Fig. 52.1
(a, b) Schematic drawing of interfascial (a) and intrafascial nerve-sparing prostatectomy. Ef endopelvic fascia (this corresponds to the parietal layer of endopelvic fascia, i.e. levator ani fascia LAF), pf periprostatic layer (this correspond to the lateral prostatic fascia LPF), pc prostatic capsule, pp prostatic pedicle, nvb neurovascular bundle (By Stolzenburg et al. [20], with permission from “Elsevier” in lieu of “Springer”. )
52.3 Indications and Contraindications of Descending Technique of Laparoscopic Radical Prostatectomy
The indications for the descending technique is the same as that of any radical prostatectomy. The contraindications are those conditions which preclude any laparoscopic surgery.
52.4 Required Instruments
The required material is simple and comprises (Fig. 52.2a–g):
Fig. 52.2
View of the basic instruments needed for a LRP: (a) The five trocars. (b) The components of a 5-mm trocar: obturator, threaded cannula and seals. (c) A sealed 10-mm cannula and obturator. (d) Suction-irrigation cannula. (e) Fenestrated grasper (Johan). (f) Bipolar grasper, monopolar scissor, fine forceps and needle-holder. (g) Clips applier (Aesculap®)
- 1.
A 0° camera + endoscope, and a video + insufflator column.
- 2.
Five cannulas (trocars): One 10-mm for the endoscope and four 5-mm threaded cannulas for the instruments.
- 3.
Laparoscopic instruments: One each of fenestrated forceps (Johan’s grasper), fine forceps, monopolar scissor, bipolar grasper, suction-irrigation device, needle-holder and 5-mm clip-applier.
- 4.
Suture materials: One 26-cm long 3/0 V-Loc™ thread mounted on a 25-mm needle, one 3/0 Monocryl® (poliglecaprone 25) mounted on a 26-mm needle, one no 1 Vicryl® (polyglactin 910), one 4/0 rapid Vicryl® or one stapler.
- 5.
Tissue retrieval pouch: One Lapbag® 75 × 150 mm.
- 6.
Basic open surgery items:
Characteristically we do not use Hem-o-lock® clips, Ligasure™ vessel sealing, or Harmonic scalpel (Ultracision®). We rarely use the Veress insufflation needle.
52.5 Details of the Technique
- 1.
Patient’s skin preparation and installation: Once patient is under general anesthesia, sterile drapes are placed. The patient is then catheterized using a 2-way 18-Fr Foley’s device, 5 cc water is used to inflate the balloon. Prophylactic antibiotic is given. The patient’s positioning is supine in 30° Trendelenberg position with the legs kept slightly apart, and the video column is placed between the legs.
- 2.
The following port description applies for a right-handed surgeon who will stand on the left side of the patient. A 10-mm incision is made in the skin and the rectus sheath just 1 cm below or above the umbilicus respectively for the extraperitoneal or transperitoneal approach. For the extraperitoneal technique, a 10-mm trocar (port 1) is obliquely inserted at an angle of about 45°, while for the transperitoneal access the insertion is performed in a more perpendicular direction.
Telescope tip is used in combination with pneumodissection to create a larger working space in the extraperitoneal technique, until the Retzius space is developed, and the bladder neck, the pubic arch, i.e. the symphysis pubis + the horizontal pubic rami, and the inferior epigastric arteries are clearly visualized. Rest of the trocars are placed as shown in the figure (Fig. 52.3).
Port 2 and 4 are the left hand and right hand surgeon working port respectively. Port 3 and 5 are for the assistant.
- 3.
Surgical steps:
Note: When the transperitoneal technique is performed, the procedure starts posteriorly by releasing the sigmoid colon from its parietal attachment and cautiously mobilizing it up, in order to free the true pelvis. Then the urachus is sectioned and the urinary bladder is progressively released from the anterior abdominal wall. The dissection is carried out laterally till the umbilical ligaments to develop the Retzius space. The pubic arch is clearly visualized and the anterior aspect of the prostate is identified along with the fascial tendinous arch of the pelvis. From this point, the two approaches (transperitoneal and extraperitoneal) are identical.
Step 1: Bladder neck approach and dissection (Fig. 52.4a–e). Three tricks can be used to identify the bladder neck:
Fig 52.4
Bladder neck dissection. (a) The bladder neck is the last portion of the flabby bladder just above the firm prostate. (b) The dissection starts on the left side (c) Dissection continued on the right side and posteriorly. (c) The assistant opens the fenestrated forceps below the bladder neck to show the demarcation between the prostate and the bladder. (d) The bladder neck is now fully skeletonized. (e) Division of the bladder neck
- (a)
“Palpation” with the bipolar forceps and/or the suction cannula: The urinary bladder is flabby while the prostate is firm. The bladder neck corresponds to the last flabby cm just above the firm-feeling prostate.
- (b)
Traction on the catheter: The balloon is blocked at the bladder neck.
- (c)
Traction on the bladder dome: The angle between the stretched bladder and the fixed prostate becomes obvious.
Once the bladder neck is identified, the catheter balloon is emptied. Dissection starts anteriorly and continues on both sides and posteriorly until the vasa deferentia or the seminal vesicles are identified. Small blood vessels may be encountered, which are fulgurated using the bipolar forceps. Urethra is skeletonized to clearly demarcate the bladder from the prostate, the bladder neck is opened and the catheter pulled back.Related posts:
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- (a)
