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Radical Laparoscopic Prostatectomy: Managing Localized Prostate Cancer Chase Wilson M1
Patient Presentation Difficulty urinating Decreased force of urine flow Blood in urine and/or semen Swelling in legs Pelvic pain
Clinical Screening Digital Rectal Exam (DRE) Abnormal size/texture of prostate PSA > 4.0 ng/mL
Diagnostic Tools and Stages of Prostate Cancer Ultrasound Prostate biopsy (Gleason score) CT Scan MRI Stage I—not detectable on DRE Stage II—detectable on DRE, confined to prostate Stage III—spread to seminal vesicles/nearby tissues Stage IV—complete metastasis
Non-Surgical Treatment Options Radiation Therapy External radiation Brachytherapy (radioactive seeds) Hormone therapy (decrease testosterone levels) Medications Orchiectomy Chemotherapy
Surgical Treatment Options Retropubic Surgery Perineal Surgery Laparoscopic Surgery Robotic Surgery
Advantages of Laparoscopic Approach Better visualization of prostate anatomy Reduced blood loss Better nerve sparing Quicker post-operative recovery
Laparoscopic Prostatecomy: Operating Room Layout Surgeon Patient in 30° Trendelenburg Assistants Video monitors
Standard Laparoscopic Instruments 0° Laparoscope Fine dissecting scissors Ultrasonic dissectors Fine grasping forceps Needle holder Suction-irrigation device Retrieval bag Grasping urinary catheter 2.0 braided suture, 26 mm needle 3.0 absorbable, monofilament suture, 26 mm needle
Trocar Placement A: Below umbilicus B: 2 cm medial to ASIS C: Between A & B D: Midline, between umbilicus and pubic symphysis E: 2 cm medial to ASIS
Instrument Placement Laparoscope Grasper/s uction Grasper/suction, scissors Ultrasonic scissors, needle holder Forceps, grasper
Prostatectomy Procedure 1 Detach bladder from anterior abdominal wall (D1_:12) Detach bladder from anterior abdominal wall (D1_:12) 2 Anterior and lateral dissection of prostate (:16-40) Anterior and lateral dissection of prostate (:16-40) 3 Divide prostate and bladder neck (D2_:02-08) Divide prostate and bladder neck (D2_:02-08) 4 Dissection of ductus deferens and seminal vesicles (:12) Dissection of ductus deferens and seminal vesicles (:12) 5 Incise Denovillier’s fascia, dissect prostate from rectum (:22) Incise Denovillier’s fascia, dissect prostate from rectum (:22)
Prostatectomy Procedure 6 Carefully dissect neurovascular bundles from lateral prostate (:28) Carefully dissect neurovascular bundles from lateral prostate (:28) 7 Hemostasis and division of superficial dorsal vein (:46) Hemostasis and division of superficial dorsal vein (:46) 8 Divide prostate and urethra (:52) Divide prostate and urethra (:52) 9 Remove prostate, seminal vesicles, and ductus deferens (:57) Remove prostate, seminal vesicles, and ductus deferens (:57) 10 Vesicourethral anastomosis (D3) Vesicourethral anastomosis (D3)
Detach Bladder Anterior abdominal wall Bladder Future Retzius’ space
Anterior/Lateral Dissection Pelvic rim Prostate Location of superficial dorsal vein (Inside Retzius’s space)
Superficial Dorsal Vein Superficial dorsal vein Prostate Pelvic rim Pelvic floor (levator ani and endopelvic fascia) Location of nerve bundle
Divide Prostate and Bladder Neck Superior prostate Urinary catheter Bladder neck
Seminal Vesicles/Ductus Deferens Location of neurovascular bundle Ductus deferens Seminal vesicle
Denovillier’s Fascia Seminal vesicle Denovillier’s fascia Neurovascular bundle Rectum (deep to denovillier’s fascia) Posterior prostate
Nerve Sparing Neurovascular bundle Fine dissecting scissors Plexus of nerves Scissors dissect between prostatic capsule and lateral prostatic fascia
Division of Superficial Dorsal Vein Superficial dorsal vein Anterior prostate
Division of Prostate and Urethra Urethra Catheter Prostate
Prostate Removal Pelvic rim Lateral prostate Superior prostate
Vesicourethral Anastomosis Urethra Catheter w/ grasper Anchor stitch Needle holder Bladder neck
Time Lapse Anastomosis Urethra Bladder neck
Post-Operative Care Infection control: Antibiotics Drain Urinary catheter (removed ~7 days post-op) Blood thinners Little pain medication necessary
Operative Complications Infection Incontinence Erectile dysfunction Persistent cancer Blood clots
References Images and Procedure: Dr. Strup’s Radical Laparoscopic Prostatectomy Teaching DVD Background information: Piechaud T, Saussine C. Laparoscopic radical prostatectomy: transperitoneal approach. Epublication: WeBSurg.com, Feb 2006; 6(2). URL: http://www.websurg.com/ref/doi- ot02en302.htmhttp://www.websurg.com/ref/doi- ot02en302.htm
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