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Laparoscopic prostatectomy1
SURGEON AT WORK
Laparoscopic Prostatectomy Robert N Cacchione, MD, Anil Mungara, MD, Stanley DeTurris, MD, Michael Savino, MD, George S Ferzli, MD, FACS sutures. If needed, one or both may be enlarged to accommodate 10-mm instruments. The most lateral ports are 5 mm and are placed just medial to the anterior superior iliac spines. These are used to introduce operating instruments, retractors, and the suction-irrigation cannula. After placement of the operating ports, the operation proceeds in six stages: dissection of the seminal vesicles, posterior dissection of the prostate, anterior dissection of the prostate, lateral mobilization of the prostate, excision of the prostate, and then creation of the vesico-urethral anastomosis.
Within the last decade we have witnessed a greatly expanded role for laparoscopy in many areas, including the management of urologic problems. These include kidney biopsy,1 nephrectomy,2 partial nephrectomy,3 management of renal cysts,4 pyeloplasty,5 ureterolithotomy,6 ureterolysis,7 ligation of varices,8 management of undescended testes,9 bladder neck suspension,10 and pelvic lymph node dissection.11 It was only a matter of time before laparoscopy would be applied to prostatectomy. We describe here our approach to this technically demanding operation. TECHNIQUE Room arrangements and patient position
Dissection of the seminal vesicles
The seminal vesicles are located posterior to the bladder and are covered by peritoneum. This peritoneum is opened over the vasa deferentia and both vasa are divided. The sigmoid colon, if it is particularly redundant, can be cumbersome during this portion of the operation. We often use an atraumatic grasper to retract the sigmoid colon in a cephalad direction to move it out of the pelvis. The vasa deferentia are then dissected medially and inferiorly toward the seminal vesicles. Care must be taken during this first portion of the procedure to avoid injury to the ureters, which pass posteriorly and inferiorly to the vasa deferentia as they enter the posterior bladder (Fig. 3). Although monopolar or bipolar electrocautery can be used to perform this step, it has been our practice to use an ultrasonic dissecting instrument. After the distal vasa deferentia and seminal vesicles are completely dissected from the posterior bladder, the posterior liberation of the prostate begins.
The anesthesiologist and anesthesia machine are stationed at the head of the operating table during the entire procedure, with the monitor at the foot of the table. The surgeon and assistant stand opposite each other at either side of the patient. The patient is positioned supine on the operating table with both arms well-padded and tucked securely at his sides. He is positioned so that the break in the operating table falls between the umbilicus and the anterior superior iliac spine. The table can then be flexed to open a view of the pelvis (Fig. 1). The area to be exposed extends from the xyphoid process to the upper thigh and should be shaved and prepared appropriately. Port placement
The operation proceeds using five operating ports. These are placed in a horizontal line at the level of the umbilicus (Fig. 2). The umbilical port is 10 mm in size. A 10-mm, zero-degree laparoscope is inserted at this site and remains there through most of the procedure. Two 5-mm ports are placed along the lateral rectus borders. These are used to introduce operating instruments and
Posterior dissection of the prostate
The seminal vesicles lead directly to the prostate in the midline superiorly. The dissection continues posteriorly and inferiorly through Denonvilliers’ fascia, separating the prostate anteriorly from the rectum posteriorly. We perform this portion of the dissection bluntly keeping just anterior to the thin layer of adipose tissue over the rectum. Once the urogenital diaphragm is reached the dissection proceeds laterally and anteriorly. The cavern-
No competing interests declared.
Received February 28, 2001; Revised June 4, 2001; Accepted June 8, 2001. From the Department of Laparoscopic Surgery, Staten Island University Hospital, Staten Island, NY. Correspondence address: George S Ferzli, MD, FACS, 78 Cromwell Ave, Staten Island, NY 10304.
© 2001 by the American College of Surgeons Published by Elsevier Science Inc.
