4. RESULTADOS
4.2 Programas de financiación para la construcción de los ecosistemas: Una
4.2.1 La importancia de las regiones: la Smart Specialisation
Inderbir Gill
Friday
June
:-- Surgical session
Laparoscopic Radical Prostatectomy
Laparoscopic Radical Prostatectomy (Step by step)
Inderbir Gill, MD, MCh
Head, Section of Laparoscopic And Minimally Invasive Surgery Glikman Urological Institute
Executive Director
The Minimally Invasive Surgery Center
The Cleveland Clinic Foundation, Cleveland, USA
Indications
Similar to open surgery, laparoscopic radical prostatectomy is indicated for patients with organ-confined prostate cancer. Concomitant laparoscopic pelvic lymph node dissection is reserved for patients with PSA ≥ 10 ng/dl and Gleason score ≥7. Frozen section analysis of the lymph nodes is obtained prior to proceeding with radical
prostatectomy.
Contraindications
Initially in our experience, laparoscopic radical prostatectomy was limited to non-obese patients (≤200 lb), with smaller prostate glands (< 50 gm weight), where potency was not a concern. Patients who had received prior LHRH agonist therapy were excluded. With increasing experience, we now offer the laparoscopic technique to patients with larger prostate glands. Until date the largest gland we have removed weighed 222 gms. Currently, our selection criteria do not include any specific size limitation. The procedure is now also offered to those seeking nerve-sparing prostatectomy, and to patients who have undergone neoadjuvant hormonal treatment. Further, patients with history of prostatitis, prior TURP, and prior hernia repair are not contraindicated. Currently, we do not
offer the laparoscopic approach to patients with a history of prior pelvic external beam irradiation. Preoperative Preparation
Two bottles of magnesium citrate are administered the afternoon prior to the date of surgery. Patients are advised to consume only clear liquids starting the afternoon prior to surgery. On call to the OR, the patient receives a dose of intravenous broad-spectrum antibiotic.
Patient Position
The patient is positioned in a modified lithotomy position. In order to facilitate unrestricted perineal access during the procedure, the legs are abducted and placed in Allen stirrups. Compression stockings are utilized during and after the procedure. The arms are placed in an adducted position, and the patient is placed in a 300 Trendelenberg position. The operative field and perineum are prepped and draped, and the patient is catheterized with a 22F Foley catheter from the sterile operative field.
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A 5-port approach is employed. The bladder is inflated with 200 cc saline, and an inverted-U shaped peritoneotomy is created. The incision begins lateral to the median umbilical ligament on the right side, transects the urachus high, and terminates lateral to the medial umbilical ligament of the left side. The urachus should be divided high along the anterior abdominal wall to prevent an inadvertent cystotomy. The space of Retzius is entered and the loose connective tissue is dissected meticulously to identify the puboprostatic ligaments and endopelvic fascia. The bladder is emptied and the superficial dorsal vein is controlled with bipolar electrocoagulation.
Incision of the Endopelvic fascia
The puboprostatic ligaments are not divided. The endopelvic fasciae are incised with laparoscopic shears, bilaterally. The incision extends anteriorly up to the prostatic apex where limited blunt dissection with a laparoscopic Kittner in the region of the prostatic apex creates space for subsequent placement of a suture for control of the dorsal vein.
Control of the dorsal vein
After ensuring that the bladder is empty the Foley catheter is replaced with a 20 F metal sound. The sound facilitates identification of the urethra, and thereby prevents inadvertent incorporation of the urethra into the dorsal vein suture. A 2.0 Vicryl suture on a 21-mm CT-1 needle is employed to secure the dorsal vein. The dorsal vein suture is passed posterior to the dorsal vein and anterior to the urethra. This maneuver is facilitated by the presence of a urethral sound. The suture is placed in a backhand fashion utilizing a needle driver in the right hand (right handed surgeon). A backhand left handed stitch is utilized to anchor the suture to the pubic periosteum. A back bleeding stitch is placed near the base of the prostate.
