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VIDEO LAPARORADICAL CYSTECTOMY IN FEMALE
V5
V6
DESCRIPTION OF THE SURGICAL ANATOMY OF THE FASCIAS SURROUNDING THE PROSTATE DURING LAPAROSCOPIC RADICAL PROSTATECTOMY
HOW TO PREVENT IATROGENIC CAPSULAR INCISION DURING LAPAROSCOPIC NERVE-SPARING RADICAL PROSTATECTOMY
Fournier G.H.1, Valeri A.1, Rammal A.1, Joulin V.1, John D.1, Taccoen X.1, Deruelle C.1, Doucet L.2, Volant A.2, Cussenot O.3 1
2
University Hospital of Brest, Urology, Brest, France, University Hospital of Brest, Pathology, Brest, France, 3University Hospital Tenon, Urology, Paris, France INTRODUCTION & OBJECTIVES: Knowledge of surgical anatomy of the periprostatic fascias is essential when performing radical prostatectomy and already described previously for open procedures. The view of the operative field is different when performing the procedure via a laparoscopic approach due to the magnification and the oblique view with an angle of 45°. To describe the surgical anatomy of the fascias surrounding the prostate and clearly visible during a laparoscopic transperitoneal approach. MATERIAL & METHODS: Transperitoneal approach. RESULTS: The endopelvic fascia is first opened laterally after entering the retzius space. The two layers of this fascia can be differentiated (i.e. parietal and visceral), especially at the level of the prostatic base. At the bladder neck level when the dissection is completed the anterior layer of the Denonvilliers fascia is reached and then opened covering the vas on the median line. Afterwards the posterior layer of the same fascia is opened allowing to dissect posteriorly in the prerectal space. Lateral insertions of the Denonvilliers fascia on the medial border of the neurovascular bundles are clearly seen and incised from the prostatic base to the apex when performing a nerve sparing procedure. Laterally interfacial dissection (between visceral part of endopelvic fascia and periprostatic fascia) allows the bundle to be separated from the prostate. CONCLUSIONS: Anatomical knowledge of the fascias surrounding the prostatic gland is essential to perform laparoscopic radical prostatectomy via either interfacial or extrafascial approach. Furthermore the quality of the vision allowed by the laparoscopic approach is a useful tool for educational purposes. V2
ADVANCES IN LAPAROSCOPIC PELVIC SURGERY Wednesday, 5 April, 14.30-16.00, eUro Auditorium / Level 1 LAPAROSCOPIC PARTIAL CYSTECTOMY FOR
Fournier G.H.1, Valeri A.1, Rammal A.1, Joulin V.1, Donohue J.1, Deruelle C.1, Cormier L.2, Taccoen X.1, Doucet L.3, Volant A.3 1
University Hospital of Brest, Urology, Brest, France, 2University Hospital of Nancy, Urology, Nancy, France, 3University Hospital of Brest, Pathology, Brest, France INTRODUCTION & OBJECTIVES: During laparoscopic radical prostatectomy a perfect knowledge of the anatomical landmarks is essential to prevent iatrogenic prostatic capsular violation, avoiding so the carcinologic risk of positive margins especially inj pT2 tumours. The laparoscopic magnification of the operative field allows the surgeon to visualize the periprostatic structures during the different steps of the procedure. MATERIAL & METHODS: To show the different critical steps during the laparoscopic prostatectomy via an antegrade approach when the risk of capsular incision is possible and the manner to overcome it. RESULTS: At the level of the bladder neck a careful dissection close to the posterior bladder wall is mandatory especially in case of median lobe in order to avoid intraprostatic incision in the plan of the simple prostatectomy. The two next critical steps are posterolaterally during the nerve sparing procedure and at the apex. After releasing the seminal vesicles and section of the vas the denonvilliers fascia is opened transversally and then incised along the medial border of the neurovascular bundles from the base to the apex posteriorly. Laterally the dissection runs between the visceral part of the endopelvic fascia and the periprostatic fascia. Finally the apical dissection starts just below the santorini’s plexus and a great care is needed to expose laterally the apex before transsection of the uretra. CONCLUSIONS: The most critical steps where the risk of capsular incision is maximal are during the posterolateral dissection and at the apex. Precise knowledge of anatomical landmarks and a precise dissection are essential not to compromise carcinologic results.