454
ISSN 1072-7515/01/$21.00 PII S1072-7515(01)01022-5
Vol. 193, No. 4, October 2001
Cacchione et al
Laparoscopic Prostatectomy
455
Figure 1. The patient is positioned supine with his arms at his sides. The table can be flexed to open the view to the pelvis.
ous nerves are located just lateral to the prostate and are encountered for the first time during this part of the dissection. Care is taken to avoid injury to the nerves, and the use of bipolar electrocautery on a fine-tipped instrument, or the ultrasonic dissector, is desirable. It is important to continue the dissection inferiorly all the way to the urogenital diaphragm because it makes the anterior dissection easier.
the pubis are identified. Much of the fat is removed from the anterior surface of the bladder. This will help to better visualize the junction between the bladder neck and the prostate. The anterior dissection continues beyond the pubic symphysis to the prostatic apex. Initially we would proceed with ligation and division of the dorsal vein plexus at this point. We now find it easier to proceed instead with the lateral mobilization of the prostate, saving the ligation of the veins for later.
Anterior dissection
The peritoneum is opened anteriorly between the dome of the bladder and the pubic symphysis. This space of Retzius is opened bluntly. The pubic symphysis is cleared and Cooper’s ligaments and the superior rami of
Figure 2. Trocar placement.
Lateral mobilization
At this stage the endopelvic fascia is incised and additional dissection along the lateral margin of the prostate is performed. We use the ultrasonic dissector or sometimes the bipolar electrocautery with fine tips in this area. The lateral dissection of the bladder and prostate then leads to the second view of the cavernous nerves, this time from the anterior aspect (Fig. 4). We will attempt to avoid injury to the nerves because we favor a nerve-sparing approach. If it appears that the tumor in-
Figure 3. Posterior anatomy showing seminal vesicles, vasa deferentia, and ureters.
456
Cacchione et al
Laparoscopic Prostatectomy
J Am Coll Surg
Figure 5. The anastomosis.
Figure 4. Anterior anatomy showing the lateral bundles and dorsal vein.
vades the lateral bundles, they may not be spared if complete tumor excision is to be achieved. Excision of the prostate
Once the prostate is free laterally, we separate the prostate from the bladder at the bladder neck. The balloon of the Foley catheter can be inflated to 30 mL, which may further improve visualization of the bladder-prostate junction. The bladder neck is opened, the catheter is removed, and the division is completed. If the bladder neck is opened too far from the junction between bladder and prostate, injury to the ureteral orifices on the posterior aspect of the bladder can occur. We now routinely administer indigo carmine during the procedure to assist in the identification of the ureteral orifices. The seminal vesicles are delivered anteriorly through the space between the bladder and the prostate. By placing anterior and cephalad traction on the seminal vesicles and prostate, any remaining tissue between the prostate and the neurovascular bundles can be easily seen and divided. The neurovascular bundles fall away from the
prostate posteriorly and laterally as the anterior and cephalad traction is maintained on the seminal vesicles and prostate. All that remains is the division of the dorsal veins and the urethra. The prostate is suspended from the urethra like an apple on its branch. The dorsal vein at this stage can be managed easily by suture ligation or by coagulation with the ultrasonic dissector. The urethra is finally transected at the prostatic apex. The prostate and attached seminal vesicles are placed in a retrieval bag. The anastomosis is created after the specimen is moved out of the pelvis. The anastomosis
The final goal is to connect the bladder neck to the urethra. Although some authors advocate a running suture, we accomplish the task by careful placement of 6 to 12 interrupted sutures, using absorbable 2-0 or 3-0 polyglactin suture material on a 1/2-curve 36-mm tapered needle. It may be necessary to narrow the opening of the bladder neck if there is a mismatch in size between it and the urethra. This is also done using absorbable sutures, in either a running or interrupted fashion. Sutures for the anastomosis are planned so that the posterior ones are placed first and so that the knots are tied on the outside of the bladder (Fig. 5). The stitches for the anas-
Vol. 193, No. 4, October 2001
