Contents
Introduction 133 Patient Positioning 133 Trocar Placement 133 Surgeons' Position 135
Retzius Space Development 135 Bladder Neck Dissection 135
Seminal Vesicles and Vas Deferens Dissection 135 Ligation of Santorini's Complex and Preservation
of the Accessory Sphincteric Nerve 136 Neurovascular Bundle Dissection 136 Apical Dissection 136
Anastomosis 137
Postoperative Management 139 Discussion 139
Conclusions 140 References 140
Introduction
Laparoscopic radical prostatectomy is now an accepted minimally invasive treatment for localised prostate cancer [1±4]. Access to the prostate gland can be ob- tained by two distinct techniques. Initially our French colleagues, led by the Montsouris group, advocated a transperitoneal approach. This technique is based on the primary incision ofthe peritoneum above the rec- tovesical cul-de-sac followed by dissection of the semi- nal vesicles [6±10]. However, this approach does not adhere to the basic laparoscopic tenet ofreplicating the open operation. Therefore, we developed an alter- native, purely extraperitoneal approach. This tech- nique is being adopted by an increasing number of centres [11±13]. We have now performed in excess of 250 extraperitoneal radical prostatectomies (Table 1) and in this chapter we will describe our technique in a step-by-step manner, including any modifications that we have made since our initial series was pub- lished [4].
Patient Positioning
It is important to ensure that the operating table is positioned correctly for this procedure. The foot of the table should be at the level ofthe patient's pelvis.
This allows the upper body to descend for a Trende- lenburg position. The patient is placed supine with the legs abducted, allowing the laparoscopy column to be placed between the legs ofthe patient and thus be nearer to the surgeons.
All pressure points are protected and the patient is secured. The patient is prepped and draped and cathe- terised.
Trocar Placement
The initial incision is made infraumbilically to the right ofthe midline. The rectus abdominalis muscle's anterior aponeurosis is incised on the right ofthe linea alba. The muscular fibres are cleared to the right and the posterior aponeurosis is identified. To mini- mise perioperative CO2 leakage, a purse string suture is placed on the anterior aponeurosis and the lens, with a 10-mm trocar, is advanced along the posterior
6.2 Extraperitoneal Laparoscopic Radical Prostatectomy:
The Brussels Technique
Renaud Bollens, Sarb Sandhu, Thierry Roumeguere, Claude Schulman
Table 1. Demographics (n=250 patients) andoncologic re- sults
Mean age (years) 62 (48±70)
Mean PSA 7.6 (2.2±12.4)
Mean Gleason score 6 (4±8)
pT2a 12%
pT2b 45%
pT3 43%
N0 30
N1 3
NX 167
Positive margins in pT2 9.6%
aponeurosis towards the semicircular arch ofDouglas (no. 1, Fig. 1). The CO2 pressure is set at 12 mmHg on high flow. The tip of the lens is used to develop the space ofRetzius. Care is taken to avoid damaging the epigastric vessels (Figs. 1, 2).
A second 5-mm port (no. 4, Fig. 1) is inserted 2 cm above the pubic bone to the left of the midline;
this minimises the degree ofconflict between the in- fraumbilical lens and any instrument placed in the su- prapubic port. The bipolar forceps are placed in the suprapubic port and along with the lens are used to develop the space lateral to the right epigastric vessel between the peritoneum, the transversalis fascia and the inguinal ligament ± the space ofBogros. This dis- section is carried out under direct vision with the in- struments advancing in the direction ofthe right ante- rior superior iliac crest. The bipolar forceps are used to elevate the epigastric vessels while the lens is used to mobilise the loosely adherent peritoneal reflection off the deep inguinal ring. If the peritoneum is per- forated it can act as a flap valve trapping the CO2, which increases intraperitoneal CO2pressure and thus reduces the extraperitoneal space. Ifthis occurs, the peritoneal perforation should be extended and this will allow equilibration in the pressure ofCO2, and thus improve the volume ofthe working space.
Having developed the right Bogros space, the bipo- lar forceps are used to lift the epigastric vessels with their tips pushing on the abdominal wall, identifying the site ofthe insertion oflateral 10-mm trocar, i.e.
two centimetres medial to the anterior superior iliac spine. The skin is incised from the tip of the bipolar forceps laterally. The trocar is placed in the incision and by pushing down on the muscle and not the skin, the port is introduced (no. 3, Fig. 1). The direction of the trocar is inferior but parallel to the bipolar for- ceps; this further protects the epigastric vessels.
