ILLUSTRATIONS by STEPHAN SPITZER, http://www.spitzer-illustration.com
Laparoscopic radical prostatectomy was first reported by Schuessler et al. in 1992 and has recently become a routine procedure at specialized centres [2–4]. Current accepted indications are clinical T1 and T2 cancers. Reported benefits of the laparoscopic approach include less blood loss and pain, a shorter hospital stay and convalescence, and improved cosmesis [3,4]. Also, the magnified view of the laparoscope may allow better visualization of the anatomy, translating into more precise and less traumatic dissection of vital structures. We initially began using the Montsouris technique [3,4] but our experience has expanded and we have made several modifications to the operation. We report the details of our technique of laparoscopic nerve-sparing radical retropubic prostatectomy.
The patient is instructed to stop any aspirin products 10 days before the planned surgery. Warfarin therapy is discontinued at least 5 days before surgery, after consultation with the patient's primary medical physician. On the day before surgery the patient is maintained on a clear liquid diet and instructed to drink a light mechanical bowel preparation at 14.00 hours, and to use an enema at 19.00 hours. After midnight the patient discontinues any oral intake, other than normal medications with a sip of water. The patient is given intravenous antibiotics before the skin incision.
As with any surgical procedure, properly functioning equipment and hardware is essential for a smooth operation; this is accentuated in complicated laparoscopic procedures. The devices and instruments needed for successful laparoscopic prostatectomy (Table 1) are used to provide visual access to the operative field, maintain a blood-free environment, meticulously dissect the surrounding structures, reconstruct the urinary tract, remove the specimens, and close the access sites. Properly functioning instruments and hardware are essential. The surgeon and entire operating team should be familiar with all equipment, to manage any malfunctions that may occur. Extra equipment should be available if a replacement is needed.
|Laparoscopes, 0° and 30°||High-flow insufflator|
|Veress needle||Chip camera|
|Trocars: 5 and 10 mm||Video recorder|
|Bipolar forceps||Photo printer|
|Needle holders||Harmonic scalpel generator|
|Graspers/dissectors||Bipolar and monopolar|
|Open surgical tray|
SPECIMEN REMOVAL AND CLOSURE
The specimen and anastomotic needles are placed in a specimen bag and removed through the umbilical port, by extending the incision as needed. This incision is then closed in two layers with 0-polyglactin for the fascia and 4–0 poliglecaprone (subcuticular) for the skin. The abdomen is again fully inspected to assure haemostasis. A passive drain is placed through the left lateral port and draped over the urethrovesical anastomosis. The two pararectal port sites are closed in two layers. A Carter-Thomason needle is used to facilitate closure of the fascia with 0-polyglactin sutures. Before the last port is removed the pneumoperitoneum is fully reduced, and before skin closure the wounds are infiltrated with local anaesthetic. The skin layers are closed with 4–0 poliglecaprone sutures in a running subcuticular fashion. The drain is sutured to the skin with a 2–0 Nylon suture. Each port site is dressed with sterile strips and dry gauze dressings. The drain is covered with dry, sterile gauze. The Foley catheter is secured to the patient's right leg. The patient is given intravenous nonsteroidal analgesia before extubation, then extubated and transported to the recovery room.
Patients are immediately placed on their preoperative medications and are allowed to have sips of clear liquids. Analgesia is maintained with intravenous nonsteroidal medication with intravenous opioids for ‘breakthrough’ pain. Patients are advanced to full clear liquids on the first day after surgery and a regular diet thereafter. A daily suppository is given to stimulate gastrointestinal activity. Patients are quickly converted to oral analgesics. Patients are taught about care of the catheter on the first day. Drains are removed when output is minimal. Patients are instructed to continue Kegel exercises. Once tolerating oral intake, comfortable on oral medications, and ambulating well, patients are discharged from the hospital.
‘SURGEON TO SURGEON’
Previously, we used a classic Montsouris technique by incising the peritoneum between the bladder and rectum. The pouch of Douglas was entered and the seminal vesicles and ampulla of the vas deferens dissected. Subsequently, the bladder was reflected posteriorly and the dissection was continued anteriorly through the space of Retzius. Several patients developed small anastomotic leaks, detected on cystography, that communicated with the peritoneal cavity. We have since modified our procedure to eliminate this dissection of the pouch of Douglas, and dissect the seminal vesicles and vas deferens through the anterior dissection. The peritoneal incision probably contributed to the intraperitoneal leaks. Since changing the dissection of the seminal vesicles and the vas deferens there have been no intraperitoneal leaks.
Previously we made the urethrovesical anastomosis with interrupted sutures, each tied intracorporeally. We noticed that significant tension was placed on the initial anastomotic sutures. Several times the initial suture pulled through either the urethral mucosa or the bladder neck. Since changing to a running ‘parachute’ technique, this has been eliminated.
