Laparoscopic Radical prostatectomy – surgical removal of prostate and seminal vesicles, along with adjacent tissue to ensure negative margins
- Usual Patients
- Patients with localized prostatic cancer of low or intermediate risk (cT1a-cT2c, Gleason Score 2-7, PSA10yrs)
- In very selected cases
- Patients with low volume, high risk prostate cancer (cT3a or Gleason Score 8-10 or PSA >20ng/ml)
- Patients with very high risk localized prostate cancer (cT3b-cT4 N0 or any T N1)
- Methods and comparison (advantages/disadvantages)
- Lap RP (nsEERPE)
- Access into extraperitoneal space without entry into peritoneal cavity
- Minimization of risk of visceral trauma, quicker mobilization of intestines, containment of possible urinary leaks outside peritoneal cavity
- Surgical Steps
- Positioning of patient
- 1. Dissection and entry into extraperitoneal space
- 2. Planning and placement of ports
- 3.Balloon inflation of extraperitoneal space (under direct vision)
- 4.Dissection of extraperitoneal space and identification of key landmarks
- 5.Dissection of anterior surface of prostate and endopelvic fascia
- 6.Ligation of deep venous plexus of Santorini
- 7.Dissection of prostatic base and bladder neck (reconstruction of bladder neck?)
- 8.Dissection of vas deferens and seminal vesicles
- 9.Dissection of posterior prostatic surface
- 10.Dissection of prostatic pedicles and preservation of neurovascular bundles (intrafascial dissection?)
- 11.Dissection of prostatic apex and urethral sphincter complex
- 12.Entrapment of surgical specimen
- 13.Construction of vesicourethral anastomosis
- 14.Retrieval of surgical specimen
- 15.Exit from extraperitoneal space, removal of trocars and suture of incisions
- Access into peritoneal cavity through all layers of abdominal wall and subsequent exposure of extraperitoneal organs
- Familiar route for laparoscopic surgeons
- Tips and Tricks
- Careful placement of trocars avoids clashing of instruments, damage to epigastric vessels, and makes suturing easier.
- In obese patients, trocars may be moved forward by a few centimeters.
- Before insufflation of the extraperitoneal space, use fingers to swipe adhesions at linea alba
- Insufflation of the extraperitoneal space requires approximately 60 pumps of the balloon
- When placing trocars aided by the scope’s vision, always aim to go directly through muscle, and not through other intervening tissue. If there are adhesions, make sure to dissect them
- If an intrafascial approach is considered, the endopelvic fascia should not be incised, but rather bluntly pushed away. Dissection should happen on the plane of the prostatic capsule
- Suture of the DVC is easier with a straightened CT1 needle, as the passage under the DVC will be easier to direct.
- When identifying the bladder neck, tug on the catheter (with a filled balloon). The border between the prostate and the bladder should be readily seen.
- When dissecting the anterior portion of the bladder neck, aim to dissect directly downwards exactly in the border between the bladder and prostate. This will result in a smaller bladder neck and no prostatic tissue left behind.
- Identify the ureteral orifices before starting dissection of the posterior bladder neck.
- If the ductus deferens is not readily seen after dissection of the posterior bladder neck, consider changing the cleavage plane as you may be entering the prostate, Also, beware of through and through injuries to the bladder during this phase.
- Try to dissect the posterior aspect of the prostate by stripping Denonvilier’s fascia in order to maintain an intrafascial approach
- When dissecting the seminal vesicles, remember to adequately ligate the vessels on the tips of the vesicles, as they may bleed profusely
- Do not use any source of energy near the pedicle and the NVB if performing nerve sparing surgery. Use clips and scissors to dissect tissue
- Use the assistant’s grasper to roll the prostate in more convenient directions for dissection
- When dissecting the apex, place the assistant’s grasper on the base of the prostate to pull on the prostate in a cranial direction . This will allow for easier apical dissection
- Protect the rectum under the urethra when dissecting the apex by placing the assistant’s cannula there.
- The anastomosis may be constructed continuously or with interrupted sutures, as long as sutures are placed with precision. The use of a UR6 needle is recommended
- Check for water-tightness of the anastomosis by instilling 120ml of saline into the bladder
Laparoscopic Radical Prostatectomy – Extraperitoneal approach, nerve sparing
Laparoscopic Radical Prostatectomy – Extraperitoneal approach, non-nerve sparing
Laparoscopic Radical Prostatectomy – Dissecting the Anterior surface