an anatomic study. Urology 1994; 44 (4): 530-34
  • 18. Santorini’s plexus
    (Dorsal Vein Plexus)
    Santorini GD, Observationes anatomicae, 1724
  • 19. Anatomical milestones
    The Journal of Urology Vol. 121: 198-200; 1979
    An Anatomical Approach to the Surgical
    Management of the Dorsal Vein and Santorini’s
    Plexus during Radical Retropubic Surgery
    William G. Reiner & Patrick C. Walsh
    V. Ficarra
  • 20. Deep Dorsal Vein Complex
    V. Ficarra
  • 21. Deep Dorsal Vein Complex
    Courtesy by Dr. Ficarra
  • 22.
  • 23. Selective ligature of DVC
    Montorsi F. et al Eur Urol 48: 938-945; 2005
  • 24. Selective ligature of DVC
    • Stolzenburg et al (EurUrol 2006) :
    preservation of puboprostaticligaments
    continence at 3 M : 76% vs 48%
    • Porpiglia (Eur Urol 2009) :
    selectiveligature of deepvenous plexus
    continence at 3 M : 76% vs 50%
  • 25. Anatomical landmarks:
    Urethral Sphincter
    • Membranous urethra (sphincteric urethra)
    • 26. In itscoursefrom the apex of the prostate to the perinealmembrane,
    • 27. the membranous urethra spansoneverage
    • 28. 2 to 2.5 cm (range 1.2 to 5 cm)
  • Apicaldissection : tips & tricks
    Urethral stump length, PSM and
    continence after RALP
    first 200 cases: transection of the urethra at
    the prostatourethral junction:
    PSM 17,6% (74% apical)
    continence at 6 mo: 89%
    second 200 cases: transection 3-6 mm distal
    to the prostatourethral junction:
    PSM 7.5% (apical 5.5%)
    continence at 6 mo: 91%
    Borin, et al 2007
  • 29. Anatomical landmarks:
    externalsphincteric complex
    • At the apex of the prostate, circular fibers surround the urethra, and they thin posteriorly to insert into a fibrous raphe.
    Myers RP et al; J. Urol., 1987; 138(3):543-50
  • 30. Anatomical landmarks:
    urethral sphincter
    CG:Cowpers gland
    LA: levator ani
    *: striated part
    X: external smooth
    muscular part
    : internal smooth muscular part
    Stolzenburg et al Eur Urol 2007; 51: 629-39
  • 31. Anatomy of the Sphincter
  • 32. “croissant”
    “doughnut”
    Prostate Shape and Sphincter Preservation
    Myers R Prostate shape, external striated urethral sphincter and radical prostatectomy:
    the apical dissection. J Urol 1987; 138 (3): 543-50
  • 33. Anatomy of the Prostate Apex
    Graefen M et al, Eur Urol 2006
  • 34. Importance of urethral length and fibrosis
    Paparel et al. EurUrol 2009:55;629–639
  • 35. Importance of urethral length and fibrosis
    Post-RP T2-weighted image from a 61-yr-old continentpatientshowing no postoperativefibrosis:
    grade 0 for the urethralwall (arrow) and for the peri-urethraltissue (dashedarrows)
    Paparel et al. EurUrol 2009:55;629–639
  • 36. Importance of urethral length and fibrosis
    Post-RP T2-weighted endorectal MRI from a 56-yr-old patientshowinggrade I urethralfibrosis (arrow) and grade III circumferentialperiurethralfibrosis (dashedarrows).
    Paparel et al. EurUrol 2009:55;629–639
  • 37. Importance of urethral lenght
    Paparel et al. EurUrol 2009:55;629–639
  • 38. Vision onto the Prostate Apex
    antegradetechnique, wherelateraldissection is done
    >> bettervisualisation of sphincteric complex & apex
  • 39. Functional organisation
    of the NVB
    Costello A. et al BJU Inter 2004; 94: 1071-1076
  • 40. How I do it…
  • 41. Prostate Size and Shape
    Myers R Prostate shape, external striated urethral sphincter and radical prostatectomy:
    the apical dissection. J Urol 1987; 138 (3): 543-50
  • 42. Apical dissection
    Anatomicalvariation
  • 43.
    • Puboprostatic ligament preservation has been proposed to achieve accelerated return of continence after nerves-paring procedures.
    • 44. Even with this technique, the rates of immediate post-operative continence remain low.
    • 45. A possible explanation could be that because there is demonstrable anatomic continuity with the bladder, there are no conceivable means of preserving the pubovesical ligaments during RALP, and there must be interruption at some point to expose the prostatourethral junction
    Asimakopoulos et al. EurUrol 2010;58:407–417
  • 46.
    • The management of the dorsal vascular complex (DVC) could also have important implications in continence recovery
    • 47. It has been demonstrated that the ‘‘cut and ligate’’ of the DVC technique offers quicker continence recovery than a ‘‘ligate and cut’’ technique.
    • 48. However, both selective and standard ligation present inherent drawbacks; thus, a ‘‘no touch’’ approach might be the ideal way to manage the DVC
    Asimakopoulos et al. EurUrol 2010;58:407–417
  • 49. Selective vs. standard ligation of the DVC
    Potential drawbacks
    Asimakopoulos et al. EurUrol 2010;58:407–417
  • 50. The curved arrow indicates the avascular plane present between the point at which the detrusor apron (DA) leaves the prostate (to attach to the pubis) to the anterior prostate-urethral junction.
    From this level, it starts the anterior dissection of the pubovesical complex
    Asimakopoulos et al. EurUrol 2010;58:407–417
  • 51. The anterior surface of the prostate has been totally freed from both the detrusor apron and the dorsal vascular complex
    * Bladder neck
    ** Membranous urethra
    Asimakopoulos et al. EurUrol 2010;58:407–417
  • 52. Asimakopoulos et al. EurUrol 2010;58:407–417
  • 53.
    • At catheter removal, 80% (24 patients) were completely dry (0 pads), while 20% (6 patients) used a single liner for security
    • 54. One month after surgery, according to the ICSmaleSF questionnaire (0max, 24 min), 28 patients presented a score of 0, while two patients scored 1 (loss of urinewhen coughing or sneezing) at catheter removal
    • 55. After 3 mo, 22 of 30 patients (73%) presented an IIEF score >17 (with or without PDE-5 inhibitors).
    • 56. 13 of 22 potent patients had an Erection Hardness Score of 3, and 9 of 22 patients had a score of 4.
    Asimakopoulos et al. EurUrol 2010;58:407–417
  • 57. Conclusions
    • Carefulapicaldissection is important
    • 58. Probablyadds to earlycontinence :
    • 59. Preservation of pubourethral suspension ligaments
    • 60. Selectiveligation of DVC
    • 61. Preservation of sphincericmuscle fibers bydissectingfollowing the apicalsurface
    • 62. Nerve sparing technique
    • 63. Antegrade dissection
    • 64. Pubo-vescical complex sparing?

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