3.10 Prostatic Adenomectomy3.10.1 Laparoscopic Adenomectomy

René Sotelo Noguera, Camilo Mejia Buendia

Introduction Open surgery has been the gold standard for the treatment of benign, symptomatic, large-volume prostatic hyperplasia. Since 2002, many laparoscopic studies have been conducted that duplicate this technique. These investigators have achieved results comparable to open surgery, while main-taining the advantages of a minimally invasive approach.

Mariano et al. [1] first reported the use of a laparoscopic approach for simple prostatectomy that was performed in a patient with benign prostatic hyperplasia (BPH). In this case report, a longitudinal vesicocapsular incision was made to extract a 120-g prostate adenoma, with a total of four haemostatic sutures used for vascular control. Van Velthoven et al. [2] reported their initial experience with laparoscopic extraperitoneal Millin prostatectomy in 18 patients, duplicat-ing the open technique. Sotelo et al. [3, 4] described a horizontal cystotomy incision proximal to the junction of the bladder and prostate. The technique was performed for laparoscopic simple prostatectomies in 17 patients with symptomatic significant prostatomegaly as well as robotically in seven patients. A French group [5] has described how to assist the enucleation with the finger. In this section, we will describe the developed technique in detail.

Indications Preoperative evaluation includes history and physical examination, as well as digital rectal examination and routine laboratory tests. These include prostate-specific antigen, International Prostate Symptom Score (IPSS) and quality of life (QOL) questionnaires, uroflowmetry, and transrectal ultrasound (TRUS) evaluation with prostate volume measurement.

!" Selection criteria are symptomatic BPH with a TRUS and an estimated gland weight of 60 g or more.

Contra- !"Prostate cancerindications !"Morbid obesity" !"Anticoagulation therapy" !"Anaesthetic contra-indications

Preoperative !"The patient should stop taking antiplatelet or any anticoagulant medication at least 8 days Preparation before surgery

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Step 1: Port placement

A five-port extraperitoneal or transperitoneal approach is used with the patient under general anaesthesia, in a modified Trendelenburg position (Step 1). The camera trocar is placed through the rectus muscle sheath on the right side just under the umbilicus. The left trocars are placed on the line between the umbilicus and anterior left iliac crest. The medial trocar is inserted 2–3 cm from

the umbilicus and the lateral 2–3 cm from the iliac crest. The right trocars are placed as mirror images to the left ones. The insertion of the camera trocar for the transperi-toneal approach is performed with either a Veress needle or the open Hasson technique. Alternatively, balloon dilation of the extraperitoneal space is performed.

Step 2: Entrance to the Retzius space and initiation of cystotomy

After mobilising the bladder (for the transperitoneal approach), the Retzius space is entered and the anterior surface of the prostate capsule is cleared of overlying fatty tissue (Step 2a). The extraperitoneal approach does not require bladder mobilisation as the Retzius space is accessed directly during the balloon dilation. A haemo-static back bleeding stitch is placed near the prostate

base, which also allows the anterior traction of the pros-tate. A transverse cystotomy incision is made 1–2 cm proximal to the junction of the bladder and the prostate (Step 2b). An ultrasonic scalpel or J-hook electrocautery instrument is used because they provide accurate inci-sions and haemostasis.

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Step 3: Cystotomy

The anterior bladder neck is incised and the bladder lumen is entered (Step 3a). Alternatively, the incision could be made over the junction of the bladder and prostate as per the surgeon’s preference. The prostate and bladder mucosa are visualised and should be carefully inspected. The ureteral orifices should be identified. The latter structures are usually close to the large medial

lobes and may interfere with the adenoma excision, resulting in injury. In difficult cases, the bilateral inser-tion of double-J stent is advisable. The latter manoeuvre provides constant visualisation of the orifices and it is easier to avoid injuries. Step 3b shows a bulging large median lobe of the prostate with the bladder mucosa overlying the prostate.

Step 4: Traction of the medial lobe

A large, bulging medial lobe can be retracted anteriorly in an efficacious manner with a figure-eight stay stitch. The suture is placed using a standard laparoscopic method or using a Keith needle or Carter-Thomason port closure needle device. Step 4a demonstrates the placement of retraction suture using a needle holder. The two ends of the stay stitch are retrieved and anchored

outside of the anterior abdominal wall. Thus, continuous traction of the prostate adenoma towards the abdominal wall is applied and the dissection of the adenoma from the surrounding prostatic tissue is facilitated (Step 4b). Continuous retraction of the adenoma by the assistant using a grasper is not advisable.

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Step 5: Bladder mucosal incision and subcapsular dissection plane

The excision of the prostatic adenoma is initiated by a horizontal posterior incision on the bladder mucosa overlying the prostate lobes at the site of the bladder neck (Step 5a). This semicircular mucosal incision is located between the 8 o’clock and 6 o’clock positions of the bladder neck and is extended up to the 4 o’clock posi-tion. The dissection plane is gradually deepened until the prostatic adenoma is identified by its characteristic

white texture. Careful blunt and electrocautery dissec-tion is performed to reach the proper subcapsular plane outside the prostate adenoma and inside the prostatic capsule (Step 5b). A Monocryl suture on a CT-1 needle is placed through the one of the lobes of the adenoma for retraction purposes. The retracted lobe is the first to be further dissected.

Step 6: Mucosal incision and initiation of adenoma enucleation

Semicircular movements, using J-hook electrocautery, ultrasonic scissors and/or a suction-irrigation cannula, progressively free the adenoma from the inside of the prostate capsule. The left lateral lobe is dissected first. Step 6a presents the dissection of adherences at the proximal side of the subcapsular plane between the left lobe and the prostatic capsule. The initial mucosal inci-

sion is completed circumferentially to provide adequate exposure to the underlying prostate (Step 6b). The as-sistant uses the suction cannula to provide tension to the opposite side and to facilitate the dissection. In fact, the cleavage plane between the prostatic adenoma and capsule is better identified by the latter manoeuvre.

