Laparoscopic Prostatectomy Intra- and Extraperitoneal Techniques

1. Laparoscopic Prostatectomy
Intra- and Extraperitoneal Techniques
George Ferzli, MD, FACS
Robert Cacchione, MD; Paul Sayad, MD

Department of Laparoscopic Surgery
Staten Island University Hospital

2. Prostate Cancer Statistics
•96,000 men diagnosed in the US 1987
•26,000 cancer deaths 1987
•122,000 men diagnosed in the US 1991
•32,000 cancer deaths 1991
•200,000 men diagnosed in the US 1998
•40,000 cancer deaths 1998

3. Methods of Treating Localized
Prostate Cancer
•Surgery
–Retropubic Prostatectomy
–Perineal Prostatectomy
–Laparoscopic Prostatectomy
•Radiation Therapy
–External Beam
–Interstitial Seed Implantation
•Watch and Wait

4. Evolution of Laparoscopic
Surgery for Prostate Cancer
•Extraperitoneal Hernia Repair
•Pelvic Lymph Node Dissection
•Bladder Neck Suspension
•Sigmoid and Rectal Resections
•Prostatectomy

5. Anatomy of the Prostate
•Bladder
•Ureter
•Vas deferens
•Seminal vesicle
•Prostate

6. Prostatectomy: Analogy to
Fundoplication
esophageal tumor - prostate
stomach - bladder
esophagus - urethra
vagus – neurovasc. bundle

7. Placement of Trocars
•4-5 trocars in line with
the iliac crests
•Camera is placed in
the umbilicus

8. Placement of Trocars
(Totally Extraperitoneal Technique)

9. •Intraperitoneal
–Transperitoneal
access to seminal
vesicles
–Dissection of
prostatorectal space
•Extraperitoneal
–Dissection of
retropubic space
–Mobilization of
prostatic block
Steps of the Procedure

10. Step 1: Transperitoneal Access to
Seminal Vesicles
•Transperitoneal approach to vas deferens
•Total mobilization of seminal vesicles

11. Step 1: Transperitoneal Access to
Seminal Vesicles
•Transperitoneal approach to vas deferens
•Total mobilization of seminal vesicles

12. Step 2: Dissection of the
Prostatorectal Space
•Incision of aponeurosis
•Liberation of anterior rectal wall to prostatic apex
•Lateral dissection of rectum

13. Step 2: Lateral Dissection of
Rectum
vas
deferens
neurovascular
bundle
seminal
vesicle
urethra
pubic bone
ureter
bladder
rectum
prostate
dorsal vein

14. Step 3: Dissection of the Anterior
Pubic Space
•Extraperitoneal
dissection of prevesical
fascia
•Dissection of retropubic
space and endopelvic
fascia laterally
•Division of dorsal vein
complex
•Section of urethra at
prostatic apex

15. Step 3: Dissection of the Anterior
Pubic Space

16. Step 3: Division of Dorsal Vein

17. Step 3: Section of Urethra at
Prostatic Apex

18. Step 4: Mobilization of the
Prostate
•Sectioning of anterior
bladder neck
•Mobilization and
removal of prostate
•Ureterovesicle
anatomosis

19. Step 4: Sectioning of Anterior
Bladder Neck

20. Step 4: Ureterovesicle
Anastomosis

21. Laparoscopic Prostatectomy
•Transabdominal
–Schuessler, et al. J Urol 147:246A, 1992
–Schuessler, et al. Urology 50:854, 1997
–Guillonneau, et al. Eur Urol 36:14, 1999
–Guillonneau, et al. Prostate 39:71, 1999
–Guillonneau, et al. J Urol 163:418, 2000
–Abbou, et al. Urology 55:630-33, 2000
•Extraperitoneal
–Raboy, Ferzli. Urology 50:849, 1997
–Raboy, Ferzli. Surg Endosc 12:1264, 1998

22. Results of Laparoscopic
Prostatectomy
Schuessler. Urol. 50:854-57, 1997.
Patients 9
Mean age 65.6 yrs
Mean PSA 14.9 ng/mL
Mean Gleason Score 5.7
Conversion rate 0%
OR time 9.4 hrs
Mean blood loss 583 mL
Transfusion rate NA
Deaths 0
Mean hospital stay 7.3 days
Negative margains 89%
Mean follow-up 26 months
PSA> 0.1ng/mL NA

23. Results of Laparoscopic
Prostatectomy
Raboy, Albert, Ferzli. Surg Endosc. 12:1264-67, 1998.
Patients 2
Mean age 60.5 yrs
Mean PSA 7.3 ng/mL
Mean Gleason Score 6.5
Conversion rate 0%
OR time 4.9 hrs
Mean blood loss 500 mL
Transfusion rate NA
Deaths 0
Mean hospital stay 2.5 days
Negative margains 100%
Mean follow-up 24 months
PSA> 0.1ng/mL NA

24. The Last French Revolution
•Laparoscopic Cholecystectomy
–Mouret
–Dubois
–Perrissat
–Mouiel

25. The Next French Revolution
•Laparoscopic Prostatectomy
–Vallancien
–Guillonneau
–Abbou
–Gaston

26. Results of Laparoscopic
Prostatectomy
Guillonneau. J Urol 163:418-22, 2000.
Patients 120
Mean age 64 yrs (±5.8)
Mean PSA 10.8 ng/mL (±6.7)
Mean Gleason Score 6 (±1)
Conversion rate 5.8%
OR time 239 min (±59)
Mean blood loss 402 mL (±293)
Transfusion rate 10%
Deaths 0
Mean hospital stay 6 days (±3.3)
Negative margains 85%
Mean follow-up 2.2 months
PSA> 0.1ng/mL 94.7%

27. Results of Laparoscopic
Prostatectomy
Abbou. Urol. 55:630-633, 2000.
Patients 43
Mean age 64.4 yrs (±6.1)
Mean PSA 9.6 ng/mL (±6.2)
Mean Gleason Score 5.9 (±1.1)
Conversion rate 0%
OR time 5.3 hrs
Mean blood loss NA
Transfusion rate 4.7%
Deaths 0
Mean hospital stay 5.9 days
Negative margains 72.1%
Mean follow-up 6.3 months
Continence rate 84%
PSA> 0.1ng/mL 100%

28. Robotics in Urology
•Jonas and Kramer of Frankfurt University
Hospital recently completed 4 of a series of
30 cases using the da Vinci robotic system.

29. Totally Extraperitoneal
vs
Transabdominal
•A proposed study to compare the two routes
of access was abandoned because the
transabdominal method was judged superior
–more room for dissection
–less trouble maintaining pneumoperitoneum
–easier to dissect the seminal vesicles
–difficult to apply the totally extraperitoneal
method to patients with large prostates

30. Conclusions
•Oncologic results of laparoscopic
prostatectomy appear similar to the open
procedure given the available early data
•Functional results of laparoscopic
prostatectomy are encouraging but patient
numbers are as yet too few to make
conclusions on potency and continence

31. Conclusions
•Although it can be performed totally
extraperitoneally, we recommend the
transperitoneal route
–provides larger working space avoids excluding
patients based on prostate size
–easier to maintain pneumoperitoneum
–better visualization posteriorly means safer
dissection of the seminal vesicles and rectum