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LAPAROSCOPIC ANATOMICAL VIEW OF CRUCIAL SURGICAL PASSAGES IN RADICAL PROSTATECTOMY
V7
LAPAROSCOPIC PROSTATIC SURGERY Friday, 28 March, 14.00-15.30, eURO Auditorium
V37
V38
THE INTRAFASCIAL NERVE-SPARING ENDOSCOPIC EXTRA PERITONEAL RADICAL PROSTATECTOMY (NSEERPE)
LAPAROSCOPIC ANATOMICAL VIEW OF CRUCIAL SURGICAL PASSAGES IN RADICAL PROSTATECTOMY
6WRO]HQEXUJ-81, Rabenalt R.1, Do M.1, Schwalenberg T.1, Neuhaus J.1, /LDWVLNRV(12
Gaboardi F., Galli S., Scieri F., Pietrantuono F., Gregori A., Kartalas Goumas I., Stener S., Incarbone G.P.
1 8QLYHUVLW\ RI /HLS]LJ 'HSW RI 8URORJ\ /HLS]LJ *HUPDQ\ 2University of 3DWUDV'HSWRI8URORJ\/HLS]LJ*UHHFH
/6DFFR+RVSLWDO'HSWRI8URORJ\0LODQ,WDO\
Introduction & Objectives: Endoscopic extra peritoneal radical prostatectomy (EERPE) has become the standard surgical approach to RUJDQFRQᚏQHG SURVWDWH FDQFHU LQ RXU FHQWUH ,Q VHOHFWHG SDWLHQWV QHUYH sparing radical prostatectomy is performed with the aims of maintaining sexual function and promoting early recovery of continence after surgery, ZLWKRXWFRPSURPLVLQJWKHᚏQDORQFRORJLFDORXWFRPH Material & Methods: Based on anatomical studies and our experience with QHUYHVSDULQJ ((53( ZH KDYH IXUWKHU UHᚏQHG RXU WHFKQLTXH 7KLV '9' demonstrates our new approach, the intrafascial nerve-sparing EERPE, step by step and aims to demonstrate its feasibility and reproducibility. Results: In contrast to the steps followed for “standard nsEERPE”, during an intrafascial nsEERPE the endopelvic fascia is not incised. Instead, VWDUWLQJ IURP WKH EODGGHU QHFN WKH SHULSURVWDWLF IDVFLD LV VKDUSO\ LQFLVHG on each side ventrally, medial to the puboprostatic ligaments, to develop the plane directly on prostatic capsule. The same plane is developed posteriorly, without incision of Denonvilliers fascia. After dissection of the prostatic pedicles all nerves dorsolaterally and laterally are preserved using clips and cold scissors. Conclusions: 7KH PDLQ JRDO RI WKLV WHFKQLTXH LV WR GHYHORS WKH ULJKW SODQHDQGᚏQDOO\GHWDFKWKHSURVWDWHOHDYLQJLQWDFWDOOODWHUDOHQYHORSLQJ periprostatic fascia (including the endopelvic fascia), the neurovascular structures within and puboprostatic ligaments as a continuous structure.
