Apical dissection athens 2011

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Apical dissection athens 2011

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

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