Laparoscopic Radical
Prostatectomy
Dr. J.L Hoepffner
Clinique St Augustin,
Bordeaux
FRANCE

History
 Schuessler ‘94
 Raboy ‘97
 Gaston ‘97
 Guillonneau ‘98
 2006: 50% prostatectomies laparoscopic

LAPAROSCOPIC APROACH
 TRANSFORMATION of the
PROSTATECTOMY :
– Mini invasive Surgery
–
–
–
–
–
Easier exposition, Magnification of the vision
Définition anatomic plans
Précision of the gestual , Miniaturisation of the sutures
Bloodless
Post-operative more simple

LAPAROSCOPIC APROACH
 IMPROVEMENT OPEN SURGERY
 SAFETY ONCOLOGIC
 REDUCTION OF FUNCTIONAL
SEQUELLA

LAPAROSCOPIC APROACH
 LIMITS AND DISAVANTAGES :
– Quality of the vision
– Steadiness of the instrument
– Difficulty of the access ,
– Limit of the angular dissection
– Discomfort of the surgeon

LAPAROSCOPIC APROACH
 NEW LIMITS FOR A DISSECTION
PRESERVATIVE AND ATRAUMATIC
OF THE PROSTATE
 NEW LIMITS FOR PROGRESS IN
ERECTILE PRESERVATION

ROBOT ASSISTED:
ONE ANSWER ?
 QUALITE OF OPERATIVE VISION +++
 PRECISION OF THE ANATOMIC
DEFINITION
 REDUCTION TRAUMATIC DISSECTION
 DISAPPAERANCE OF THE LIMITS OF
THE DISSECTION
 COMFORT AND LOGICAL ERGONOMY
FOR THE SURGEON

ROBOT ASSISTED :
A TECHNICAL ADVANTAGE?
DEMONSTRATION :
 Bladder neck dissection
 Bundle preservation
 Suturing

Opératoring Indications
 Curative
 T1 – T2
 T3 ?
 Gleason score / age
 Nerve Sparing ?
 Alternative : EBRT – brachytherapy

Pre-operative Status
 Cardiovasculary exam
 Respiratory Fonction
 Hemostasis blood test
 No autologus transfusion
 8-10 weeks after biopsies

Pré-opératorive State
 Obesity not exclude
 No bowel préparation
 No specific contre-indications to the laparoscopic surgery

Technique
 Patient in Trendelenburg position
 One surgeon, one assistant
 5 trocars: 1 x 10 mm , 4 x 5mm
 Video column between the legs
 Laparoscope 0°

Laparoscopic Instruments
•Needle driver
•Monopolaire
•Bipolaire
•Grasp
•Thin grasp

LAPAROSCOPIC APROACH

LAPAROSCOPIC APROACH

THE ROBOT

Optic Ports
Assistent Ports
Robot Ports

The ‘Da Vinci’ Sytem

THE ROBOT

THE ROBOT

THE ROBOT

Laparoscopic Bladder Neck
Dissection

Bladder Neck Robotic
Dissection

Seminales Vesicules
Laparoscopic Dissection

Right Bundle Laparoscopic
Dissection

Intrafasciale Robotic Dissection

Apex Laparoscopic Dissection

Apex Robotic Dissection (1)

Apex Robotic Dissection(2)

DVC Suture
(running suture)

Urétro-Vésicale Laparoscopic
Anastomosis
(running suture)

Anastomose Robotique urétro-vésicale
(running suture)

Laparoscopic Data
 3000 patients
 Study of 1574 files
 Mean Psa 6,72
 Mean Gleason score 6,27
 Age 61,9 years old
Eur Urol. 2006 Feb;49(2):344-52

OUR DATA
 OPERATIVE TIME 120 MN
 HOSPITALISATION 5.7 JOURS
 0 CONVERSION in 7 years

OUR DATA
COMPLICATIONS
HAEMORRHAGES 1.3%
ANASTOMOSIS FISTULA 0.3%
RECTAL INJURY 0.5%
URETERAL INJURY one case
ANASTOMOTIC STENOSIS <1%
EVENTRATION <1%