tomosis are some of the most challenging and technically demanding sutures to place. Frequently, backhanded suturing is required, especially in a patient whose pelvis is particularly narrow. Just before the final two sutures are placed, a large-bore Foley catheter with a 30-mL balloon is placed through the anastomosis into the bladder. Once this process is completed a soft closed suction drain is placed through one of the lateral ports and directed near the suture line. Finally, inflating the bladder with saline tests the anastomosis for potential leaking points. The operating ports are removed and all ports 1 cm or larger are closed with suture at the fascial level. Postoperative care
The nasogastric tube is removed in the recovery room after postoperative nausea has subsided. A normal diet is resumed on the first postoperative day. Patients are encouraged to sit in a chair on the night of the operation and to ambulate on the first postoperative day. Most patients are ready for discharge from the hospital by the third postoperative day; the Foley catheter is left in place for 5 to 7 days. RESULTS We have attempted a number of different techniques including a totally extraperitoneal approach to accomplish this operation.12 We have completed the operation in the sequence described here using the same operating team in 12 patients during the last year. They ranged in age from 48 to 62 years. The average PSA level in this group of patients was 6.8 ng/mL (range 5.1 to 9.8 ng/ mL), and all 12 patients had a Gleason score of 6. As Guillonneau and Vallancien13 have reported, we have found that a methodical approach has done much to reduce our operative time. We now can complete the procedure in less than 200 minutes (range 120 to 315 minutes). All 12 operations were completed laparoscopically. With followup ranging up to 1 year (mean followup is 6 months), we have had no patients with permanent incontinence, although some have had to wear pads for a short time. Some of our patients were not potent before the operation, but of those that were potent, some are able to have sensations, soft erections, and intercourse. It
Cacchione et al
Laparoscopic Prostatectomy
457
is too early in our experience to accurately report on potency. Complications we have seen include bladder spasm, bladder neck stricture, postoperative ileus, and bleeding from a trocar site. Other reported complications from laparoscopic prostatectomy include rectal injury, obturator nerve injury, anastomotic leak, acute retention, and urinary tract infection.14,15 Because laparoscopic prostatectomy is becoming more widely recognized as a safe alternative procedure to open prostatectomy, we believe that a standardized, reproducible sequence is necessary. Our approach has evolved into the steps described here to complete this technically demanding operation. REFERENCES 1. Healey D, Newman R, Choen M, et al. Laparoscopically assisted percutaneous renal biopsy. J Urol 1993;150:1218–1221. 2. Kavoussi L, Kerbl K, Capelouto C, et al. Laparoscopic nephrectomy for renal neoplasms. Urology 1993;42:603–609. 3. Winfield H, Donovan J, Godet A, et al. Laparoscopic partial nephrectomy: initial case report for benign disease. J Endourol 1993;7:521–526. 4. Rubenstein S, Hulbert J, Pharand D, et al. Laparoscopic ablation of symptomatic renal cysts. J Urol 1993;150:1103–1106. 5. Schuessler W, Grune M, Tecuanhuey L, et al. Laparoscopic dismembered pyeloplasty. J Urol 1993;150:1795–1799. 6. Raboy A, Ferzli G, Ioffreda R, et al. Laparoscopic ureterolithotomy. Urology 1992;39:223–225. 7. Kavoussi L, Clayman R, Brunt L, et al. Laparoscopic ureterolysis. J Urol 1992;147:426–429. 8. Donovan J, Winfield H. Laparoscopic varix ligation. J Urol 1992;147:77–81. 9. Lowe D, Brock W, Kaplan G. Laparoscopy for localization of nonpalpable testes. J Urol 1984;131:728–729. 10. Albala D, Schuessler W, Vancaille T. Laparoscopic bladder suspension for the treatment of stress incontinence. Semin Urol 1992;10:222–226. 11. Ferzli G, Trapasso J, Raboy A, et al. Extraperitoneal endoscopic pelvic lymph node dissection. J Laparoendosc Surg 1992;2:39– 44. 12. Raboy A, Ferzli G, Albert P. Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy. Urology 1997;50:849–853. 13. Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris technique. J Urol 2000;163:1643–1649. 14. Abbou C, Salomon L, Hoznek A, et al. Laparoscopic radical prostatectomy: preliminary results. Urology 2000;55:630–634. 15. Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris experience. J Urol 2000;163:418–422.