Introduction & Objectives: $OWKRXJKUDGLFDOSURVWDWHFWRP\LVDFRGLᚏHG RSHUDWLRQ FRPSOLFDWLRQV OLNH EOHHGLQJ LQMXULHV WR DGMDFHQW DQDWRPLFDO VWUXFWXUHVOLNHXUHWHUDQGUHFWXPSRVLWLYHVXUJLFDOPDUJLQVLQFRQWLQHQFH and impotence can occur. The laparoscopic approach gives a privileged intraoperative point of view. This video shows how this surgical anatomical NQRZOHGJHFDQEHKHOSIXOWRDYRLGWKHVHFRPSOLFDWLRQV Material & Methods: In the video we highlighted each critical passage showing the anatomic laparoscopic view, considering possible complications DQG VKRZLQJ WKH FRUUHFW WHFKQLTXH RI GLVVHFWLRQ 7KH VXUJLFDO SDVVDJHV considered were: 1. Dissection of pubo-prostatic ligaments (continence, margins and bleeding) 2. Isolation of the rhabdosphincter from the apex (continence) 3. Santorini plexus haemostatic suture (bleeding, margins, urethral injury) 4. Transection of the apex and of the anterior urethra (continence and margins) 5. Transection of the posterior urethra FRQWLQHQFH PDUJLQV DQG UHFWDO LQMXULHV %ODGGHU QHFN GLVVHFWLRQ (continence and margins) 7. Seminal vesicles dissection (bleeding) 8. Anatomic relationships between seminal vesicles and ureter (ureteral lesions) 9. Section of prostatic pedicles (margins, erectile dysfunction and bleeding) 10. Neurovascular bundle isolation from the lateral aspects of the prostate (erectile dysfunction) Conclusions: 7KHRSWLFDOPDJQLᚏFDWLRQRIODSDURVFRSLFDSSURDFKDOORZV WR YLVXDOL]H YHU\ FOHDUO\ DOO DQDWRPLFDO GHWDLOV XVHIXO WR SUHYHQW PDMRU FRPSOLFDWLRQV0RUHRYHUWKLVNQRZOHGJHDOORZVWRFKRRVHWKHEHVWSODQHV of dissection in order to reduce the incidence of positive margins and to obtain better functional results, whatever surgical approach is used.
V39 SUTURELESS VESICO-URETHRAL ANASTOMOSIS: INTRODUCTION OF A NOVEL DEVICE AND ONE YEAR CLINICAL DATA IN A SINGLE PATIENT Kella N.
V40 LAPAROSCOPIC RADICAL PROSTATECTOMY IN A RENAL ALLOGRAFT RECIPIENT: SURGICAL TECHNIQUE Fournier G.1, Erauso A.1, Rammal A.1, Moal M.C.2, Joulin V.1, Deruelle C.1, Rousseau B.1, Valeri A.1 Brest University Hospital, Dept. of Urology, Brest, France, 2Brest University Hospital, Dept. of Nephrology, Brest, France
Urology San Antonio, Research Department, San Antonio, United States of America
1
Introduction & Objectives: Continuum™ is a new technology designed to automate the vesico-urethral anastomosis procedure, without the need for suturing, after radical prostatectomy. The device, which can be used with open, laparoscopic, or robotic approaches to radical prostatectomy, approximates the bladder and urethral WLVVXHVWRPLQLPL]HH[WUDYDVDWLRQZKLOHVLPXOWDQHRXVO\SURYLGLQJDFRQGXLWIRUWKH drainage of urine from the bladder as the anastomotic site heals. In this video we LQWURGXFHWKHGHYLFHLWVFRPSRQHQWVDQGLQVHUWLRQDQGUHPRYDOWHFKQLTXHV:H DOVREULHᚐ\GLVFXVVRQHRIHLJKWFDVHVSHUIRUPHGZKLFKKDYHKDGRQH\HDUIROORZ up. Continuum™ is an investigational device in the United States and is being VWXGLHGLQFOLQLFDOWULDOV&RQWLQXXPറLVD&(PDUNHGGHYLFHLQWKH(8
