Dr. J.L HoepffnerClinique St Augustin,

Bordeaux

FRANCE

Laparoscopic Radical Laparoscopic Radical ProstatectomyProstatectomy

HistoryHistory

Schuessler ‘94Raboy ‘97Gaston ‘97Guillonneau ‘982006: 50% prostatectomies laparoscopic

LAPAROSCOPIC APROACH LAPAROSCOPIC APROACH

TRANSFORMATION of the PROSTATECTOMY :– Mini invasive Surgery– Easier exposition, Magnification of the vision – Définition anatomic plans– Précision of the gestual , Miniaturisation of the sutures – Bloodless– Post-operative more simple

LAPAROSCOPIC APROACHLAPAROSCOPIC APROACH

IMPROVEMENT OPEN SURGERY

SAFETY ONCOLOGIC

REDUCTION OF FUNCTIONAL SEQUELLA

LAPAROSCOPIC APROACHLAPAROSCOPIC APROACH

LIMITS AND DISAVANTAGES : – Quality of the vision – Steadiness of the instrument– Difficulty of the access , – Limit of the angular dissection

– Discomfort of the surgeon

LAPAROSCOPIC APROACHLAPAROSCOPIC APROACH

NEW LIMITS FOR A DISSECTION PRESERVATIVE AND ATRAUMATIC OF THE PROSTATE

NEW LIMITS FOR PROGRESS IN ERECTILE PRESERVATION

ROBOT ASSISTED: ROBOT ASSISTED: ONE ANSWER ?ONE ANSWER ?

QUALITE OF OPERATIVE VISION +++ PRECISION OF THE ANATOMIC

DEFINITION REDUCTION TRAUMATIC DISSECTION DISAPPAERANCE OF THE LIMITS OF

THE DISSECTION COMFORT AND LOGICAL ERGONOMY

FOR THE SURGEON

ROBOT ASSISTED : ROBOT ASSISTED : A TECHNICAL ADVANTAGE?A TECHNICAL ADVANTAGE?

DEMONSTRATION :

Bladder neck dissection Bundle preservation Suturing

Curative T1 – T2T3 ?Gleason score / ageNerve Sparing ?Alternative : EBRT – brachytherapy

Opératoring IndicationsOpératoring Indications

Pre-operative StatusPre-operative Status

Cardiovasculary examRespiratory FonctionHemostasis blood testNo autologus transfusion8-10 weeks after biopsies

Obesity not excludeNo bowel préparation No specific contre-indications to the

laparoscopic surgery

Pré-opératorive StatePré-opératorive State

TechniqueTechnique

Patient in Trendelenburg positionOne surgeon, one assistant5 trocars: 1 x 10 mm , 4 x 5mm Video column between the legsLaparoscope 0°

Laparoscopic InstrumentsLaparoscopic Instruments

•Needle driver

•Monopolaire

•Bipolaire

•Grasp

•Thin grasp

LAPAROSCOPIC APROACHLAPAROSCOPIC APROACH

LAPAROSCOPIC APROACHLAPAROSCOPIC APROACH

THE ROBOT

Trocards PlacementTrocards Placement

Assistent Ports

Optic Ports

Robot Ports

The   ‘Da Vinci’  Sytem The   ‘Da Vinci’  Sytem

THE ROBOT

THE ROBOT

THE ROBOT

Laparoscopic Bladder Neck Laparoscopic Bladder Neck Dissection Dissection

Bladder Neck Robotic Bladder Neck Robotic Dissection Dissection

Seminales Vesicules Seminales Vesicules Laparoscopic DissectionLaparoscopic Dissection

Right Bundle Laparoscopic Right Bundle Laparoscopic DissectionDissection

Intrafasciale Robotic DissectionIntrafasciale Robotic Dissection

Apex Laparoscopic DissectionApex Laparoscopic Dissection

Apex Robotic Dissection (1)Apex Robotic Dissection (1)

Apex Robotic Dissection(2)Apex Robotic Dissection(2)

DVC SutureDVC Suture(running suture)(running suture)

Urétro-Vésicale Laparoscopic Urétro-Vésicale Laparoscopic Anastomosis Anastomosis

(running suture)(running suture)

Anastomose Robotique Anastomose Robotique urétro-vésicale urétro-vésicale

(running suture)(running suture)

Laparoscopic DataLaparoscopic Data

3000 patientsStudy of 1574 filesMean Psa 6,72Mean Gleason score 6,27Age 61,9 years old

Eur Urol. 2006 Feb;49(2):344-52

OUR DATA OUR DATA

OPERATIVE TIME 120 MNHOSPITALISATION 5.7 JOURS0 CONVERSION in 7 years

OUR DATAOUR DATA

COMPLICATIONS

HAEMORRHAGES 1.3%

ANASTOMOSIS FISTULA 0.3%

RECTAL INJURY 0.5%

URETERAL INJURY one case

ANASTOMOTIC STENOSIS <1%

EVENTRATION <1%

OUR DATAOUR DATA

PATHOLOGICAL RESULTS 1293

PT2A 10.2%

PT2B.C 57.8%

PT3A 28.2%

PT3B 3.8%

MARGINSMARGINS

TOTAL 22%

T2 14%

T3 36%

FUNCTIONAL RESULTSFUNCTIONAL RESULTS

CONTINENCE

ERECTION : THE CHALLENGE – better result ? – Better complete recovery? – reduce the delay of recovery ?