CAVEATS AND SURGICAL TIPS
It should be intuitive that the experience of the surgeon and entire laparoscopic team is vital to the success of a smooth operation. All those involved with the patient should be familiar with the laparoscopic hardware and instruments, should a malfunction occur, and should be able to troubleshoot all the devices used during the procedure. The surgeon should have precise, ambidextrous laparoscopic skills. This includes the ability to place the needle intracorporeally and knot-tying techniques. Most of the dissection is done using the left ports for the surgeon and the right ports for the assistant. However, the surgeon should be able to use all the ports as needed during the procedure. This is most relevant for placing the urethrovesical anastomotic suture; this task is arguably the most technically difficult to master. The assistant should have appropriate laparoscopic skills to facilitate exposure of the dissection and to maintain a dry field should bleeding occur. It is obvious that all those involved with the operation should have an accurate knowledge of each step, to anticipate instrument changes and possible complications that may change the course of the procedure.
Several factors may be used to predict a difficult case. Morbid obesity, previous abdominal surgery, especially colorectal, previous TURP, a history of prostatitis, a prostate of > 120 g, or a history of pelvic radiation should warn the surgeon that access and dissection could be difficult. However, none of these should be considered an absolute contraindication for the laparoscopic approach. Initially, surgeons should tackle the uncomplicated cases. With increasing experience, more difficult cases can be attempted.
Injury to bowel, vascular structures or other abdominal contents can occur during all steps of the procedure. As in all surgery, recognising the injuries in a timely fashion is essential. If small bowel is injured, the surgeon should determine if a primary repair is appropriate. These injuries can be repaired with laparoscopic closure. If the rectum is injured, it can be repaired intracorporeally. However, if the pelvis has received previous radiation, a diverting colostomy should be seriously considered. If there is a vascular injury the surgeon should rapidly determine if conversion to open repair is needed. If the injury can be adequately visualized, primary laparoscopic repair can be attempted. If the injury is not visualized adequately or if blood loss is rapid, then compression should be applied with laparoscopic instruments and an open incision rapidly made.
Dissecting the apex and placing the dorsal vein complex suture can be difficult to master; knowledge of the apical anatomy is essential. Meticulous and bloodless dissection, as well as the magnification of the laparoscope, helps to identify the correct planes of suture placement. As previously mentioned, a metal urethral sound can be very helpful in identifying the urethra.
Dissecting the bladder neck can be very difficult. Once again, maintenance of a blood-free field is needed to visually identify the correct plane between detrusor and prostate. Once the bladder neck has been opened, the ureteric orifices may be visualized and injury to the ureter prevented. If the patient has a large prostate or a large middle lobe, the surgeon should proceed carefully, knowing that the distal ureters may be displaced from their normal path. Dissecting a large middle lobe may be very difficult and an experienced surgeon is then vital. If the bladder neck is significantly larger than the urethral cuff, as often occurs with a large middle lobe, it may be reconstructed as necessary with intracoporeal suturing. We have done this along the base and along the anterior bladder neck. This should be determined by the surgeon's experience and preference, as well as the patient's anatomy. It is often easier to visualize the anterior surface of the bladder neck as this area is closer to the laparoscope.
The vas deferens and seminal vesicles should be dissected very gently, as these structures are prone to tearing from vigorous traction. Monopolar electrocautery should not be used and bipolar electrocautery should be minimized to prevent inadvertent trauma to the neurovascular bundles. Careful and active retraction of these structures by the assistant is extremely helpful.
Dissecting the base of the prostate from the rectum can be difficult; inflammatory reaction is often encountered. The perirectal fat plane can be a welcome visual clue to guide the dissection. Again, monopolar cautery should not be used in this area, to prevent thermal injury to the rectum.
When the lateral pedicles are dissected, the perforating vessels to the prostate can persistently bleed. Careful identification of these vessels and transection using the harmonic scalpel can prevent significant blood loss. Gentle pressure can be used at all times to control this bleeding, as the remainder of the pedicle is transected. We have found the use of pro-coagulation materials, mainly FloSeal matrix, has been very helpful in maintaining a dry field. Again, the surgeon should know that any use of electrocautery in this region can cause thermal injury to the neurovascular bundle.
The urethrovesical anastomosis can be difficult to make; previous experience in intracorporeal suturing and practice in pelvic trainers can be very helpful. The surgeon should have precise ambidextrous skills and be able to use all of the ports to place the anastomotic sutures accurately. Care should be taken to prevent any tearing of the urethra or bladder neck. As previously noted, we now use a running ‘parachute’ technique to prevent any one suture from tearing the tissue.