Identification and transection of the bladder neck, and dissection of the vasa and seminal vesicles
Manipulation of the urethral sound facilitates laparoscopic identification of its tip, which is an important guide for identification of the anterior bladder neck. The base of the prostate is identified and the anterior bladder neck is dissected. Anterior traction placed on the back bleeding stitch by the assistant facilitates precise identification of the anterior bladder neck. The anterior bladder neck is then transected. The posterior bladder neck is incised along the base of the prostate gland, carrying the incision posteriorly through the anterior leaf of Denonvillier’s fascia. The vasa and seminal vesicles are identified posterior to the Denonvilliers fascia. During this step of the dissection, an assistant depresses the bladder posteriorly. The vasa are dissected, secured and then divided. Anterior traction on the vasa facilitates dissection of the seminal vesicles, which lie lateral to the vasa. The artery to the seminal vesicle, which is encountered near its tip is secured with a hemostatic Hem-o-lok clip (Weck Closure Systems, Research Triangle Park, NC). Since the neurovascular bundles lie in close proximity to the tips of the
Anterolateral traction on the vasa and seminal vesicles in a contralateral direction facilitates dissection of the lateral pedicles. For nerve-sparing procedures we have completely eliminated the use of any form of electrocoagulation during this step. The pedicles are controlled with hemostatic clips and transected with “cold” laparoscopic shears. Also, the harmonic scalpel with its limited lateral spread of energy (0-1 mm) is a useful adjunct.11 Dissection is performed in proximity to the prostate, in an antegrade fashion, and any vascular perforators from the neurovascular bundles are meticulously clipped and transected. (Figure 7) Such micropedicle release frees the neurovascular bundles up to the apex of the prostate.
Apical dissection
At this time the prostate remains attached only at its apex. While maintaining cephalad traction on the gland, the dorsal vein complex is divided. The urethral sound is utilized to precisely identify the urethra distal to the prostate apex. The urethra is transected, the rectourethralis plate is incised, and any remaining attachments between the prostate and rectum are divided. The specimen comprising of the prostate, seminal vesicles and vasa, is
entrapped in a 10-mm specimen bag. Urethrovesical anastomosis
Prior to performing the anastomosis the bladder neck is inspected. In case it appears significantly larger than the urethral lumen it is narrowed with interrupted sutures of 2.0 Vicryl. Hemostasis is confirmed in the prostatic bed. Currently we perform a running anastomosis with a double-armed 2-0 monocryl suture on a 5/8 circle GU-6 needle. This technique was initially described by Van Velthoven and colleagues.12 The double-armed suture is created on the back table by knotting the free ends of two monocryl sutures (one dyed and the other undyed), each measuring 11 inches to one-another. The needles are passed through the posterior lip of the bladder neck in an outside-in fashion, at 6’ and 6 O’ clock positions. One suture is then run in a clockwise direction, and the other anticlockwise. Following the completion of the posterior row of the anastomosis the metal sound is replaced with a 22 F Foley catheter. Once the anastomosis is completed the sutures are tied to each other at the 12 O’clock position. The anastomosis is tested by inflating the bladder with 200 cc of saline.
A 10mm Jackson Pratt drain is placed in the pelvis, and the specimen is extracted through a circumumbilical exten- sion of the primary port site.