V7 BLADDER
V8 VIDEO LAPARORADICAL CYSTECTOMY IN FEMALE
MULLERIANOSIS
Gaboardi F.1, Bozzola A.1, Galli S.1, Gregori A.1, Scieri F.1, Stener S.1, Rocco B.2
Pansadoro V., Emiliozzi P., Federico G., Martini M., Pansadoro A., Pizzo M.,
1 Ospedale Sacco, U.o. Di Urologia, Milan, Italy, 2Istituto Europeo Di Oncologia, Divisione Di Urologia, Milan, Italy
Scarpone P. Vincenzo Pansadoro Foundation, Urology, Rome, Italy INTRODUCTION & OBJECTIVES: Bladder Müllerianosis is a rare event due to the localisation of Endometriosis, Endocervicosis and Endosalpingiosis embedded in the bladder wall. Since it is a benign disease a laparoscopic approach is indicated. In this case the lesion, 25 x 30 mm., was in direct contact with the uterine wall. MATERIAL & METHODS: At the beginning of the procedure a resectoscope is introduced in the bladder through the urethra and blocked with a Martin arm. In this way it is possible to have, during the surgical procedure, a continuous transvesical endoscopic control. A trans umbilical pneumoperitoneum is performed and three more 5 mm ports are introduced, in the shape of a diamond. Utilising an Harmonic Ace and under endoscopic control the limits of the lesion are identified and a Partial Cystectomy is performed. RESULTS: The specimen is extracted with an endobag and the bladder is closed with two running sutures. CONCLUSIONS: Frozen section confirm the diagnosis. A catheter is left in place for 5 days.
INTRODUCTION & OBJECTIVES: Radical cystectomy is the treatment of choice for advanced transitional cell carcinoma of the bladder. The laparoscopic approach is feasible, but the technique is still not well codified, particularly in female patients. In this Video we describe our technique of transperitoneal video laparo radical cystectomy in a female affected by bladder cancer. The anatomical approach is one of the main issues of this surgical technique. MATERIAL & METHODS: The bladder is approached transperitoneally using 5 trocars. After dissection of the infundibulopelvic ligament with the ovarian pedicle, the broad ligament is incised along the umbilical artery. After a retrograde dissection of the umbilical artery, superior and inferior vesical arteries are identified and easily controlled. The dissection is then carried down to the pelvic ureter, near the terminal branches of the uterine artery. In case of pelvic exoneration, after the en bloc cystohystero-annessiectomy, the anterior vaginal wall is removed and the urethra is transected as low possible. According to tumour stage, when there is an indication to perform orthotopic neobladder reconstruction, some of the urethra and the anterior vaginal wall are preserved. In this case bladder and uterus are removed separately. RESULTS: 1 anterior pelvic exenteration with ureterocutaneostomy e 1 radical cystectomy with hystero-annessiectomy and orthotopic ileal neobladder were performed. No conversion to open surgery was necessary. Operating Time for the ablative part of the procedure and blood loss were 150’ and 180’ and 220 and 440 ml for the pelvic exoneration and for the cystectomy, respectively. Postoperative pain was easily controlled with minor analgesics (NSAIDs). The patients were ambulant on the 1st and 3rd postoperative day and recovered bowel activity in the course of the 1st and 5th postoperative day. They were discharged on the 8th and 9th postoperative day. CONCLUSIONS: Laparoscopic radical cystectomy in females is a feasible operation. It is easy to standardize but technically demanding and should be performed in centres with large experience in laparoscopic surgery. As far as oncological outcomes are concerned, long follow up is needed.