Fig. 1. Placement of trocar. 1 First 10-mm trocar with lapa- roscopic rodlens. 2 10-mm port as working instrument. 3 10-mm port as suction. 4 5-mm port as palpator. 5 5-mm port as working instrument
Fig. 2. Creation of the extraperitoneal space. The first trocar with the laparo- scope is inserted1 cm from the mid-line on the right side at the umbilical level and the space is developed under contin- uous optical control to avoidinjury to the peritoneum or bloodvessels
To develop the left Bogros space, the monopolar diathermy scissors are placed in the right lateral port to aid the bipolar forceps. The technique for develop- ing the left Bogros space and placing the left lateral 10-mm trocar is as for the right side (no. 2, Fig. 1).
The last 5-mm port is inserted into the right rectus muscle (no. 5, Fig. 1). Particular care must be taken to identify and protect the right epigastric vessels. The lens being on the right ofthe linea alba allows this to be carried out under direct visual control.
Surgeons' Position
The surgeon stands on the left of the patient facing the caudal monitor and uses the left lateral port and the right 5-mm port. The assistant stands on the right ofthe patient also facing the monitor and uses the in- fraumbilical port to control the lens and the right lat- eral port for suction. In order to minimise the poten- tial for conflict between the surgeon's right arm and the assistant's left arm, the surgeon stands on a plat- form. This allows the surgeon and the assistant to work in different horizontal planes. A second assistant can retract the bladder with the suprapubic port ifre- quired and is responsible for the urethral bougie, which can aid in the dissection ofthe prostate.
Retzius Space Development
Prior to dissecting the prostate, any residual perito- neal attachments are mobilised; this further improves the working space. The periprostatic fat is removed from the anterior aspect of the prostate and the super- ficial dorsal vein is diathermied with the bipolar for- ceps. The limit ofthe periprostatic fat helps identify the bladder neck.
Bladder Neck Dissection
In the past we started our dissection at the apex of the prostate but ifbleeding occurs at this stage and is not adequately controlled, the blood can pool in the dependent areas and thus compromise the later dissec- tion ofthe seminal vesicles. Therefore, we now start our dissection at the bladder neck. Fibres from the puboprostatic ligament run towards the bladder. The bladder neck is identified as the point where these fi-
bres decussate. Iffurther confirmation is required in- termittent traction can be applied to the catheter bal- loon.
To facilitate the urethrovesical anastomosis, preser- vation ofthe bladder neck is attempted. Applying traction to the bladder cranially with counter-caudal traction to the prostate and monopolar diathermy al- lows the plane between the prostate and the bladder neck to develop. Bipolar diathermy is used to cauterise any bleeding. Ifthe bladder neck cannot be preserved, i.e. previous TURP, the presence ofa median lobe, or difficult planes, then the bladder neck is recon- structed.
The urethra is identified and its anterior plate is di- vided. The catheter is then removed and replaced with a metal bougie. By elevating the bougie, the posterior urethral plate and bladder neck is identified. The pos- terior dissection is started laterally and progresses medially. This minimises the opportunity for the de- velopment offalse planes. In our experience, this method allows rapid dissection combined with preser- vation ofthe bladder neck.
Once the bladder neck is dissected, the vertical fi- bres of the fascia covering the vas deferens and semi- nal vesicles are visualised. Mobilising the bladder off the vas and the seminal vesicles further develops this plane. Ifnecessary a probe can be inserted via the su- prapubic port to aid in retraction ofthe bladder.
Seminal Vesicles and Vas Deferens Dissection
The fascia covering the vas and seminal vesicles is in- cised 1 cm from the prostate. This fascia merges with the peritoneum, and one can inadvertently incise the peritoneum ifone drifts too far cranially. Once the vas deferens is identified, it is mobilised off the prostate and divided. It is important not to dissect the vas from its lateral seminal vesicles. A good length of vas allows one to apply traction, which in turn aids in the liberation ofthe seminal vesicles.
There are three vascular pedicles, the first is identi- fied anteriorly between the vas and the seminal vesi- cle, the second and most significant is at the apex of the seminal vesicle, and the third is on the posterior aspect ofthe vesicles. All three have to be identified and cauterised with bipolar diathermy. By applying continuous traction to the vas deferens, the attached seminal vesicle is elevated. The apical pedicle defines
the limit ofthe seminal vesicle. Once this has been di- vided, the vesicle is completely free anteriorly, the posterior dissection is relatively straightforward and uses the same technique oftraction and counter-trac- tion coupled with judicious diathermy.