Results
Guillonneau and Vallencien reported their experience following 350 laparoscopic radical prostatectomies performed between January 1998 and March 2000.13 Laparoscopic radical prostatectomy was performed utilizing a transperitoneal technique. Initially, the peritoneum posterior to the bladder was incised. The seminal vesicles and vasa were then dissected. The Denonvillier’s fascia was then incised. Subsequently, the space of Retzius was entered and the prostate was dissected in an antegrade fashion. Urethrovesical anastomosis was performed with interrupted 3-0 absorbable sutures. Mean operating time was 217 ± 59 mins. Within this series the operating time was lesser for the later 200 cases (195 ± 56 mins). The average estimated blood loss was 354 ± 250 cc. The
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average postoperative catheterization time was 5.8 ± 3.3 days and the average length of stay in the hospital was 6 ± 3.9 days. The continence rate was 85.5 % for the initial 133 patients. Continence was evaluated utilizing a validated continence questionnaire. Potency was successfully preserved in 59 % of 22 selected consecutive patients. In an earlier study Guillonneau and colleagues demonstrated lower costs associated with laparoscopic radical prostatectomy compared to open radical prostatectomy in France. ($ 1,237 lesser).14
More recently the same group reported oncologic results following 1000 laparoscopic radical prostatectomies.15 Preoperative clinical stages (TNM 1997 classification) included T1a in 6 patients (0.6%), T1b in 3 patients (0.3%), T1c in 660 patients (66.5%), T2a in 304 (30.4%), and T2b in 27 patients (2.7%). The average preoperative PSA was 10 ± 6.1 ng/ml (range 1.5 to 55 ng/ml). Postoperative pathologic staging for the patients were as follows; pT2aN0 in 203 patients (20.3%), pT2bN0 in 572 (57.2%), pT3aN0 in 142 (14.2%), pT3bN0 in 77 (7.7%), and pT1-T3N1 in 6 patients (0.6%). Positive surgical margins were detected in 6.9% patients with pT2a tumors, 18.6% pT2b, 30% pT3a and 34% in patients with pT3b tumors. Progression free survival was 91.8% for patients with pT2aN0 tumors, 88% for pT2bN0, 77% for pT3aN0, 44% for pT3bN0, and 50% for pT1-T3N1 tumors. In addition, within this series progression free survival was 94% for patients with negative surgical margins and 80% for patients with positive surgical margins.
Guillonneau and colleagues in 2001 also reported perioperative complications following 567 laparoscopic radical prostatectomies.16 Of the 567 patients, 458 patients underwent laparoscopic radical prostatectomy without concomitant lymphadenectomy. One hundred and five complications occurred in 97 patients, including 21 major complications and 83 minor complications. Intraoperative complications included bladder injury in 9, ureteral injury in 3, inadvertent incorporation of the ureteral orifices into the urethrovesical anastomotic suture causing anuria in 1, rectal injury in 8, small bowel injury in 2, colonic injury in 1, epigastric artery injury in 3. Postoperative complications included anastomotic fistula in 57 patients, postoperative ileus in 6, compressive neuropraxia in 2, axonal degeneration secondary to hemorrhagic shock in 1, lymphorrhea in 1, deep vein thrombosis in 2, and wound dehiscence in 4. Of these patients 21 required reoperative intervention, and 10 were admitted to the intensive care unit. The same group also assessed results following their initial 120 laparoscopic radical prostatectomies.17 In order to assess the learning curve, patients were divided into 3 groups; initial 40 cases, the next 40 cases, and the last 40 cases performed. Mean operative times were 282 minutes, 247 minutes, and 231 minutes, respectively. Estimated blood loss was 534 cc for the initial group, 517 cc for the next group of 40 patients, and 277 for the last 40 patients within the study. Open conversion rates were 10%, 7.5%, and 0%, respectively. Mean catheter times were 7.9 days, 7.3 days, and 5.7 days, respectively. The authors reported that the learning curve involved about 40 cases per surgeon.
were T1 and 43 T2. Based on preoperative PSA and Gleason scores (PSA ≤10.0 ng/ml, Gleason score ≤7) pelvic lymphadenectomy was not performed in 78 patients. There were no open conversions. After overcoming the learning curve, following 20 initial cases, the average operative time for laparoscopic radical prostatectomy was 3.5 hours. Average time for procedures including the performance of pelvic lymphadenectomy was 4 hours. Four patients required blood transfusions. Median duration for catheter removal following the procedure was 4 days. Average length of hospital stay was 6.1 days, excluding the first ten patients in their series. Tumors included 101 pT2 tumors and 33 pT3 tumors. Positive margins were detected in 16.8% of pT2 specimens and 48.8% in pT3 specimens. Potency was preserved in 56 % of patients at one year. Daytime continence was achieved in 86.2 % patients, and all patients were continent at night.