Introduction & Objectives: 7R RXU NQRZOHGJH LW LV WKH ᚏUVW YLGHR UHSRUWLQJ /DSDURVFRSLF 5DGLFDO 3URVWDWHFWRP\ /53 LQ D UHQDO DOORJUDIW UHFLSLHQW DQG VKRZLQJWKHVSHFLᚏFIHDWXUHVRIWKHSURFHGXUH
Material & Methods: 7KHGHYLFHLVSODFHGVLPLODUO\WRD)ROH\FDWKHWHUDQGZRUNV EHVW ZKHQ WKH EODGGHU QHFN DSSUR[LPDWHV WKH VL]H RI WKH &RQWLQXXPറ GHYLFH We observe the device in the abdominal cavity and advance the tip through the EODGGHUQHFNLQWRWKHEODGGHU:HWKHQLQᚐDWHWKHEDOORRQWRFF8VLQJWKHFRQWURO handle, we deploy the bladder approximation structures while they are still inside WKHEODGGHU1H[WZHEULQJGRZQWKHEODGGHUQHFNWRDSSRVHWKHXUHWKUDOVWXPS We then deploy the urethral approximation structures using the control handle. $IWHU GHSOR\PHQW ZH SHUIRUP DQ H[WUDYDVDWLRQ FKHFN E\ ᚏOOLQJ WKH EODGGHU ZLWK FFRIVDOLQH:HWKHQLQVSHFWWKHDQDVWRPRWLFVLWHIRUOHDNDJH$IWHUGD\V SHUWKHVWXG\SURWRFRODᚏOOLQJF\VWRJUDPLVFRPSOHWHGWRFKHFNIRUH[WUDYDVDWLRQ All eight patients, including the one shown in this video, demonstrated complete KHDOLQJRIWKHDQDVWRPRVLVDWRQHZHHNDQGWKHGHYLFHZDVUHPRYHG7KLVPLUURUV our conventional anastomosis Foley catheter removal. Conclusions: Continuum™ is a promising new technology to facilitate the vesicoXUHWKUDO DQDVWRPRVLV DIWHU UDGLFDO SURVWDWHFWRP\ 7KH GHYLFH DOORZV D TXLFN UH DQDVWRPRVLV ZLWK WKH SRWHQWLDO IRU IXQFWLRQDO HTXLYDOHQFH WR D VWDQGDUG VXWXUHG anastomosis.
Eur Urol Suppl 2008;7(3):338
Material & Methods: 7KHSDWLHQWZDV\RKDGDNLGQH\WUDQVSODQWLQWKHOHIWLOLDF fossa 8 years ago. Prostate cancer was a cT1c stage, Gleason score 7(3+4), and SUHRS36$QJP/7KHVHUXPFUHDWLQLQHOHYHOZDVPFPROP/3UHRSZRUN XS ZDV QHJDWLYH IRU PHWDVWDVLV &7 DQG ERQH VFDQ 7KH VSHFLᚏF DVSHFWV RI WKH VXUJLFDOWHFKQLTXHDUHUHSRUWHGVWHSE\VWHS Results: :HXVHGDᚏYHSRUWFRQᚏJXUDWLRQ7KHOHIWWURFDUORFDWHGLQWKHLOLDFDUHD was translated medially in order to avoid an injury of the renal transplant. During WKH 5HW]LXV VSDFH DSSURDFK D FDUHIXO GLVVHFWLRQ ZDV QHFHVVDU\ WR LGHQWLI\ WKH neoureter coming from the left pelvic wall and running medially to reach the bladder. Pelvic lymphadenectomy was impossible on the left side due to the presence of the renal allograft and was not performed on the right so as to not compromise a potential second graft in the future. The next steps was performed according to WKHFODVVLFDOWHFKQLTXHLQFOXGLQJHQGRSHOYLFIDVFLDRSHQLQJGRUVDOYHQRXVFRPSOH[ FRQWUROEODGGHUQHFNWUDQVVHFWLRQVHPLQDOYHVLFXOHVGLVVHFWLRQDQGQHXURYDVFXODU EXQGOHV VSDULQJ WHFKQLTXH )LQDOO\ WKH DQDVWRPRVLV ZDV FDUULHG RXW XVLQJ interrupted stiches. The post op follow up was uneventful. The serum creatinine was unchanged. The patient was discharged at day 7 and the Foley catheter was OHIWLQSODFHGXULQJZHHNV GD\VLQQRQWUDQVSODQWSDWLHQW GXHWRDXULQDU\WUDFW infection and was removed after cystography. Pathological report concluded: pT2a, QHJDWLYHVPDUJLQV*OHDVRQVFRUH $WPRQWKV36$ZDV QJP/WKH patient was continent and had not recovered erectile function. Conclusions: /53 LQ D UHQDO WUDQVSODQW SDWLHQW LV IHDVLEOH EXW VOLJKW WHFKQLFDO PRGLᚏFDWLRQVDUHUHTXLUHGLQRUGHUWRDYRLGDQLQMXU\RIWKHNLGQH\JUDIWRURIWKH ureter.
