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

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

12. Puboprostatic ligaments

13. Dorsal Vein ComplexMyers RP Urology 2002; 59 (4): 472-9

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

23. Selective ligature of DVC Montorsi F. et al Eur Urol 48: 938-945; 2005

26. In itscoursefrom the apex of the prostate to the perinealmembrane,

27. the membranous urethra spansoneverage

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

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 junctionAsimakopoulos et al. EurUrol 2010;58:407–417

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 DVCAsimakopoulos 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

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

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?