AUA 2017: Laparoscopic Radical Prostatectomy
Dr. Touijer started my noting that for the majority of the case he uses a pneumoperitoneum of 12 mmHg, lower than the standard 15 mmHg typically used for robotic prostatectomy. Subsequently, he starts the procedure by identifying and dissecting the vas deferens and seminal vesicles taking care to clip the vasculature intimately associated with the seminal vesicles. Next, he proceeds with the posterior dissection to the apex of the prostate, taking care not to injure the rectum in the process. Following this, after entering the space of Retzius and dropping the bladder, he identifies and incises the endopelvic fascia, taking care not to injure the neurovascular bundle (NVB). He notes that it is very important to not use cautery during these key steps of the procedure to minimize risk of injury to the NVB. Before starting the bladder neck dissection, he places a dorsal venous complex (DVC) backbleeding stitch, which he states helps with controlling venous bleeding during the subsequent bladder neck dissection. The bladder neck dissection is carried through till the Foley catheter is identified, which is followed by the posterior bladder neck dissection to the level of the posteriorly located seminal vesicles and vas deferens. He notes that this is often the most difficult portion of the procedure anatomically and states that looking for the longitudinal fibers of the bladder neck can assist with orientation. He then turns his attention to the final dissection of the NVB and prostate pedicles, noting that he uses no cautery but rather a laparoscopic peanut to gently dissect the NVB posteriorly. Attention is then turned to the apical dissection, at which point he increases the pneumoperitoneum to 20 mmHg to assist with control of the DVC, which is ligated with cold scissors. To assist with control of arterial bleeding he subsequently places a 3-O suture at the level of the DVC. Once the anterior urethra is divided, the prostate is free and inspected for quality of dissection. Dr. Touijer notes that he then places one interrupted suture to start the urethrovesical anastomosis in order to bring the bladder in close proximity to the urethra (relieving any tension on the anastomosis), followed by a running circumferential suture to complete the anastomosis.
Although laparoscopic prostatectomy is not nearly as common as robotic prostatectomy in the United States, when polling the audience, nearly 25% of the international crowd still perform the procedure. As Dr. Touijer notes during the Q & A with Dr. Dasgupta “there is no question that for surgeons who are comfortable performing laparoscopic radical prostatectomy with appropriate oncologic and functional outcomes, this is significantly more cost-effective than robotic prostatectomy.”
Presented By: Karim Touijer, Memorial Sloan Kettering Cancer Center, New York, NY, USA
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre
Twitter: @zklaassen_md
at the 2017 AUA Annual Meeting - May 12 - 16, 2017 – Boston, Massachusetts, USA