Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques

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Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques

  1. 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. 2. Prostate Cancer Statistics <ul><li>96,000 men diagnosed in the US 1987 </li></ul><ul><li>26,000 cancer deaths 1987 </li></ul><ul><li>122,000 men diagnosed in the US 1991 </li></ul><ul><li>32,000 cancer deaths 1991 </li></ul><ul><li>200,000 men diagnosed in the US 1998 </li></ul><ul><li>40,000 cancer deaths 1998 </li></ul>
  3. 3. Methods of Treating Localized Prostate Cancer <ul><li>Surgery </li></ul><ul><ul><li>Retropubic Prostatectomy </li></ul></ul><ul><ul><li>Perineal Prostatectomy </li></ul></ul><ul><ul><li>Laparoscopic Prostatectomy </li></ul></ul><ul><li>Radiation Therapy </li></ul><ul><ul><li>External Beam </li></ul></ul><ul><ul><li>Interstitial Seed Implantation </li></ul></ul><ul><li>Watch and Wait </li></ul>
  4. 4. Evolution of Laparoscopic Surgery for Prostate Cancer <ul><li>Extraperitoneal Hernia Repair </li></ul><ul><li>Pelvic Lymph Node Dissection </li></ul><ul><li>Bladder Neck Suspension </li></ul><ul><li>Sigmoid and Rectal Resections </li></ul><ul><li>Prostatectomy </li></ul>
  5. 5. Anatomy of the Prostate <ul><li>Bladder </li></ul><ul><li>Ureter </li></ul><ul><li>Vas deferens </li></ul><ul><li>Seminal vesicle </li></ul><ul><li>Prostate </li></ul>
  6. 6. Prostatectomy: Analogy to Fundoplication esophageal tumor - prostate stomach - bladder esophagus - urethra vagus – neurovasc. bundle
  7. 7. Placement of Trocars <ul><li>4-5 trocars in line with the iliac crests </li></ul><ul><li>Camera is placed in the umbilicus </li></ul>
  8. 8. Placement of Trocars (Totally Extraperitoneal Technique)
  9. 9. <ul><li>Intraperitoneal </li></ul><ul><ul><li>Transperitoneal access to seminal vesicles </li></ul></ul><ul><ul><li>Dissection of prostatorectal space </li></ul></ul><ul><li>Extraperitoneal </li></ul><ul><ul><li>Dissection of retropubic space </li></ul></ul><ul><ul><li>Mobilization of prostatic block </li></ul></ul>Steps of the Procedure
  10. 10. Step 1: Transperitoneal Access to Seminal Vesicles <ul><li>Transperitoneal approach to vas deferens </li></ul><ul><li>Total mobilization of seminal vesicles </li></ul>
  11. 11. Step 1: Transperitoneal Access to Seminal Vesicles <ul><li>Transperitoneal approach to vas deferens </li></ul><ul><li>Total mobilization of seminal vesicles </li></ul>
  12. 12. Step 2: Dissection of the Prostatorectal Space <ul><li>Incision of aponeurosis </li></ul><ul><li>Liberation of anterior rectal wall to prostatic apex </li></ul><ul><li>Lateral dissection of rectum </li></ul>
  13. 13. Step 2: Lateral Dissection of Rectum vas deferens neurovascular bundle seminal vesicle urethra pubic bone ureter bladder rectum prostate dorsal vein
  14. 14. Step 3: Dissection of the Anterior Pubic Space <ul><li>Extraperitoneal dissection of prevesical fascia </li></ul><ul><li>Dissection of retropubic space and endopelvic fascia laterally </li></ul><ul><li>Division of dorsal vein complex </li></ul><ul><li>Section of urethra at prostatic apex </li></ul>
  15. 15. Step 3: Dissection of the Anterior Pubic Space
  16. 16. Step 3: Division of Dorsal Vein