LAPAROSCOPIC PROSTATIC SURGERY Friday, 28 March, 14.00-15.30, eURO Auditorium
V37
V38
THE INTRAFASCIAL NERVE-SPARING ENDOSCOPIC EXTRA PERITONEAL RADICAL PROSTATECTOMY (NSEERPE)
LAPAROSCOPIC ANATOMICAL VIEW OF CRUCIAL SURGICAL PASSAGES IN RADICAL PROSTATECTOMY
6WRO]HQEXUJ-81, Rabenalt R.1, Do M.1, Schwalenberg T.1, Neuhaus J.1, /LDWVLNRV(12
Gaboardi F., Galli S., Scieri F., Pietrantuono F., Gregori A., Kartalas Goumas I., Stener S., Incarbone G.P.
1 8QLYHUVLW\ RI /HLS]LJ 'HSW RI 8URORJ\ /HLS]LJ *HUPDQ\ 2University of 3DWUDV'HSWRI8URORJ\/HLS]LJ*UHHFH
/6DFFR+RVSLWDO'HSWRI8URORJ\0LODQ,WDO\
Introduction & Objectives: Endoscopic extra peritoneal radical prostatectomy (EERPE) has become the standard surgical approach to RUJDQFRQᚏQHG SURVWDWH FDQFHU LQ RXU FHQWUH ,Q VHOHFWHG SDWLHQWV QHUYH sparing radical prostatectomy is performed with the aims of maintaining sexual function and promoting early recovery of continence after surgery, ZLWKRXWFRPSURPLVLQJWKHᚏQDORQFRORJLFDORXWFRPH Material & Methods: Based on anatomical studies and our experience with QHUYHVSDULQJ ((53( ZH KDYH IXUWKHU UHᚏQHG RXU WHFKQLTXH 7KLV '9' demonstrates our new approach, the intrafascial nerve-sparing EERPE, step by step and aims to demonstrate its feasibility and reproducibility. Results: In contrast to the steps followed for “standard nsEERPE”, during an intrafascial nsEERPE the endopelvic fascia is not incised. Instead, VWDUWLQJ IURP WKH EODGGHU QHFN WKH SHULSURVWDWLF IDVFLD LV VKDUSO\ LQFLVHG on each side ventrally, medial to the puboprostatic ligaments, to develop the plane directly on prostatic capsule. The same plane is developed posteriorly, without incision of Denonvilliers fascia. After dissection of the prostatic pedicles all nerves dorsolaterally and laterally are preserved using clips and cold scissors. Conclusions: 7KH PDLQ JRDO RI WKLV WHFKQLTXH LV WR GHYHORS WKH ULJKW SODQHDQGᚏQDOO\GHWDFKWKHSURVWDWHOHDYLQJLQWDFWDOOODWHUDOHQYHORSLQJ periprostatic fascia (including the endopelvic fascia), the neurovascular structures within and puboprostatic ligaments as a continuous structure.