Gill and colleagues reported their experience following 150 laparoscopic prostatectomies.19 They reported various technical variations that were implemented within the learning curve. The transperitoneal approach was employed in 106 patients and 44 patients underwent an extraperitoneal laparoscopic radical prostatectomy. Unilateral nerve- sparing radical prostatectomy was performed in 40 patients, and bilateral nerve sparing surgery in 32. The ureth- rovesical anastomosis was performed with a running suture in 103 cases, and in an interrupted fashion in 47 patients. In order to evaluate the learning curve the patients were divided into 3 groups of 50 each, which included the initial 50, second 50, and most recent 50 cases. OR time decreased from 315 mins for the initial group, to 235 mins in the second group, and 233 mins for the more recent group of patients. Estimated blood loss was 355 cc for the initial group, 310 cc for the second group of patients and 295 cc for the more recent group of patients. Hospital stay averaged 51 hours for the initial group, 39 hours for the second group, and 34 hours for the more recent group of patients. Catheter duration was 15 days, 4 days and 4 days for the initial, second and more recent group of patients, respectively. Continence rate assessed utilizing a validated questionnaire was 94 % at 6 months. Rassweiler and colleagues reported results following 180 laparoscopic radical prostatectomies.20 Laparoscopic radical prostatectomy was performed utilizing a transperitoneal approach. Initially, the space of Retzius was entered and the prostate was dissected in a retrograde fashion. Anastomosis was performed with interrupted sutures. The mean operative time was 271 mins (range, 150-500 mins). The reintervention rate was 4.4 %, and complication rate was 18.8 %. Positive margins were detected in 2.3 % pT2 tumors, 15 % pT3a and 34 % in pT3b tumors. After a median follow up of 12 months, PSA relapse was observed in 5 % patients. Median catheter time was 7 days (range 5 to 30), and the anastomosis was demonstrated to be watertight in 83 % patients. Anastomotic strictures requiring laser incision were reported in 3.3 % cases. Continence was 97 % at one year.
Turk and colleagues reported results following 125 cases of laparoscopic radical prostatectomy. 21 The procedures were performed utilizing a transperitoneal approach with initial dissection of the seminal vesicles and vasa. Following this, the space of Retzius was entered and the prostate was dissected in an antegrade fashion. Average operative time was 255 minutes, estimated blood loss was 185 cc, and 2 patients required blood transfusions (2%). Catheters were removed in 5.5 days, and average length of stay in the hospital was 8 days. Five patients developed a total of 10 complications (4%). None of the cases needed conversion to open surgery. A continence rate of 86% at 6 months was achieved.
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The technique was initially described by Raboy and colleagues in 1997. 8,22 The extraperitoneal space was digitally dissected following initial extraperitoneal access through a 1-cm infraumbilical incision. A 5-port extraperitoneal approach was employed. The endopelvic fascia was incised bilaterally, and the puboprostatic ligaments and the dorsal venous complex were divided with an Endo-GIA stapler. The urethra was sharply divided, and retrograde dissection of the prostate was performed. The bladder neck was subsequently divided, and the seminal vesicles and vasa dissected bilaterally. The specimen was entrapped in a specimen bag. Urethrovesical anastomosis was performed over a 20 F Foley catheter and knots were tied extracorporeally. In 2 patients, the OR time was 5 hrs 45 mins, and 4 hrs, respectively. Estimated blood loss was 600 cc and 400 cc, respectively. Catheter was removed 2 weeks postoperatively.