Laparoscopic Prostatectomy Robert N Cacchione, MD, Anil Mungara, MD, Stanley DeTurris, MD, Michael Savino, MD, George S Ferzli, MD, FACS sutures. If needed, one or both may be enlarged to accommodate 10-mm instruments. The most lateral ports are 5 mm and are placed just medial to the anterior superior iliac spines. These are used to introduce operating instruments, retractors, and the suction-irrigation cannula. After placement of the operating ports, the operation proceeds in six stages: dissection of the seminal vesicles, posterior dissection of the prostate, anterior dissection of the prostate, lateral mobilization of the prostate, excision of the prostate, and then creation of the vesico-urethral anastomosis.
Within the last decade we have witnessed a greatly expanded role for laparoscopy in many areas, including the management of urologic problems. These include kidney biopsy,1 nephrectomy,2 partial nephrectomy,3 management of renal cysts,4 pyeloplasty,5 ureterolithotomy,6 ureterolysis,7 ligation of varices,8 management of undescended testes,9 bladder neck suspension,10 and pelvic lymph node dissection.11 It was only a matter of time before laparoscopy would be applied to prostatectomy. We describe here our approach to this technically demanding operation. TECHNIQUE Room arrangements and patient position
Dissection of the seminal vesicles
The seminal vesicles are located posterior to the bladder and are covered by peritoneum. This peritoneum is opened over the vasa deferentia and both vasa are divided. The sigmoid colon, if it is particularly redundant, can be cumbersome during this portion of the operation. We often use an atraumatic grasper to retract the sigmoid colon in a cephalad direction to move it out of the pelvis. The vasa deferentia are then dissected medially and inferiorly toward the seminal vesicles. Care must be taken during this first portion of the procedure to avoid injury to the ureters, which pass posteriorly and inferiorly to the vasa deferentia as they enter the posterior bladder (Fig. 3). Although monopolar or bipolar electrocautery can be used to perform this step, it has been our practice to use an ultrasonic dissecting instrument. After the distal vasa deferentia and seminal vesicles are completely dissected from the posterior bladder, the posterior liberation of the prostate begins.
The anesthesiologist and anesthesia machine are stationed at the head of the operating table during the entire procedure, with the monitor at the foot of the table. The surgeon and assistant stand opposite each other at either side of the patient. The patient is positioned supine on the operating table with both arms well-padded and tucked securely at his sides. He is positioned so that the break in the operating table falls between the umbilicus and the anterior superior iliac spine. The table can then be flexed to open a view of the pelvis (Fig. 1). The area to be exposed extends from the xyphoid process to the upper thigh and should be shaved and prepared appropriately. Port placement
The operation proceeds using five operating ports. These are placed in a horizontal line at the level of the umbilicus (Fig. 2). The umbilical port is 10 mm in size. A 10-mm, zero-degree laparoscope is inserted at this site and remains there through most of the procedure. Two 5-mm ports are placed along the lateral rectus borders. These are used to introduce operating instruments and
Posterior dissection of the prostate
The seminal vesicles lead directly to the prostate in the midline superiorly. The dissection continues posteriorly and inferiorly through Denonvilliers’ fascia, separating the prostate anteriorly from the rectum posteriorly. We perform this portion of the dissection bluntly keeping just anterior to the thin layer of adipose tissue over the rectum. Once the urogenital diaphragm is reached the dissection proceeds laterally and anteriorly. The cavern-
No competing interests declared.
Received February 28, 2001; Revised June 4, 2001; Accepted June 8, 2001. From the Department of Laparoscopic Surgery, Staten Island University Hospital, Staten Island, NY. Correspondence address: George S Ferzli, MD, FACS, 78 Cromwell Ave, Staten Island, NY 10304.
© 2001 by the American College of Surgeons Published by Elsevier Science Inc.
