Laparoscopic Radical Prostatectomy
The patient is placed in a supine position with 10-20 degrees of Trendelenberg. A 20 Fg catheter is inserted per urethra and 20cc of water inserted into the balloon.
- one 5mm, two 12mm disposable trocars
- 5mm fenestrated Johan grasping forceps x2
- 5mm Needle holders x2
- Laparoscopic pledgets
- 10mm bipolar diathermy
- 5mm Maryland forceps
- 5mm J Hook
- Urethral sound
- 5mm scissors
- Medium (purple) Haemo-Lock Clips
- Suction irrigation
A 10mm incision is made just inferior to the umbilicus and the anterior rectus sheath is incised using MacIndoe scissors. The anterior sheath is then retracted vertically using a 5mm retractor.
A 10mm diameter inflatable balloon port (Tyco XB2 Endoview) is inserted through the incision in the anterior rectus sheath and passed caudally until the symphysis pubis can be palpated. A zero degree laparoscope is then passed into the port and the balloon is inflated with a hand pump. Approximately 400cc of air is insufflated until the following landmarks can be identified:
- Left and Right inferior epigastric arteries
- pubic arch and symphysis
- external iliac vessel pulsation
- internal inguinal rings are checked for any signs of herniation.
The balloon is then deflated and the preperitoneal space is checked for haemorrhage.
The placements of ports are very much operator dependent, however the following points need to be considered:
- with only one assistant only three ports are required – two for the surgeon and one for the free hand of the assistant for traction and suction.
- if an additional assistant is used or robotic camera holder employed, four ports can be utilized.
- a minimum of one 10mm port is required to allow introduction of sutures for intra-corporeal stitching. Two 10mm ports allow more flexibility.
- if the surgeon’s operating ports are placed either side of the primary camera port, this allows easier triangulation, but is less ergonomic. The alternative is to have the two operating ports to the left of the camera.
All ports should be inserted under endoscopic vision angled down towards the prostate. Structures to be avoided during placement include the inferior epigastric arteries, iliac veins, bladder and peritoneum.
A bilateral lymphadenectomy is conducted removing lymphatic tissue in the area bounded by the pubic bone, external iliac vein and obturator nerve. The lymphatic channels are sealed using 5mm titanium ligaclips to prevent a post-operative lymphocele.
- Endopelvic fascia incision.
The prostate is retracted medially using a laparoscopic pledget, thus placing the endopelvic fascia under tension. A 1mm puncture is made in the fascia using a monopolar hook and then a linear incision is made in the endopelvic fascia from the vesico-prostatic junction to the edge of the pubo-prostatic ligaments using cold scissors. The lateral edge of the dorsal venous complex is then defined using a lap pledget.
This process is repeated on the contralateral side.
- Dorsal venous complex ligation.
The prostate is retracted inferiorly and a 1 Polysorb suture cut to 20cm is mounted in a needle holder in a plane parallel to the pubic arch. The needle is then rotated between the DVC and urethral wall and withdrawn at the contralateral side of the apex. A surgeon’s knot tied intracorporeally is then used to secure the DVC and pubo-prostatic ligaments. A helpful technique to facilitate this manoeuvre includes replacing the catheter with the urethral sound so that the prostate can be moved from side to side to facilitate the entry point of the needle and pick-up.
A further suture is then placed at the level of the anterior bladder neck to prevent back-bleeding from the superficial vesical veins.
- Anterior bladder neck dissection.
The pre-prostatic veins are divided between the sutures with cold scissors and a lateral release performed bilaterally to allow the NVBs to fall posteriorly. The anterior neck is then identified by gentle to-and-fro traction on the urethral catheter. A combination of sharp and blunt dissection is then used to delineate the anterior and lateral walls of the bladder neck. Extra care on the lateral aspect of the anterior bladder neck will help prevent ureteric damage at the next step of the procedure.
The urethra is then incised anteriorly, the catheter balloon deflated and the catheter is grasped with a Johann forceps and used to retract the prostate superiorly by the assistant.
- Posterior bladder neck dissection.
The posterior bladder neck is easily visualized with the prostate retracted and is then assessed for the presence of a median lobe and the exact location of the ureteric orifices. A horizontal incision is then made at the proposed line of trans-section. As this incision is developed, the posterior edge of the bladder neck is grasped in the midline with a Johann forceps and retracted anteriorly. The posterior bladder wall is then peeled off the prostate with a combination of sharp and blunt dissection. Care must be taken not to button-hole the posterior wall of the bladder. The anterior layer of Denonvillier’s fascia is then identified as a midline raphe and incised horizontally.
Incision of the mid-line raphe allows access to the paired ampullae which are grasped and retracted cranially. The vasa deferentia are dissected free of their investing tissue and ligated with locking nylon clips. These are then divided with cold scissors.
- Dissection of seminal vesicles.
The freed ampullae are then grasped and retracted anteriorly. This allows access laterally to the seminal vesicles. Whilst it is safe to perform the circumferential dissection with bipolar diathermy, the tips of the vesicles lie very close to the NVBs and it is important not to use any thermal or electrical energy in this region. The artery is therefore ligated with locking nylon clips.
Both seminal vesicles are then grasped and retracted anteriorly. The urethral sound is re-inserted and the prostate angled laterally. This places the lateral pedicle under tension and allows accurate vision of the NVB. If a nerve-sparing procedure is to be carried out, then each feeding vessel to the prostate is individually clipped and divided and all forms of thermal energy are avoided. This process is repeated on the contralateral side.
The prostate is then retracted posteriorly placing it under tension. Cold scissors are then used to dissect the apex of the prostate free taking care to preserve the external-urethral sphincter mechanism and the NVBs that pass just lateral to the sphincter complex.
The anterior urethra is transsected just distal to the apex of the prostate and the urethral sound advanced. The urethral is then elevated anteriorly and the posterior wall and recto-urethralis divided. The specimen is then placed in an entrapment bag.
- Vesico-urethral anastomosis
Two 3/0 laparoscopic sutures (EV-23 17mm needle) are then tied together and introduced via one of the 10mm ports. Van Velthoven described a technique of a continuous Vesico-urethral anastomosis that, once mastered results in a tension-free, water-tight anastomosis that takes 30 minutes to complete (5). This technique is endorsed by the author.
An 18F silicon catheter is inserted and the anastomosis is checked for integrity by filling the bladder with 250cc of warm saline. The specimen is delivered using an Espiner retrieval bag via the camera (sub umbilical) port.
This allows for a very good final cosmetic result!