Bossche and colleagues reported results of a prospective comparative study between open and extraperitoneal laparoscopic radical prostatectomy.23 The study involved 162 patients, 77 of which were treated open surgically, and 85 utilizing an extraperitoneal laparoscopic technique. Mean operative time was longer for the laparoscopic cases than the open cases (288 ± 67 mins vs. 168 ± 52 mins). Compared to open retropubic prostatectomy, laparoscopic prostatectomy was associated with lesser blood loss (400 cc vs. 1300 cc), shorter catheterization time (6 vs. 14 days), shorter length of hospital stay (8 vs. 16 days), and fewer minor complications (11.8% vs. 24.6%). Both the open and laparoscopic groups were similar in terms of the number of major complications (5% vs. 2.4%). For pT2 tumors, positive margins were similar for the open and laparoscopic groups (7.3% vs. 7.8%). PSA progression at 1 yr was similar for both groups. Continence rates (83.9% vs. 80.7%), and potency rates (55% vs. 65%) were comparable between the open and laparoscopic cases. This study demonstrated that open retropubic and laparoscopic prostatectomy were similar from a oncologic and functional standpoint.
Friday
June
Laparoscopic Radical Prostatectomy (Step by step)
Ingolf Türk, MD, PhD
Director, Minimally Invasive Urologic SurgeryDepartment of Urology Lahey Clinic Medical Center Burlington, USA
Impact of Laparoscopy on Prostate Cancer Treatment
Laparoscopic radical prostatectomy (LRP) is an emerging treatment modality for localized prostate cancer that seeks to combine the benefits of minimally invasive approach with the advantages of surgical removal and staging of the tumor.
LRP is the latest technical innovation in prostate cancer care. If measured by treatment side effects, LRP is arguable the most profound technical innovation in years. It offers:
—improved visualization —reduced blood loss —more precise dissection
—better preservation of anatomical structures —reduced intra- and postoperative morbidity —faster recovery with shorter catheter time
LRP has become a routine clinical procedure in increasing numbers of specialized centres. Because the technique of this procedure is teachable, the surgical results of LRP are reproducible. LRP has significant advantages in terms of blood loss and visibility. That provides an optimal environment for delicate preparation of urethra and neurovascular bundles which results and excellent functional results. Regarding the oncological efficacy LRP has proven to be a sufficient alternative with complete removal of the cancer. Positive margin rates are comparable to those after open radical prostatectomy and the available data’s regarding the oncological outcome suggesting that LRP is not compromising the cancer cure.
Friday
June
:- Scientific Session
Moderators Frans Debruyne & Aldo Bono
State of the Art lectures
Mitchell Benson :- How Should PSA be incorporated into Clinical Practice
Discussion
Gianfranco Gualdi : Endorectal MR and 3D MR spectroscopic Imaging in Prostate Cancer
Discussion
Liliane Boccon-Gibod :-- Microfocal prostate cancers: current dilemmas
Discussion
Face to Face
Moderators David Paulson & Arcangelo Pagliarulo
John Libertino : RRP: Tips and Tricks, can these be transferred to LRP?
vs. Peter Scardino Or Viceversa?
Discussion
Bertrand Guillonneau : Laparoscopic radical Prostatectomy:
vs. Claude Schulman Transperitoneal or Extra peritoneal?
Discussion
Bertrand Guillonneau :- The MSKCC Experience
vs. Peter Scardino Discussion
State of the Art lecture
Moderators Michael Marberger & Franco Bergamaschi
Face to Face
Richard Gaston :- Robotics today
vs. Bertrand Guillonneau Discussion
State of the Art lecture
Round table
Moderator : Laurent Boccon-Gibod
Impact of Laparoscopy on Prostate cancer treatment
Participants Mitchell Benson
Richard Gaston Inderbir Gill Bertrand Guillonneau John Libertino David Paulson Peter Scardino Ingolf Türk Friday June th