454
ISSN 1072-7515/01/$21.00 PII S1072-7515(01)01022-5
Vol. 193, No. 4, October 2001
Cacchione et al
Laparoscopic Prostatectomy
455
Figure 1. The patient is positioned supine with his arms at his sides. The table can be flexed to open the view to the pelvis.
ous nerves are located just lateral to the prostate and are encountered for the first time during this part of the dissection. Care is taken to avoid injury to the nerves, and the use of bipolar electrocautery on a fine-tipped instrument, or the ultrasonic dissector, is desirable. It is important to continue the dissection inferiorly all the way to the urogenital diaphragm because it makes the anterior dissection easier.
the pubis are identified. Much of the fat is removed from the anterior surface of the bladder. This will help to better visualize the junction between the bladder neck and the prostate. The anterior dissection continues beyond the pubic symphysis to the prostatic apex. Initially we would proceed with ligation and division of the dorsal vein plexus at this point. We now find it easier to proceed instead with the lateral mobilization of the prostate, saving the ligation of the veins for later.
Anterior dissection
The peritoneum is opened anteriorly between the dome of the bladder and the pubic symphysis. This space of Retzius is opened bluntly. The pubic symphysis is cleared and Cooper’s ligaments and the superior rami of
Figure 2. Trocar placement.
Lateral mobilization
At this stage the endopelvic fascia is incised and additional dissection along the lateral margin of the prostate is performed. We use the ultrasonic dissector or sometimes the bipolar electrocautery with fine tips in this area. The lateral dissection of the bladder and prostate then leads to the second view of the cavernous nerves, this time from the anterior aspect (Fig. 4). We will attempt to avoid injury to the nerves because we favor a nerve-sparing approach. If it appears that the tumor in-
Figure 3. Posterior anatomy showing seminal vesicles, vasa deferentia, and ureters.
456
Cacchione et al
Laparoscopic Prostatectomy
J Am Coll Surg
Figure 5. The anastomosis.
Figure 4. Anterior anatomy showing the lateral bundles and dorsal vein.
vades the lateral bundles, they may not be spared if complete tumor excision is to be achieved. Excision of the prostate
Once the prostate is free laterally, we separate the prostate from the bladder at the bladder neck. The balloon of the Foley catheter can be inflated to 30 mL, which may further improve visualization of the bladder-prostate junction. The bladder neck is opened, the catheter is removed, and the division is completed. If the bladder neck is opened too far from the junction between bladder and prostate, injury to the ureteral orifices on the posterior aspect of the bladder can occur. We now routinely administer indigo carmine during the procedure to assist in the identification of the ureteral orifices. The seminal vesicles are delivered anteriorly through the space between the bladder and the prostate. By placing anterior and cephalad traction on the seminal vesicles and prostate, any remaining tissue between the prostate and the neurovascular bundles can be easily seen and divided. The neurovascular bundles fall away from the
prostate posteriorly and laterally as the anterior and cephalad traction is maintained on the seminal vesicles and prostate. All that remains is the division of the dorsal veins and the urethra. The prostate is suspended from the urethra like an apple on its branch. The dorsal vein at this stage can be managed easily by suture ligation or by coagulation with the ultrasonic dissector. The urethra is finally transected at the prostatic apex. The prostate and attached seminal vesicles are placed in a retrieval bag. The anastomosis is created after the specimen is moved out of the pelvis. The anastomosis
The final goal is to connect the bladder neck to the urethra. Although some authors advocate a running suture, we accomplish the task by careful placement of 6 to 12 interrupted sutures, using absorbable 2-0 or 3-0 polyglactin suture material on a 1/2-curve 36-mm tapered needle. It may be necessary to narrow the opening of the bladder neck if there is a mismatch in size between it and the urethra. This is also done using absorbable sutures, in either a running or interrupted fashion. Sutures for the anastomosis are planned so that the posterior ones are placed first and so that the knots are tied on the outside of the bladder (Fig. 5). The stitches for the anas-
Vol. 193, No. 4, October 2001
