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Radical Laparoscopic Prostatectomy:

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)

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Radical Laparoscopic Prostatectomy:

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  1. Radical Laparoscopic Prostatectomy: Managing Localized Prostate Cancer Chase Wilson M1

  2. Patient Presentation • Difficulty urinating • Decreased force of urine flow • Blood in urine and/or semen • Swelling in legs • Pelvic pain

  3. Clinical Screening • Digital Rectal Exam (DRE) • Abnormal size/texture of prostate • PSA > 4.0 ng/mL

  4. 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

  5. Non-Surgical Treatment Options • Radiation Therapy • External radiation • Brachytherapy (radioactive seeds) • Hormone therapy (decrease testosterone levels) • Medications • Orchiectomy • Chemotherapy

  6. Surgical Treatment Options • Retropubic Surgery • Perineal Surgery • Laparoscopic Surgery • Robotic Surgery

  7. Advantages of Laparoscopic Approach • Better visualization of prostate anatomy • Reduced blood loss • Better nerve sparing • Quicker post-operative recovery

  8. Laparoscopic Prostatecomy: Operating Room Layout Video monitors Assistants Surgeon Patient in 30° Trendelenburg

  9. 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

  10. 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

  11. Instrument Placement Laparoscope Grasper/suction Forceps, grasper Grasper/suction, scissors Ultrasonic scissors, needle holder

  12. Prostatectomy Procedure • Detach bladder from anterior abdominal wall (D1_:12) • Anterior and lateral dissection of prostate (:16-40) • Divide prostate and bladder neck (D2_:02-08) • Dissection of ductus deferens and seminal vesicles (:12) • Incise Denovillier’s fascia, dissect prostate from rectum (:22)

  13. Prostatectomy Procedure • Carefully dissect neurovascular bundles from lateral prostate (:28) • Hemostasis and division of superficial dorsal vein (:46) • Divide prostate and urethra (:52) • Remove prostate, seminal vesicles, and ductus deferens (:57) • Vesicourethralanastomosis (D3)

  14. Detach Bladder Anterior abdominal wall Bladder Future Retzius’ space

  15. Anterior/Lateral Dissection Location of superficial dorsal vein Pelvic rim Prostate (Inside Retzius’s space)

  16. Superficial Dorsal Vein Superficial dorsal vein Pelvic rim Pelvic floor (levator ani and endopelvic fascia) Prostate Location of nerve bundle

  17. Divide Prostate and Bladder Neck Urinary catheter Superior prostate Bladder neck

  18. Seminal Vesicles/Ductus Deferens Seminal vesicle Location of neurovascular bundle Ductus deferens

  19. Denovillier’s Fascia Seminal vesicle Neurovascular bundle Posterior prostate Rectum (deep to denovillier’s fascia) Denovillier’s fascia

  20. Nerve Sparing Fine dissecting scissors Plexus of nerves Scissors dissect between prostatic capsule and lateral prostatic fascia Neurovascular bundle

  21. Division of Superficial Dorsal Vein Superficial dorsal vein Anterior prostate

  22. Division of Prostate and Urethra Urethra Catheter Prostate

  23. Prostate Removal Pelvic rim Lateral prostate Superior prostate

  24. VesicourethralAnastomosis Urethra Catheter w/ grasper Needle holder Bladder neck Anchor stitch

  25. Time Lapse Anastomosis Urethra Bladder neck

  26. Post-Operative Care • Infection control: • Antibiotics • Drain • Urinary catheter (removed ~7 days post-op) • Blood thinners • Little pain medication necessary

  27. Operative Complications • Infection • Incontinence • Erectile dysfunction • Persistent cancer • Blood clots

  28. 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.htm

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