OUR DATA
 PATHOLOGICAL RESULTS 1293
PT2A 10.2%
PT2B.C 57.8%
PT3A 28.2%
PT3B 3.8%

MARGINS
TOTAL 22%
T2 14%
T3 36%

FUNCTIONAL RESULTS
 CONTINENCE
 ERECTION : THE CHALLENGE
–
– better result ?
Better complete recovery?
– reduce the delay of recovery ?
– OBLIGATION of an EVALUATION

How can we improve functional result ?
?
!
Better knowledge of the prostate anatomy

Principles of preservation
High incision of pelvic fascia
From Eichelberg C,
European urology, 2006

During radical prostatectomy, innervation of the trigone, neobladder neck, and posterior urethra may become disrupted, because the surgical procedure involves anatomic dissection around the prostate, posterior aspects of the bladder base, and seminal vesicles.
afferent innervation of the trigone posterior urethra may lead to alterations in posterior urethral sensation indirectly contribute to outlet
UROLOGY 55: 820–824, 2000.

The percentage continence rates at a4 weeks and 12 months after surgery.
Level of Evidence 1b
96,3%
85,7%
62,7%
45%
From Peter Albers
BJU Int 1 0 0 , 10 5 0 – 10 5 4, 2007



Antegrade dissection
Traction on Seminal vesicles
Injury to the nerves

From Stolzemburg
European Urology 51 ( 2 0 0 7 ) 629–639

Detrusor apron
Detrusor apron (arrowheads) in Masson trichrome-stained sagittal section through adult cadaveric prostate. Detrusor apron ends in tuft (arrow) that is transected end of pubovesical (puboprostatic) ligament. Tuft contains fibrous tissue (blue) and smooth muscle fibers (red) that curve and course anteriorly to the large venous sinus. s, sphincter; u, urethra; P-pz, prostate-peripheral zone; Bu, bulb of penis; R, rectum.
Inset, magnified tuft. Note, smooth muscle fibers beneath leftmost arrowhead stained poorly.
From Robert P. Myers
UROLOGY 59: 472– 479, 2002

FUNCTIONAL RESULTS
 QUESTIONNAIRE ICS CONTINENCE
NO PADS AT 6 MONTHS 87%

FUNCTIONAL RESULTS
AUTOQUESTIONNAIRE IEFF 5 FOR
THE SEXUALITY
57% AT ONE AYEAR

LAPAROSCOPY
REVOLUTION IN THE SURGICALTECHNIQUE
RESULTS THE SAME THAN OPEN
GREAT DEVELOPPEMENT

LAPAROSCOPY
DIFFICULTY OF THE FIRST CASES
LEARNING CURVE
PUBLICITY OF A NEW TECHNIQUE

LAPAROSCOPY

ROBOTIC DATA
 230 PATIENTS 2005
 2 CONVERSIONS IN CLASSICAL LAP
 TRANSFUSION 2%
 OPERATVE TIME 150MN

Positive Margins
Laparoscopy
30,75
69,25
81,50 %
18,49%

Sexuality
80 ,3%
58,5 %
41,5 %
19,7 %

Continence
Laparoscopy at 1 Year
95 %
Robotic at 4 months
92,40 %
7,60 %
5%

ROBOTIC DATA
HOSPITALISATION 4.6 DAYS
FOR 100CAS
CONTINENCE AT 3 MONTHS 72%
ERECTION +- viagra 66.9%

CONCLUSIONS
 ROBOTIC ASSISTED :
………..MAKE EASIER THE RADICAL
PROSTATECTOMY
 Quality of the vision
 Miniaturization of the dissection
 Preservation of the anatomical structures
…….IMPROVE FUNCTIONNALS RESULTS

CONCLUSIONS
 ROBOTIC ASSISTED
………THE LIMITS :
– ECONOMIC COST
– TIME IN THE THEATER MORE LONGER
– LEARNING CURVE

CONCLUSIONS
ROBOTIC ASSISTED :
 A HIGH LEVEL OF OPERATIVE
QUALITY
 EXCELLENT FOR RADICAL
PROSTATECTOMY
 LOGICAL AFTER OR AT THE SAME
TIME FOR A LAP CENTER

CONCLUSIONS
 Radical prostatectomy: treatment of choice
 Laparoscopic prostatectomy: excellent approach
 Robotic prostatectomy: The future or the present??

But…
…we are still far away from the comprehension of the prostate’s anatomy, and we are confident that the robotic technique will give us a great help……