Radical Laparoscopic
Prostatectomy:
Managing Localized Prostate Cancer
Chase Wilson M1
S
Patient Presentation
S Difficulty urinating
S Decreased force of urine flow
S Blood in urine and/or semen
S Swelling in legs
S Pelvic pain
Clinical Screening
S Digital Rectal Exam (DRE)
S Abnormal size/texture of prostate
S PSA > 4.0 ng/mL
Diagnostic Tools and Stages of
Prostate Cancer
S Ultrasound
S Prostate biopsy
(Gleason score)
S CT Scan
S MRI
S Stage I—not detectable on
DRE
S Stage II—detectable on
DRE, confined to prostate
S Stage III—spread to seminal
vesicles/nearby tissues
S Stage IV—complete
metastasis
Non-Surgical Treatment
Options
S Radiation Therapy
S External radiation
S Brachytherapy (radioactive seeds)
S Hormone therapy (decrease testosterone levels)
S Medications
S Orchiectomy
S Chemotherapy
Surgical Treatment Options
S Retropubic Surgery
S Perineal Surgery
S Laparoscopic Surgery
S Robotic Surgery
Advantages of Laparoscopic
Approach
S Better visualization of prostate anatomy
S Reduced blood loss
S Better nerve sparing
S Quicker post-operative recovery
Laparoscopic Prostatecomy:
Operating Room Layout
Video monitors
Assistants
Surgeon
Patient in 30°
Trendelenburg
Standard Laparoscopic
Instruments
S 0° Laparoscope
S Fine dissecting scissors
S Ultrasonic dissectors
S Fine grasping forceps
S Needle holder
S Suction-irrigation device
S Retrieval bag
S Grasping urinary catheter
S 2.0 braided suture, 26 mm
needle
S 3.0 absorbable,
monofilament suture, 26
mm needle
Trocar Placement
A: Below
umbilicus
B: 2 cm medial
to ASIS
E: 2 cm medial
to ASIS
C: Between A & B
D: Midline, between
umbilicus and pubic
symphysis
Instrument Placement
Laparoscope
Grasper/s
uction
Forceps, grasper
Grasper/suction,
scissors
Ultrasonic
scissors, needle
holder
Prostatectomy Procedure
1
Detach bladder from anterior abdominal wall (D1_:12)
2
Anterior and lateral dissection of prostate (:16-40)
3
Divide prostate and bladder neck (D2_:02-08)
4
Dissection of ductus deferens and seminal vesicles (:12)
5
Incise Denovillier’s fascia, dissect prostate from rectum (:22)
Prostatectomy Procedure
6
Carefully dissect neurovascular bundles from lateral prostate (:28)
7
Hemostasis and division of superficial dorsal vein (:46)
8
Divide prostate and urethra (:52)
9
Remove prostate, seminal vesicles, and ductus deferens (:57)
10 Vesicourethral anastomosis (D3)
Detach Bladder
Anterior
abdominal wall
Bladder
Future
Retzius’ space
Anterior/Lateral Dissection
Location of
superficial
dorsal vein
Pelvic rim
Prostate
(Inside Retzius’s space)
Superficial Dorsal Vein
Superficial
dorsal vein
Pelvic rim
Pelvic floor (levator
ani and endopelvic
fascia)
Prostate
Location of
nerve bundle
Divide Prostate and Bladder
Neck
Superior
prostate
Urinary
catheter
Bladder neck
Seminal Vesicles/Ductus
Deferens
Seminal
vesicle
Location of
neurovascular
bundle
Ductus
deferens
Denovillier’s Fascia
Seminal
vesicle
Neurovascular
bundle
Posterior
prostate
Denovillier’s
fascia
Rectum
(deep to
denovillier’s
fascia)
Nerve Sparing
Fine
dissecting
scissors
Scissors dissect
between prostatic
capsule and lateral
prostatic fascia
Plexus of nerves
Neurovascular
bundle
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
S Infection control:
S Antibiotics
S Drain
S Urinary catheter (removed ~7 days post-op)
S Blood thinners
S Little pain medication necessary
Operative Complications
S Infection
S Incontinence
S Erectile dysfunction
S Persistent cancer
S Blood clots
References
S Images and Procedure: Dr. Strup’s Radical Laparoscopic
Prostatectomy Teaching DVD
S Background information:
S Piechaud T, Saussine C. Laparoscopic radical prostatectomy:
transperitoneal approach. Epublication: WeBSurg.com, Feb
2006; 6(2). URL: http://www.websurg.com/ref/doiot02en302.htm