tomosis are some of the most challenging and technically demanding sutures to place. Frequently, backhanded suturing is required, especially in a patient whose pelvis is particularly narrow. Just before the final two sutures are placed, a large-bore Foley catheter with a 30-mL balloon is placed through the anastomosis into the bladder. Once this process is completed a soft closed suction drain is placed through one of the lateral ports and directed near the suture line. Finally, inflating the bladder with saline tests the anastomosis for potential leaking points. The operating ports are removed and all ports 1 cm or larger are closed with suture at the fascial level. Postoperative care
The nasogastric tube is removed in the recovery room after postoperative nausea has subsided. A normal diet is resumed on the first postoperative day. Patients are encouraged to sit in a chair on the night of the operation and to ambulate on the first postoperative day. Most patients are ready for discharge from the hospital by the third postoperative day; the Foley catheter is left in place for 5 to 7 days. RESULTS We have attempted a number of different techniques including a totally extraperitoneal approach to accomplish this operation.12 We have completed the operation in the sequence described here using the same operating team in 12 patients during the last year. They ranged in age from 48 to 62 years. The average PSA level in this group of patients was 6.8 ng/mL (range 5.1 to 9.8 ng/ mL), and all 12 patients had a Gleason score of 6. As Guillonneau and Vallancien13 have reported, we have found that a methodical approach has done much to reduce our operative time. We now can complete the procedure in less than 200 minutes (range 120 to 315 minutes). All 12 operations were completed laparoscopically. With followup ranging up to 1 year (mean followup is 6 months), we have had no patients with permanent incontinence, although some have had to wear pads for a short time. Some of our patients were not potent before the operation, but of those that were potent, some are able to have sensations, soft erections, and intercourse. It
Cacchione et al
Laparoscopic Prostatectomy
457
is too early in our experience to accurately report on potency. Complications we have seen include bladder spasm, bladder neck stricture, postoperative ileus, and bleeding from a trocar site. Other reported complications from laparoscopic prostatectomy include rectal injury, obturator nerve injury, anastomotic leak, acute retention, and urinary tract infection.14,15 Because laparoscopic prostatectomy is becoming more widely recognized as a safe alternative procedure to open prostatectomy, we believe that a standardized, reproducible sequence is necessary. Our approach has evolved into the steps described here to complete this technically demanding operation. REFERENCES 1. Healey D, Newman R, Choen M, et al. Laparoscopically assisted percutaneous renal biopsy. J Urol 1993;150:1218–1221. 2. Kavoussi L, Kerbl K, Capelouto C, et al. Laparoscopic nephrectomy for renal neoplasms. Urology 1993;42:603–609. 3. Winfield H, Donovan J, Godet A, et al. Laparoscopic partial nephrectomy: initial case report for benign disease. J Endourol 1993;7:521–526. 4. Rubenstein S, Hulbert J, Pharand D, et al. Laparoscopic ablation of symptomatic renal cysts. J Urol 1993;150:1103–1106. 5. Schuessler W, Grune M, Tecuanhuey L, et al. Laparoscopic dismembered pyeloplasty. J Urol 1993;150:1795–1799. 6. Raboy A, Ferzli G, Ioffreda R, et al. Laparoscopic ureterolithotomy. Urology 1992;39:223–225. 7. Kavoussi L, Clayman R, Brunt L, et al. Laparoscopic ureterolysis. J Urol 1992;147:426–429. 8. Donovan J, Winfield H. Laparoscopic varix ligation. J Urol 1992;147:77–81. 9. Lowe D, Brock W, Kaplan G. Laparoscopy for localization of nonpalpable testes. J Urol 1984;131:728–729. 10. Albala D, Schuessler W, Vancaille T. Laparoscopic bladder suspension for the treatment of stress incontinence. Semin Urol 1992;10:222–226. 11. Ferzli G, Trapasso J, Raboy A, et al. Extraperitoneal endoscopic pelvic lymph node dissection. J Laparoendosc Surg 1992;2:39– 44. 12. Raboy A, Ferzli G, Albert P. Initial experience with extraperitoneal endoscopic radical retropubic prostatectomy. Urology 1997;50:849–853. 13. Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris technique. J Urol 2000;163:1643–1649. 14. Abbou C, Salomon L, Hoznek A, et al. Laparoscopic radical prostatectomy: preliminary results. Urology 2000;55:630–634. 15. Guillonneau B, Vallancien G. Laparoscopic radical prostatectomy: the Montsouris experience. J Urol 2000;163:418–422.