 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: ot02en302.htmhttp:// ot02en302.htm