Eur Urol Suppl 2006;5(2):327
V6
DESCRIPTION OF THE SURGICAL ANATOMY OF THE FASCIAS SURROUNDING THE PROSTATE DURING LAPAROSCOPIC RADICAL PROSTATECTOMY
HOW TO PREVENT IATROGENIC CAPSULAR INCISION DURING LAPAROSCOPIC NERVE-SPARING RADICAL PROSTATECTOMY
Fournier G.H.1, Valeri A.1, Rammal A.1, Joulin V.1, John D.1, Taccoen X.1, Deruelle C.1, Doucet L.2, Volant A.2, Cussenot O.3 1
2
University Hospital of Brest, Urology, Brest, France, University Hospital of Brest, Pathology, Brest, France, 3University Hospital Tenon, Urology, Paris, France INTRODUCTION & OBJECTIVES: Knowledge of surgical anatomy of the periprostatic fascias is essential when performing radical prostatectomy and already described previously for open procedures. The view of the operative field is different when performing the procedure via a laparoscopic approach due to the magnification and the oblique view with an angle of 45°. To describe the surgical anatomy of the fascias surrounding the prostate and clearly visible during a laparoscopic transperitoneal approach. MATERIAL & METHODS: Transperitoneal approach. RESULTS: The endopelvic fascia is first opened laterally after entering the retzius space. The two layers of this fascia can be differentiated (i.e. parietal and visceral), especially at the level of the prostatic base. At the bladder neck level when the dissection is completed the anterior layer of the Denonvilliers fascia is reached and then opened covering the vas on the median line. Afterwards the posterior layer of the same fascia is opened allowing to dissect posteriorly in the prerectal space. Lateral insertions of the Denonvilliers fascia on the medial border of the neurovascular bundles are clearly seen and incised from the prostatic base to the apex when performing a nerve sparing procedure. Laterally interfacial dissection (between visceral part of endopelvic fascia and periprostatic fascia) allows the bundle to be separated from the prostate. CONCLUSIONS: Anatomical knowledge of the fascias surrounding the prostatic gland is essential to perform laparoscopic radical prostatectomy via either interfacial or extrafascial approach. Furthermore the quality of the vision allowed by the laparoscopic approach is a useful tool for educational purposes. V2
ADVANCES IN LAPAROSCOPIC PELVIC SURGERY Wednesday, 5 April, 14.30-16.00, eUro Auditorium / Level 1 LAPAROSCOPIC PARTIAL CYSTECTOMY FOR
Fournier G.H.1, Valeri A.1, Rammal A.1, Joulin V.1, Donohue J.1, Deruelle C.1, Cormier L.2, Taccoen X.1, Doucet L.3, Volant A.3 1
University Hospital of Brest, Urology, Brest, France, 2University Hospital of Nancy, Urology, Nancy, France, 3University Hospital of Brest, Pathology, Brest, France INTRODUCTION & OBJECTIVES: During laparoscopic radical prostatectomy a perfect knowledge of the anatomical landmarks is essential to prevent iatrogenic prostatic capsular violation, avoiding so the carcinologic risk of positive margins especially inj pT2 tumours. The laparoscopic magnification of the operative field allows the surgeon to visualize the periprostatic structures during the different steps of the procedure. MATERIAL & METHODS: To show the different critical steps during the laparoscopic prostatectomy via an antegrade approach when the risk of capsular incision is possible and the manner to overcome it. RESULTS: At the level of the bladder neck a careful dissection close to the posterior bladder wall is mandatory especially in case of median lobe in order to avoid intraprostatic incision in the plan of the simple prostatectomy. The two next critical steps are posterolaterally during the nerve sparing procedure and at the apex. After releasing the seminal vesicles and section of the vas the denonvilliers fascia is opened transversally and then incised along the medial border of the neurovascular bundles from the base to the apex posteriorly. Laterally the dissection runs between the visceral part of the endopelvic fascia and the periprostatic fascia. Finally the apical dissection starts just below the santorini’s plexus and a great care is needed to expose laterally the apex before transsection of the uretra. CONCLUSIONS: The most critical steps where the risk of capsular incision is maximal are during the posterolateral dissection and at the apex. Precise knowledge of anatomical landmarks and a precise dissection are essential not to compromise carcinologic results.