Ligation of Santorini's Complex and Preservation of the Accessory Sphincteric Nerve
The endopelvic fascia between the prostate and the pelvic sidewall is now incised bilaterally. The adherent muscle fibres of the levatori ani are cleared off the surface of the prostate. Between the prostate and the levator ani muscle, a small accessory nerve to the ure- thral sphincter is often identified; this should be pre- served (Fig. 3). The risk ofinjury to this nerve is in- creased when the neurovascular bundles are being sa- crificed. To improve the mobilisation of the apex, the puboprostatic ligament is incised with cold scissors.
The dorsal vein complex is now readily visible, and is ligated with 0 Vicryl.
Neurovascular Bundles Dissection
The neurovascular bundles are adherent to the poste- rior aspect ofDenonvilliers fascia, therefore we devel-
op the anatomical plane between the prostate and the fascia by separating the prostate from Denonvilliers fascia and preserve the bundles with no traction. The seminal vesicles and the vas are elevated, and this de- fines the plane to be dissected. The plane is developed laterally between the prostate and the neurovascular bundle and during this process, the main vascular pedicle is identified. Blunt dissection is used to go around the pedicle, and a 0 Vicryl tie is used to con- trol the pedicle. The same technique is performed bi- laterally (Figs. 4, 5).
The pedicles are divided using cold scissors and the bundles are freed from the prostate. To avoid ther- mal injury to the neurovascular bundles, monopolar cautery is never used during this stage ofthe opera- tion, and only bipolar forceps are used to limit the ve- nous back bleeding from the prostate.
Apical Dissection
The remaining attachments ofthe prostate are the api- cal urethra and Santorini's complex. The deep dorsal veins along with the periurethral tissue are now di- vided. This allows the urethra to be clearly identified, the anterior aspect ofthis is now divided. The poste- rolateral neurovascular bundles are now identified and mobilised off the urethra. Once this has been achieved, the posterior urethral plate is divided (Fig. 6).
Fig. 3. Bladder neck dissection. The blad- der neck is usually preserved to avoid reconstruction time
This technique maximises the available urethral length as well as minimising the risk ofapical positive margins.
Anastomosis
The prostate is now placed in a laparoscopic bag (En- docatch) and the string ofthe bag is pulled through the right lateral port. A probe is introduced in the
port and the port is removed over it. The string is placed outside the port, and the port is replaced over the probe. The bag is then pulled and partially exteri- orised; this fixes the prostate out of the working envi- ronment and makes all the ports available (Figs. 7, 8).
The first suture of the anastomosis is in the mid- line at 6 o'clock. It is a U-shaped suture (Vicryl 00, SH needle), locked and tied inside the bladder. The metal bougie is then inserted into the bladder and two lateral sutures are made on each side. The final suture Fig. 4. Accessory sphincteric nerve preser-
vation. After incising the endopelvic fascia bilaterally, careful dissection is carried out to preserve the small accessory nerve to the urethral sphincter
Fig. 5. Neurovascular bundle dissection.
To minimise injury of the neurovascular bundle, we do not use bipolar coagula- tion or clips. A simple ligature is usedon the main prostatic pedicle
is at 12 o'clock and is once again a U-shaped suture.
The anastomosis is now complete.
Ifthe ureteric orifices are close to the bladder neck, the bladder neck is reconstructed at 6 o'clock. Ifthe bladder neck is too large but the ureteric orifices are a safe distance from the bladder neck, the anastomosis is carried out as before and the redundant bladder
neck is closed anteriorly using the 12 o'clock suture to carry out a running closure.
Once the anastomosis is complete, the patient is ca- theterised with an introducer. The integrity ofthe anastomosis is tested with 200 ml ofsaline. A suction drain is placed in the pelvis, the prostate is removed through an enlarged lateral port site. The aponeurosis ofall 10-mm ports are closed with 0 Vicryl and a sub- cuticular suture is used to approximate the skin.
Fig. 6. Apical dissection. The periurethral tissues are incisedfirst without the ure- thra. Defining the apex of the prostate before transacting the urethra can in- crease the urethral length
Fig. 7. Urethrovesical anastomosis. A metallic probe is used to help needle introduction into the urethra. Anastomosis is done with two U-shaped sutures and four separate stitches
Fig. 8. Endof the procedure
Postoperative Management
The patient is given appropriate analgesia as per pro- tocol. The suprapubic drain is usually removed after 48±72 h. Ifthe urine is clear at day 5 the bladder catheter is removed; ifthere is residual haematuria a cystogram is performed as a precaution.