  17. 17. Step 3: Section of Urethra at Prostatic Apex
  18. 18. Step 4: Mobilization of the Prostate <ul><li>Sectioning of anterior bladder neck </li></ul><ul><li>Mobilization and removal of prostate </li></ul><ul><li>Ureterovesicle anatomosis </li></ul>
  19. 19. Step 4: Sectioning of Anterior Bladder Neck
  20. 20. Step 4: Ureterovesicle Anastomosis
  21. 21. Laparoscopic Prostatectomy <ul><li>Transabdominal </li></ul><ul><ul><li>Schuessler, et al. J Urol 147:246A, 1992 </li></ul></ul><ul><ul><li>Schuessler, et al. Urology 50:854, 1997 </li></ul></ul><ul><ul><li>Guillonneau, et al. Eur Urol 36:14, 1999 </li></ul></ul><ul><ul><li>Guillonneau, et al. Prostate 39:71, 1999 </li></ul></ul><ul><ul><li>Guillonneau, et al. J Urol 163:418, 2000 </li></ul></ul><ul><ul><li>Abbou, et al. Urology 55:630-33, 2000 </li></ul></ul><ul><li>Extraperitoneal </li></ul><ul><ul><li>Raboy, Ferzli. Urology 50:849, 1997 </li></ul></ul><ul><ul><li>Raboy, Ferzli. Surg Endosc 12:1264, 1998 </li></ul></ul>
  22. 22. Results of Laparoscopic Prostatectomy Schuessler. Urol. 50:854-57, 1997.
  23. 23. Results of Laparoscopic Prostatectomy Raboy, Albert, Ferzli. Surg Endosc. 12:1264-67, 1998.
  24. 24. The Last French Revolution <ul><li>Laparoscopic Cholecystectomy </li></ul><ul><ul><li>Mouret </li></ul></ul><ul><ul><li>Dubois </li></ul></ul><ul><ul><li>Perrissat </li></ul></ul><ul><ul><li>Mouiel </li></ul></ul>
  25. 25. The Next French Revolution <ul><li>Laparoscopic Prostatectomy </li></ul><ul><ul><li>Vallancien </li></ul></ul><ul><ul><li>Guillonneau </li></ul></ul><ul><ul><li>Abbou </li></ul></ul><ul><ul><li>Gaston </li></ul></ul>
  26. 26. Results of Laparoscopic Prostatectomy Guillonneau. J Urol 163:418-22, 2000.
  27. 27. Results of Laparoscopic Prostatectomy Abbou. Urol. 55:630-633, 2000.
  28. 28. Robotics in Urology <ul><li>Jonas and Kramer of Frankfurt University Hospital recently completed 4 of a series of 30 cases using the da Vinci robotic system. </li></ul>
  29. 29. Totally Extraperitoneal vs Transabdominal <ul><li>A proposed study to compare the two routes of access was abandoned because the transabdominal method was judged superior </li></ul><ul><ul><li>more room for dissection </li></ul></ul><ul><ul><li>less trouble maintaining pneumoperitoneum </li></ul></ul><ul><ul><li>easier to dissect the seminal vesicles </li></ul></ul><ul><ul><li>difficult to apply the totally extraperitoneal method to patients with large prostates </li></ul></ul>
  30. 30. Conclusions <ul><li>Oncologic results of laparoscopic prostatectomy appear similar to the open procedure given the available early data </li></ul><ul><li>Functional results of laparoscopic prostatectomy are encouraging but patient numbers are as yet too few to make conclusions on potency and continence </li></ul>
  31. 31. Conclusions <ul><li>Although it can be performed totally extraperitoneally, we recommend the transperitoneal route </li></ul><ul><ul><li>provides larger working space avoids excluding patients based on prostate size </li></ul></ul><ul><ul><li>easier to maintain pneumoperitoneum </li></ul></ul><ul><ul><li>better visualization posteriorly means safer dissection of the seminal vesicles and rectum </li></ul></ul>

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