V7 BLADDER
V8 VIDEO LAPARORADICAL CYSTECTOMY IN FEMALE
MULLERIANOSIS
Gaboardi F.1, Bozzola A.1, Galli S.1, Gregori A.1, Scieri F.1, Stener S.1, Rocco B.2
Pansadoro V., Emiliozzi P., Federico G., Martini M., Pansadoro A., Pizzo M.,
1 Ospedale Sacco, U.o. Di Urologia, Milan, Italy, 2Istituto Europeo Di Oncologia, Divisione Di Urologia, Milan, Italy
Scarpone P. Vincenzo Pansadoro Foundation, Urology, Rome, Italy INTRODUCTION & OBJECTIVES: Bladder Müllerianosis is a rare event due to the localisation of Endometriosis, Endocervicosis and Endosalpingiosis embedded in the bladder wall. Since it is a benign disease a laparoscopic approach is indicated. In this case the lesion, 25 x 30 mm., was in direct contact with the uterine wall. MATERIAL & METHODS: At the beginning of the procedure a resectoscope is introduced in the bladder through the urethra and blocked with a Martin arm. In this way it is possible to have, during the surgical procedure, a continuous transvesical endoscopic control. A trans umbilical pneumoperitoneum is performed and three more 5 mm ports are introduced, in the shape of a diamond. Utilising an Harmonic Ace and under endoscopic control the limits of the lesion are identified and a Partial Cystectomy is performed. RESULTS: The specimen is extracted with an endobag and the bladder is closed with two running sutures. CONCLUSIONS: Frozen section confirm the diagnosis. A catheter is left in place for 5 days.
INTRODUCTION & OBJECTIVES: Radical cystectomy is the treatment of choice for advanced transitional cell carcinoma of the bladder. The laparoscopic approach is feasible, but the technique is still not well codified, particularly in female patients. In this Video we describe our technique of transperitoneal video laparo radical cystectomy in a female affected by bladder cancer. The anatomical approach is one of the main issues of this surgical technique. MATERIAL & METHODS: The bladder is approached transperitoneally using 5 trocars. After dissection of the infundibulopelvic ligament with the ovarian pedicle, the broad ligament is incised along the umbilical artery. After a retrograde dissection of the umbilical artery, superior and inferior vesical arteries are identified and easily controlled. The dissection is then carried down to the pelvic ureter, near the terminal branches of the uterine artery. In case of pelvic exoneration, after the en bloc cystohystero-annessiectomy, the anterior vaginal wall is removed and the urethra is transected as low possible. According to tumour stage, when there is an indication to perform orthotopic neobladder reconstruction, some of the urethra and the anterior vaginal wall are preserved. In this case bladder and uterus are removed separately. RESULTS: 1 anterior pelvic exenteration with ureterocutaneostomy e 1 radical cystectomy with hystero-annessiectomy and orthotopic ileal neobladder were performed. No conversion to open surgery was necessary. Operating Time for the ablative part of the procedure and blood loss were 150’ and 180’ and 220 and 440 ml for the pelvic exoneration and for the cystectomy, respectively. Postoperative pain was easily controlled with minor analgesics (NSAIDs). The patients were ambulant on the 1st and 3rd postoperative day and recovered bowel activity in the course of the 1st and 5th postoperative day. They were discharged on the 8th and 9th postoperative day. CONCLUSIONS: Laparoscopic radical cystectomy in females is a feasible operation. It is easy to standardize but technically demanding and should be performed in centres with large experience in laparoscopic surgery. As far as oncological outcomes are concerned, long follow up is needed.
Eur Urol Suppl 2006;5(2):327