Discussion
Over the last 5 years, several teams have developed different modalities of laparoscopic radical prostatec- tomy. The two main differences are the approaches used to gain access to the prostate, i.e. trans- or extra- peritoneal. On reviewing the recent literature, the ex- traperitoneal approach appears to be gaining favour.
Since our initial publication describing the Brussels technique [4] several revisions have been made, which have led to an improvement in our functional results.
In order to safely develop the extraperitoneal space one needs good knowledge ofthe pelvic anatomy to minimise the risk ofperitoneal perforation or vascular injury. The entire dissection should be performed un- der continuous vision. Ifthe peritoneum is perforated, the perforation may need to be extended, and a probe inserted via the suprapubic port can be used to retract the bladder and peritoneum cranially. We believe that the risk ofperitoneal or vascular injury is increased with blind or balloon dissection ofthe Retzius space and we do not advocate this.
The technique for bladder neck dissection has also evolved. Originally, we developed the urethra at the bladder neck and then divided it, leaving a consider- able urethral stump [5]. We have abandoned this in fa- vour ofthe technique described above; our present technique is safe and efficient and preserves the blad- der neck. The preservation ofthe bladder neck de- creases the risk ofureteric injury, avoids unnecessary reconstruction and reduces the operating time. If, however, there is a median lobe or ifthe planes ofdis- section are not well defined the bladder neck is sacri- ficed and reconstructed.
The division ofthe bladder neck allows one to gain optimal access to the vas deferens and the seminal vesicles. In our series, we have been able to dissect and remove the vas and seminal vesicles in all ofour patients; additionally the use ofclips or bipolar dia- thermy at this stage does not adversely affect the func- tional outcome.
The magnification and vision provided by the lapa- roscope has allowed us to identify a small accessory nerve between the prostate and the levator ani muscle.
Although previously described [14], adequate impor- tance has not been given to this nerve. The course of this nerve is not fixed, but it can run along the levator ani muscle before innervating the urethral sphincter [15]. Its precise functional impact on the continence mechanism is not fully elucidated, but we always try and preserve it.
We do not use any electrical or thermal energy to control the main prostatic pedicle, and we have been rewarded by a rapid return ofpotency in the majority ofour patients. On reviewing our last 50 cases, who had bilateral nerve sparing and who were previously sexually active, 89% were having sexual intercourse (78% spontaneously and 11% with sildenafil) at 6 months.
Modifications in our method of apical dissection have led to an improvement in the immediate conti- nence ofpatients combined with a reduction in the positive margin rate. We cut the periurethral tissue before dividing the urethra itself. This improves the length ofthe urethra, avoids traction on the posterior aspect ofthe prostatic apex and reduces the risk of leaving residual prostatic tissue close to the sphincter.
Using this apical dissection technique, the recovery of continence in our last 20 patients was significantly im- proved: perfect continence (strict definition: no pad, no leak) in 70% at 3 months and 90% at 6 months (Table 2).
The posterior and anterior U-shaped suture reduce the risk ofurinary leakage and helped to proximate the anastomosis. The bladder catheter remains in situ until at least day 5. We have attempted to remove it earlier in the past but 20% ofour patients went into retention and needed recatheterisation. This is prob- ably due to residual oedema at urethrovesical anasto-
Table 2. Continence rate (no pad, no leak) in the last 90 patients andsexual intercourse rate for the last 50 patients previously potent andbilateral nerve sparing
Continence Sponta- neous sexual intercourse
Withsildenafil Total
1 month 51% 48% +8% 56%
3 months 84% 56% +12% 68%
6 months 91% 78% +11% 89%
mosis. With respect to our oncological results, the most important criteria for surgical evaluation is the positive margin rate for pT2 tumours, and this is 10%.
Conclusions
Laparoscopic radical prostatectomy is an acceptable alternative to open surgery and has become the proce- dure ofchoice in an increasing number ofcentres around the world. The Brussels technique is a pure extraperitoneal approach most comparable to the ref- erence procedure described by Walsh.
The main goal ofa new surgical procedure for radi- cal prostatectomy is to improve recovery ofcontinence and sexual function without compromising the onco- logical results. With increasing experience, this tech- nique has evolved, allowing us to optimise our func- tional results whilst maintaining the oncological im- perative.
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