Laparoscopic radical prostatectomy: extraperitoneal approach

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Laparoscopic   radical   prostatectomy:   extraperitoneal   approach

Authors
C Abbou
Mots-clés
laparoscopy,radical prostatectomy,extraperitoneal approach,prostate
Type de vidéo
Durée
25'00''
Publication
2004-12
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Dec 2004;4(12).
URL: http://www.websurg.com/doi-vd01en1553e.htm

Laparoscopic   radical   prostatectomy:   extraperitoneal   approach

1. Extraperitoneal space dissection 00'13''
We begin by an umbilical incision and we open transversally the rectal sheath. And then I introduce my finger just between the muscle and the posterior sheath. As we already have a finger in each side, we can develop the space with the finger and then we push two trocars. You see exactly where I am here, I have my lateral trocar here. You see the pubic bone here, we are going to develop the space here gently; in a few seconds you’ll see the iliac vein here, we are not going to do a lymph node dissection in this patient but to do it it’s easy it is here, and we can do a lymph node dissection; it’s an extensive lymph node dissection that we do usually, just an obturator one. Here we have the right endopelvic fascia, the prostate is here, we have to remove this fat and we know that in this fat, there is a superficial vein. So we have to go slowly not to have problems with these vessels, behind the bone, arteries and vein. Now we have a good view of the space and we open the endopelvic fascia; this is not mandatory, you don’t have to open it, but when you open it, you just have to do it very laterally. Here we have the lateral view of the apex of the prostate so we stop this step here and carry it on a bit later. The most important thing for each patient is to be sure to have the best vision possible of the apex, because the apex is so important in terms of oncologic control, you need to have the best oncologic control so if you need to divide the puboprostatic ligament, then do it, if not leave it as it is only a question of having the best exposure of the apex. The puboprostatic ligament is right here, we can cut it if we want. You see it is white. It is important to have a good dissection laterally to this ligament here and to remove all the muscle. We can cut it a little bit more. The ligament is here, we can see it very well. Now we stop the dissection of the apex here, we will do it better later. Now we are going to divide the bladder neck, and for that we need a good exposure. Here we can see the prostate and here the implantation of the bladder neck. We are going to do that in order to pull the prostate up and have the best possible exposure of the bladder neck. Here I place an additional trocar, it’s a sub-pubic trocar in order to pull this suture here. We pull the bladder neck in order to have the best exposure possible. When you have beating like that, it means that you are exactly in the sight of a bladder neck. We push the catheter inside and take the catheter as such to have the best view of the bladder neck. The view of the bladder neck here is absolutely perfect so we can do a good job on it. It is possible to go around the bladder neck, that is what we did in the beginning of our experience, we had some positive margins in the bladder neck. So we decided to open the bladder neck and go behind, so we leave a part of the bladder mucosa. We do the same thing on the other side. If you don’t have a good exposure, this step can be very difficult. If it is good exposure, you can deal with a difficult patient. There are some very difficult patients sometimes, when the prostate is huge with a big medial lobe. This is the medial lobe here. In a few seconds, we will dissect the seminal vesicles, the exposure must be good now. Now we have a nice view of the seminal vesicle here and the vas here, usually we have a little bit more, we have the anterior aspect of the Denonvilliers’ fascia, sometimes thin and sometimes thick, in this patient, it is thin. Usually, it is nice to open it under visual control. First thing you do is take the vas, there is always a small artery behind. The second vas is here. The bundle is here and the seminal vesicle was on the bundle so we have to dissect it gently. We will not use any coagulation. When the dissection of the seminal vesicle is finished, we will arrive exactly at the site of the pedicle. The prostatic pedicle is there, the bundle is down here and goes behind the prostate and something is going up like that because you are pulling the seminal vesicle and this thing that is going up is the pedicle. This is the posterior aspect of the Denonvilliers’ fascia here, we open it, you see it here and we are in the prerectal space here. We are exactly at the site of the prostatic pedicle. I ask my assistant to pull the seminal vesicle, we see the Denonvilliers’ fascia here and the dissection of the seminal vesicle. It is important to open the Denonvilliers’ fascia; doing that, we see the rectal fat; and doing that, the seminal vesicle can go up easily. This is not the bundle, but the pedicle, we are right here close to the prostate. We place a clip here on the pedicle. You see the prostate here and the pedicle here. See the vessels of the pedicle, the pedicle is the hilum of the prostate and so you have the vessels here. We take the seminal vesicles altogether, we have some tissue here remaining in the middle. I like to do that posteriorly, I will find all the tissue behind the prostate. The problem is to go for the bundles, they are here but sometimes there is a remaining vessel of the pedicle. We must place clips here, we can see perfectly well the space between the prostate and the pedicle. When you have finished with the pedicle, usually you can just push the bundle down and you can dissect it down like that. There is one or two remaining vessels but you can just push the bundle down. We see on the other side the prostate quite well, we do the same thing, push this tissue. In the posterior aspect of the prostate is not a problem, it becomes a problem close to the bundle. I think we are quite all right in terms of the posterior dissection. Now I am going to use a Beniquet, I will tell you for what reason. When I push the prostate down, the urethra is pushed down. We have a good separation between the urethra and the dorsal vein complex so I can go ahead here with a complete lateral dissection. This is the urethra here and the dorsal vein complex. I like to place 2 knots, 2 stitches. This is the step of the apical dissection, you can see here the dorsal vein complex and the prostate is here. I have to divide the dorsal vein complex and pull the prostate. Sometimes the prostate is very low, sometimes more than one third of the prostate is below this point. It is very important to pull the dorsal vein complex here and then the prostate goes up here so we have to go very slowly in order not to open the prostate, but just stay below the dorsal vein complex. You can see here the tissue and slowly the prostate is going up. Now we are in contact with the urethra, we are going to divide the urethral stump. This is the urethra, we can see it very well. Now you can mobilize the prostate like that, what I will do is place this grasper here and we are going to turn the prostate. We see the bundle here, the periprostatic fascia here and we develop the dissection of the bundle progressively. The apical dissection is very important because most of the positive margin is coming from the apex, I have a nice dissection of the urethra, and here is the recto-urethralis. We do the same thing on the other side, this is the bundle here, the periprostatic fascia here, and we are quite in contact with the urethra. The urethra is not completely dissected here, but it doesn’t matter as we’ll do it later, this part has tissue stuck to it. Now we cut the urethra here, not too far from the prostate, I feel the catheter with the tip of my scissors. The urethra is now opened and we have just the recto-urethralis that is remaining. What we do now again in order to have the best possible control of the apex is to turn the prostate and to divide this tissue under visual control. The bundle is here, I stay very close to the prostate. Ok now we are going to remove the specimen, I always remove the specimen immediately, it weighs around 70 grams. This is the bladder neck, which is nice, not too large, the orifices are very deep probably. The principle of this suture is to have 2 needles, and the knot between the 2 needles and the length of the tape is around 30cm, you can see here the direction and then the bladder comes easily. I used to push the catheter like that and the catheter helps me to be in the exact direction. This is the right suture, I give this suture to my assistant in order for him to pull on it like that and I take the left needle. You see one orifice here is already far, there is no problem, it is 1cm below. The catheter goes in directly. For the last stitch, I always take the dorsal vein complex, it is solid and I never tear it, it is just for good suspension of the bladder neck and putting less traction on the suture after the surgery. It is usually watertight so I don’t pull on the balloon, it is watertight. We now place a small drain for 24 hours.