Introduction & Objectives: $OWKRXJKUDGLFDOSURVWDWHFWRP\LVDFRGLᚏHG RSHUDWLRQ FRPSOLFDWLRQV OLNH EOHHGLQJ LQMXULHV WR DGMDFHQW DQDWRPLFDO VWUXFWXUHVOLNHXUHWHUDQGUHFWXPSRVLWLYHVXUJLFDOPDUJLQVLQFRQWLQHQFH and impotence can occur. The laparoscopic approach gives a privileged intraoperative point of view. This video shows how this surgical anatomical NQRZOHGJHFDQEHKHOSIXOWRDYRLGWKHVHFRPSOLFDWLRQV Material & Methods: In the video we highlighted each critical passage showing the anatomic laparoscopic view, considering possible complications DQG VKRZLQJ WKH FRUUHFW WHFKQLTXH RI GLVVHFWLRQ 7KH VXUJLFDO SDVVDJHV considered were: 1. Dissection of pubo-prostatic ligaments (continence, margins and bleeding) 2. Isolation of the rhabdosphincter from the apex (continence) 3. Santorini plexus haemostatic suture (bleeding, margins, urethral injury) 4. Transection of the apex and of the anterior urethra (continence and margins) 5. Transection of the posterior urethra FRQWLQHQFH PDUJLQV DQG UHFWDO LQMXULHV %ODGGHU QHFN GLVVHFWLRQ (continence and margins) 7. Seminal vesicles dissection (bleeding) 8. Anatomic relationships between seminal vesicles and ureter (ureteral lesions) 9. Section of prostatic pedicles (margins, erectile dysfunction and bleeding) 10. Neurovascular bundle isolation from the lateral aspects of the prostate (erectile dysfunction) Conclusions: 7KHRSWLFDOPDJQLᚏFDWLRQRIODSDURVFRSLFDSSURDFKDOORZV WR YLVXDOL]H YHU\ FOHDUO\ DOO DQDWRPLFDO GHWDLOV XVHIXO WR SUHYHQW PDMRU FRPSOLFDWLRQV0RUHRYHUWKLVNQRZOHGJHDOORZVWRFKRRVHWKHEHVWSODQHV of dissection in order to reduce the incidence of positive margins and to obtain better functional results, whatever surgical approach is used.
V39 SUTURELESS VESICO-URETHRAL ANASTOMOSIS: INTRODUCTION OF A NOVEL DEVICE AND ONE YEAR CLINICAL DATA IN A SINGLE PATIENT Kella N.
V40 LAPAROSCOPIC RADICAL PROSTATECTOMY IN A RENAL ALLOGRAFT RECIPIENT: SURGICAL TECHNIQUE Fournier G.1, Erauso A.1, Rammal A.1, Moal M.C.2, Joulin V.1, Deruelle C.1, Rousseau B.1, Valeri A.1 Brest University Hospital, Dept. of Urology, Brest, France, 2Brest University Hospital, Dept. of Nephrology, Brest, France
Urology San Antonio, Research Department, San Antonio, United States of America
1
Introduction & Objectives: Continuum™ is a new technology designed to automate the vesico-urethral anastomosis procedure, without the need for suturing, after radical prostatectomy. The device, which can be used with open, laparoscopic, or robotic approaches to radical prostatectomy, approximates the bladder and urethral WLVVXHVWRPLQLPL]HH[WUDYDVDWLRQZKLOHVLPXOWDQHRXVO\SURYLGLQJDFRQGXLWIRUWKH drainage of urine from the bladder as the anastomotic site heals. In this video we LQWURGXFHWKHGHYLFHLWVFRPSRQHQWVDQGLQVHUWLRQDQGUHPRYDOWHFKQLTXHV:H DOVREULHᚐ\GLVFXVVRQHRIHLJKWFDVHVSHUIRUPHGZKLFKKDYHKDGRQH\HDUIROORZ up. Continuum™ is an investigational device in the United States and is being VWXGLHGLQFOLQLFDOWULDOV&RQWLQXXPറLVD&(PDUNHGGHYLFHLQWKH(8