– OBLIGATION of an EVALUATION

!!How can we improve functional result ? How can we improve functional result ?

Better knowledge of the prostate anatomy Better knowledge of the prostate anatomy

??

High incision of pelvic fasciaHigh incision of pelvic fascia

From Eichelberg C,

European urology, 2006

Principles of Principles of preservationpreservation

During radical prostatectomy, innervation of the trigone, neobladder neck, and posterior urethra may become disrupted, because the surgical procedure involves anatomic dissection around the prostate, posterior aspects of the bladder base, and seminal vesicles.

afferent innervation of the trigone posterior urethra may lead to alterations in

posterior urethral sensation

indirectly contribute to outlet incompetence

From Hubet John

UROLOGY 55: 820–824, 2000.

96,3%96,3%

62,7%62,7%

45%45%

85,7%85,7%

The percentage continence rates at a4 weeks and 12 The percentage continence rates at a4 weeks and 12 months after surgery. months after surgery.

From Peter Albers

Level of Evidence 1b

BJU Int 1 0 0 , 10 5 0 – 10 5 4, 2007

Antegrade dissectionAntegrade dissection Traction on Seminal vesiclesTraction on Seminal vesicles

Injury to the nervesInjury to the nerves

From Stolzemburg

European Urology 51 ( 2 0 0 7 ) 629–639

Detrusor apronDetrusor apron

Detrusor apron (arrowheads) in Masson

trichrome-stained sagittal section through

adult cadaveric prostate. Detrusor apron ends

in tuft (arrow) that is transected end of

pubovesical (puboprostatic) ligament. Tuft

contains fibrous tissue (blue) and smooth

muscle fibers (red) that curve and course

anteriorly to the large venous sinus. s,

sphincter; u, urethra; P-pz, prostate-peripheral

zone; Bu, bulb of penis; R, rectum.

Inset, magnified tuft. Note, smooth muscle

fibers beneath leftmost arrowhead stained

poorly.

From Robert P. MyersUROLOGY 59: 472– 479, 2002

FUNCTIONAL RESULTSFUNCTIONAL RESULTS

QUESTIONNAIRE ICS CONTINENCE

NO PADS AT 6 MONTHS 87%

FUNCTIONAL RESULTSFUNCTIONAL RESULTS

AUTOQUESTIONNAIRE IEFF 5 FOR THE SEXUALITY

57% AT ONE AYEAR

LAPAROSCOPYLAPAROSCOPY

REVOLUTION IN THE SURGICALTECHNIQUE

RESULTS THE SAME THAN OPEN

GREAT DEVELOPPEMENT

LAPAROSCOPYLAPAROSCOPY

DIFFICULTY OF THE FIRST CASES

LEARNING CURVE

PUBLICITY OF A NEW TECHNIQUE

LAPAROSCOPYLAPAROSCOPY

THE ROBOT ?

ROBOTIC DATAROBOTIC DATA

230 PATIENTS 2005 2 CONVERSIONS IN CLASSICAL LAP TRANSFUSION 2% OPERATVE TIME 150MN

Positive MarginsPositive Margins

LaparoscopyLaparoscopy

30,75

69,25

18,49%

81,50%

SexualitySexuality

58,5 %41,5 %

80 ,3%

19,7%

ContinenceContinence

Laparoscopy at 1 YearLaparoscopy at 1 Year

5%

95 %

Robotic at 4 months Robotic at 4 months

7,60 %

92,40 %

ROBOTIC DATAROBOTIC DATA

HOSPITALISATION 4.6 DAYS

FOR 100CAS

CONTINENCE AT 3 MONTHS 72%

ERECTION +- viagra 66.9%

CONCLUSIONS CONCLUSIONS

ROBOTIC ASSISTED :

………..MAKE EASIER THE RADICAL PROSTATECTOMY

Quality of the vision Miniaturization of the dissection Preservation of the anatomical structures

…….IMPROVE FUNCTIONNALS RESULTS

CONCLUSIONS CONCLUSIONS

ROBOTIC ASSISTED ………THE LIMITS :

– ECONOMIC COST

– TIME IN THE THEATER MORE LONGER – LEARNING CURVE

CONCLUSIONS CONCLUSIONS

ROBOTIC ASSISTED :

A HIGH LEVEL OF OPERATIVE QUALITY

EXCELLENT FOR RADICAL PROSTATECTOMY

LOGICAL AFTER OR AT THE SAME TIME FOR A LAP CENTER

CONCLUSIONSCONCLUSIONS

Radical prostatectomy: treatment of choice

Laparoscopic prostatectomy: excellent approach

Robotic prostatectomy: The future or the present??

But…But…

…we are still far away from the comprehension of the prostate’s anatomy, and we are confident that the robotic technique will give us a great help……