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Step 7: Adenoma enucleation

The dissection is extended distally through a largely avascular subcapsular plane towards the apex of the prostate. At the same time, the assistant provides suction and retraction as previously described. Haemostasis of bleeding blood vessels is ensured with electrocautery or the ultrasonic scalpel. Step 7a shows the left prostatic lobe mobilised completely from the capsule. The left

lobe is mobilised first and the right lobe follows. Step 7b shows the placement of the retraction suture on the right prostatic lobe. The enucleation of the right lobe is identi-cal to the described technique. Specific care should be taken at the apex of the prostate. The transection of the urethra includes a significant risk for injury to the exter-nal sphincter and avulsion.

Step 8: Enucleation with Sotelo prostatotomy

The adenoma is enucleated using a Sotelo prostatotome (Step 8), a metallic device similar to a curette or an osteotome. The instrument facilitates the dissection of the adherences between the adenoma and the capsula in the precise subcapsular plane (Step 8b). The instrument is used with a gently circumferential movement at the subcapsular plane and provides blunt division of the adenoma from the capsule. The curved shape of the

instrument imitates the shape of the adenoma. The assistant provides tension by retracting the prostate on the side opposite the adenoma. It is important to avoid sharp dissection with the instrument with direction towards the apex of the prostate because this may cause injury to the sphincter. The dissection is facilitated using the Sotelo prostatotome.

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Step 9: Transection of the urethra

Step 9a demonstrates a mobilised urethra from the pro-static capsule adenoma. Both lobes are free and the only adherence of the adenoma is the urethra. Intracapsular urethral transection follows and the prostatic adenoma is removed (Step 9b). Specific care is taken at this point of the procedure. Injury to the external sphincter and avulsion should be avoided. Therefore, the transection

should never be performed using the ultrasonic scalpel and only cold scissors are indicated. Coagulation should be avoided over or near the sphincter. During the dissec-tion of the lobes near the apex, gentle traction should be applied to the adenoma because the risk of avulsion in such a delicate structure is high. A urethral catheter is inserted to facilitate the visualisation of the urethra.

Step 10: Haemostasis

Every attempt is made to maintain good haemostasis during this dissection, so that enucleation proceeds under clear visualisation. If necessary, an ultrasonic scalpel or haemostatic figure-eight suture can be placed at the 4–5 and 7–8 o’clock positions at the proximal prostatic capsule. The latter sites are associated with the prostatic pedicles and the neurovascular bundles on the

external lateroposterior side of the prostate. Significant bleeding is not uncommon at this site, and efficient in-sertion of these sutures is imperative. Step 10a presents the placement of the sutures at the above sites. Step 10b demonstrates the empty prostate capsule and the ana-tomical landmarks identified after the removal of the adenoma.

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Step 11: Trigonisation

In case of a redundant or hypermobile incised edge of the bladder neck mucosa, the bladder neck stump is suture-approximated to the floor of the prostatic fossa or to the posterior wall of the urethra in an attempt to trigonise the fossa. Step 11a provides a close-up of the retracted and sutured posterior bladder neck mucosa to the level of the urethral stump. The sutures could be placed on the posterior wall of the prostatic fossa or the

posterior urethral wall depending on the tension be-tween the two structures. Step 11b shows a wider view of the trigonisation manoeuvre. The bladder neck mucosa has been sutured to the posterior urethra. Redundant bladder neck mucosa could function as a valve and interfere with urination postoperatively. The trigonisa-tion attempts to stabilise the above tissue and prevent further unwelcome events.

Step 12: Closure of the bladder

Once the surgeon is satisfied that there is adequate haemostasis, a three-channel Foley catheter (22 or 24 F) is inserted. The balloon is inflated with 25–30 cc of saline. Step 12a shows the initiation of closure of the transverse incision of the bladder. The transverse cystotomy is closed with a running Vicryl suture on a CT-1 needle in a watertight two-layer manner. Step 12b

shows completed cystotomy closure. The irrigation is connected to the catheter and the watertightness of the closure is evaluated. A nonsuction drain is inserted. The prostatic adenoma is removed using an endobag via the incision of the lateral left trocar. Careful inspection of the operative field and extraction of the trocars follows. All incisions are closed.

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Postoperative !"The continuous irrigation is usually removed after 12 h once the absence of bleeding has been Management confirmed !"The Foley urethral catheter is removed in 5–7 days

References 1. Mariano MB, Graziottin TM, Tefelli MV (2002) Laparoscopic prostatectomy with vascular control for

benign prostatic hyperplasia. J Urol 167:2528–25292. Van Velthoven R, Peltier A, Laguna MP et al (2004) Laparoscopic extraperitoneal adenomectomy

(Millin): pilot study on feasibility. Eur Urol 45:103–1093. Sotelo R, Spaliviero M, Garcia-Segui A, Novoa J, Desai MM, Kaouk JH, Gill IS (2005) Laparoscopic

retropubic simple prostatectomy. J Urol 173:757–7604. Sotelo R, Clavijo R, Carmona O, Garcia A, Banda E, Miranda M, Fagin R (2008) Robotic simple pros-

tatectomy. J Urol 179:513–5155. Njinou Ngninkeu B, de Fourmestreaux N, Lufuma E (2007) Digitally-assisted laparoscopic prostatic

adenomectomy: a preliminary report of 75 cases [abstract]. J Urol 177:578–579