1.  Radical Laparoscopic Prostatectomy: Managing Localized Prostate Cancer Chase Wilson M1

2. Patient Presentation  Difficulty urinating  Decreased force of urine flow  Blood in urine and/or semen  Swelling in legs  Pelvic pain

3. Clinical Screening  Digital Rectal Exam (DRE)  Abnormal size/texture of prostate  PSA > 4.0 ng/mL

4. Diagnostic Tools and Stages of Prostate Cancer  Ultrasound  Prostate biopsy (Gleason score)  CT Scan  MRI  Stage I—not detectable on DRE  Stage II—detectable on DRE, confined to prostate  Stage III—spread to seminal vesicles/nearby tissues  Stage IV—complete metastasis

5. Non-Surgical Treatment Options  Radiation Therapy  External radiation  Brachytherapy (radioactive seeds)  Hormone therapy (decrease testosterone levels)  Medications  Orchiectomy  Chemotherapy

6. Surgical Treatment Options  Retropubic Surgery  Perineal Surgery  Laparoscopic Surgery  Robotic Surgery

7. Advantages of Laparoscopic Approach  Better visualization of prostate anatomy  Reduced blood loss  Better nerve sparing  Quicker post-operative recovery

8. Laparoscopic Prostatecomy: Operating Room Layout Surgeon Patient in 30° Trendelenburg Assistants Video monitors

9. Standard Laparoscopic Instruments  0° Laparoscope  Fine dissecting scissors  Ultrasonic dissectors  Fine grasping forceps  Needle holder  Suction-irrigation device  Retrieval bag  Grasping urinary catheter  2.0 braided suture, 26 mm needle  3.0 absorbable, monofilament suture, 26 mm needle

10. Trocar Placement A: Below umbilicus B: 2 cm medial to ASIS C: Between A & B D: Midline, between umbilicus and pubic symphysis E: 2 cm medial to ASIS

11. Instrument Placement Laparoscope Grasper/s uction Grasper/suction, scissors Ultrasonic scissors, needle holder Forceps, grasper

12. Prostatectomy Procedure 1 Detach bladder from anterior abdominal wall (D1_:12) Detach bladder from anterior abdominal wall (D1_:12) 2 Anterior and lateral dissection of prostate (:16-40) Anterior and lateral dissection of prostate (:16-40) 3 Divide prostate and bladder neck (D2_:02-08) Divide prostate and bladder neck (D2_:02-08) 4 Dissection of ductus deferens and seminal vesicles (:12) Dissection of ductus deferens and seminal vesicles (:12) 5 Incise Denovillier’s fascia, dissect prostate from rectum (:22) Incise Denovillier’s fascia, dissect prostate from rectum (:22)

13. Prostatectomy Procedure 6 Carefully dissect neurovascular bundles from lateral prostate (:28) Carefully dissect neurovascular bundles from lateral prostate (:28) 7 Hemostasis and division of superficial dorsal vein (:46) Hemostasis and division of superficial dorsal vein (:46) 8 Divide prostate and urethra (:52) Divide prostate and urethra (:52) 9 Remove prostate, seminal vesicles, and ductus deferens (:57) Remove prostate, seminal vesicles, and ductus deferens (:57) 10 Vesicourethral anastomosis (D3) Vesicourethral anastomosis (D3)

14. Detach Bladder Anterior abdominal wall Bladder Future Retzius’ space

15. Anterior/Lateral Dissection Pelvic rim Prostate Location of superficial dorsal vein (Inside Retzius’s space)

16. Superficial Dorsal Vein Superficial dorsal vein Prostate Pelvic rim Pelvic floor (levator ani and endopelvic fascia) Location of nerve bundle

17. Divide Prostate and Bladder Neck Superior prostate Urinary catheter Bladder neck

18. Seminal Vesicles/Ductus Deferens Location of neurovascular bundle Ductus deferens Seminal vesicle

19. Denovillier’s Fascia Seminal vesicle Denovillier’s fascia Neurovascular bundle Rectum (deep to denovillier’s fascia) Posterior prostate

20. Nerve Sparing Neurovascular bundle Fine dissecting scissors Plexus of nerves Scissors dissect between prostatic capsule and lateral prostatic fascia

21. Division of Superficial Dorsal Vein Superficial dorsal vein Anterior prostate

22. Division of Prostate and Urethra Urethra Catheter Prostate

23. Prostate Removal Pelvic rim Lateral prostate Superior prostate

24. Vesicourethral Anastomosis Urethra Catheter w/ grasper Anchor stitch Needle holder Bladder neck

25. Time Lapse Anastomosis Urethra Bladder neck

26. Post-Operative Care  Infection control:  Antibiotics  Drain  Urinary catheter (removed ~7 days post-op)  Blood thinners  Little pain medication necessary

27. Operative Complications  Infection  Incontinence  Erectile dysfunction  Persistent cancer  Blood clots

28. References  Images and Procedure: Dr. Strup’s Radical Laparoscopic Prostatectomy Teaching DVD  Background information:  Piechaud T, Saussine C. Laparoscopic radical prostatectomy: transperitoneal approach. Epublication: WeBSurg.com, Feb 2006; 6(2). URL: http://www.websurg.com/ref/doi- ot02en302.htmhttp://www.websurg.com/ref/doi- ot02en302.htm