Introduction & Objectives: 7R RXU NQRZOHGJH LW LV WKH ᚏUVW YLGHR UHSRUWLQJ /DSDURVFRSLF 5DGLFDO 3URVWDWHFWRP\ /53 LQ D UHQDO DOORJUDIW UHFLSLHQW DQG VKRZLQJWKHVSHFLᚏFIHDWXUHVRIWKHSURFHGXUH
Material & Methods: 7KHGHYLFHLVSODFHGVLPLODUO\WRD)ROH\FDWKHWHUDQGZRUNV EHVW ZKHQ WKH EODGGHU QHFN DSSUR[LPDWHV WKH VL]H RI WKH &RQWLQXXPറ GHYLFH We observe the device in the abdominal cavity and advance the tip through the EODGGHUQHFNLQWRWKHEODGGHU:HWKHQLQᚐDWHWKHEDOORRQWRFF8VLQJWKHFRQWURO handle, we deploy the bladder approximation structures while they are still inside WKHEODGGHU1H[WZHEULQJGRZQWKHEODGGHUQHFNWRDSSRVHWKHXUHWKUDOVWXPS We then deploy the urethral approximation structures using the control handle. $IWHU GHSOR\PHQW ZH SHUIRUP DQ H[WUDYDVDWLRQ FKHFN E\ ᚏOOLQJ WKH EODGGHU ZLWK FFRIVDOLQH:HWKHQLQVSHFWWKHDQDVWRPRWLFVLWHIRUOHDNDJH$IWHUGD\V SHUWKHVWXG\SURWRFRODᚏOOLQJF\VWRJUDPLVFRPSOHWHGWRFKHFNIRUH[WUDYDVDWLRQ All eight patients, including the one shown in this video, demonstrated complete KHDOLQJRIWKHDQDVWRPRVLVDWRQHZHHNDQGWKHGHYLFHZDVUHPRYHG7KLVPLUURUV our conventional anastomosis Foley catheter removal. Conclusions: Continuum™ is a promising new technology to facilitate the vesicoXUHWKUDO DQDVWRPRVLV DIWHU UDGLFDO SURVWDWHFWRP\ 7KH GHYLFH DOORZV D TXLFN UH DQDVWRPRVLV ZLWK WKH SRWHQWLDO IRU IXQFWLRQDO HTXLYDOHQFH WR D VWDQGDUG VXWXUHG anastomosis.
Eur Urol Suppl 2008;7(3):338
Material & Methods: 7KHSDWLHQWZDV\RKDGDNLGQH\WUDQVSODQWLQWKHOHIWLOLDF fossa 8 years ago. Prostate cancer was a cT1c stage, Gleason score 7(3+4), and SUHRS36$QJP/7KHVHUXPFUHDWLQLQHOHYHOZDVPFPROP/3UHRSZRUN XS ZDV QHJDWLYH IRU PHWDVWDVLV &7 DQG ERQH VFDQ 7KH VSHFLᚏF DVSHFWV RI WKH VXUJLFDOWHFKQLTXHDUHUHSRUWHGVWHSE\VWHS Results: :HXVHGDᚏYHSRUWFRQᚏJXUDWLRQ7KHOHIWWURFDUORFDWHGLQWKHLOLDFDUHD was translated medially in order to avoid an injury of the renal transplant. During WKH 5HW]LXV VSDFH DSSURDFK D FDUHIXO GLVVHFWLRQ ZDV QHFHVVDU\ WR LGHQWLI\ WKH neoureter coming from the left pelvic wall and running medially to reach the bladder. Pelvic lymphadenectomy was impossible on the left side due to the presence of the renal allograft and was not performed on the right so as to not compromise a potential second graft in the future. The next steps was performed according to WKHFODVVLFDOWHFKQLTXHLQFOXGLQJHQGRSHOYLFIDVFLDRSHQLQJGRUVDOYHQRXVFRPSOH[ FRQWUROEODGGHUQHFNWUDQVVHFWLRQVHPLQDOYHVLFXOHVGLVVHFWLRQDQGQHXURYDVFXODU EXQGOHV VSDULQJ WHFKQLTXH )LQDOO\ WKH DQDVWRPRVLV ZDV FDUULHG RXW XVLQJ interrupted stiches. The post op follow up was uneventful. The serum creatinine was unchanged. The patient was discharged at day 7 and the Foley catheter was OHIWLQSODFHGXULQJZHHNV GD\VLQQRQWUDQVSODQWSDWLHQW GXHWRDXULQDU\WUDFW infection and was removed after cystography. Pathological report concluded: pT2a, QHJDWLYHVPDUJLQV*OHDVRQVFRUH $WPRQWKV36$ZDV QJP/WKH patient was continent and had not recovered erectile function. Conclusions: /53 LQ D UHQDO WUDQVSODQW SDWLHQW LV IHDVLEOH EXW VOLJKW WHFKQLFDO PRGLᚏFDWLRQVDUHUHTXLUHGLQRUGHUWRDYRLGDQLQMXU\RIWKHNLGQH\JUDIWRURIWKH ureter.