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Dr. J.L Hoepffner Clinique St Augustin, Bordeaux FRANCE

Laparoscopic Radical Prostatectomy. Dr. J.L Hoepffner Clinique St Augustin, Bordeaux FRANCE. History. Schuessler ‘94 Raboy ‘97 Gaston ‘97 Guillonneau ‘98 2006: 50% prostatectomies laparoscopic. LAPAROSCOPIC APROACH. TRANSFORMATION of the PROSTATECTOMY : Mini invasive Surgery

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Dr. J.L Hoepffner Clinique St Augustin, Bordeaux FRANCE

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  1. Laparoscopic Radical Prostatectomy Dr. J.L Hoepffner Clinique St Augustin, Bordeaux FRANCE

  2. History • Schuessler ‘94 • Raboy ‘97 • Gaston ‘97 • Guillonneau ‘98 • 2006: 50% prostatectomies laparoscopic

  3. 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

  4. LAPAROSCOPIC APROACH • IMPROVEMENT OPEN SURGERY • SAFETY ONCOLOGIC • REDUCTION OF FUNCTIONAL SEQUELLA

  5. LAPAROSCOPIC 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

  6. LAPAROSCOPIC APROACH • NEW LIMITS FOR A DISSECTION PRESERVATIVE AND ATRAUMATIC OF THE PROSTATE • NEW LIMITS FOR PROGRESS IN ERECTILE PRESERVATION

  7. ROBOT ASSISTED: 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

  8. ROBOT ASSISTED : A TECHNICAL ADVANTAGE? DEMONSTRATION : • Bladder neck dissection • Bundle preservation • Suturing

  9. Opératoring Indications • Curative • T1 – T2 • T3 ? • Gleason score / age • Nerve Sparing ? • Alternative : EBRT – brachytherapy

  10. Pre-operative Status • Cardiovasculary exam • Respiratory Fonction • Hemostasis blood test • No autologus transfusion • 8-10 weeks after biopsies

  11. Pré-opératorive State • Obesity not exclude • No bowel préparation • No specific contre-indications to the laparoscopic surgery

  12. Technique • Patient in Trendelenburg position • One surgeon, one assistant • 5 trocars: 1 x 10 mm , 4 x 5mm • Video column between the legs • Laparoscope 0°

  13. Laparoscopic Instruments • Needle driver • Monopolaire • Bipolaire • Grasp • Thin grasp

  14. LAPAROSCOPIC APROACH

  15. LAPAROSCOPIC APROACH

  16. THE ROBOT

  17. TrocardsPlacement Optic Ports Assistent Ports Robot Ports

  18. The   ‘Da Vinci’  Sytem

  19. THE ROBOT

  20. THE ROBOT

  21. THE ROBOT

  22. Laparoscopic Bladder Neck Dissection

  23. Bladder Neck Robotic Dissection

  24. Seminales Vesicules Laparoscopic Dissection

  25. Right Bundle Laparoscopic Dissection

  26. Intrafasciale Robotic Dissection

  27. Apex Laparoscopic Dissection

  28. Apex Robotic Dissection (1)

  29. Apex Robotic Dissection(2)

  30. DVC Suture(running suture)

  31. Urétro-Vésicale Laparoscopic Anastomosis (running suture)

  32. Anastomose Robotique urétro-vésicale (running suture)

  33. Laparoscopic Data • 3000 patients • Study of 1574 files • Mean Psa 6,72 • Mean Gleason score 6,27 • Age 61,9 years old Eur Urol. 2006 Feb;49(2):344-52

  34. OUR DATA • OPERATIVE TIME 120 MN • HOSPITALISATION 5.7 JOURS • 0 CONVERSION in 7 years

  35. OUR DATA COMPLICATIONS HAEMORRHAGES 1.3% ANASTOMOSIS FISTULA 0.3% RECTAL INJURY 0.5% URETERAL INJURY one case ANASTOMOTIC STENOSIS <1% EVENTRATION <1%

  36. OUR DATA • PATHOLOGICAL RESULTS 1293 PT2A 10.2% PT2B.C 57.8% PT3A 28.2% PT3B 3.8%

  37. MARGINS TOTAL 22% T2 14% T3 36%

  38. FUNCTIONAL RESULTS • CONTINENCE • ERECTION : THE CHALLENGE • better result ? • Better complete recovery? • reduce the delay of recovery ? • OBLIGATION of an EVALUATION

  39. How can weimprovefunctionalresult ? ? ! Betterknowledgeof the prostate anatomy

  40. Principlesofpreservation High incision of pelvic fascia From Eichelberg C, European urology, 2006

  41. 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.

  42. The percentage continence rates at a4 weeks and 12 months after surgery. Level of Evidence 1b 96,3% 85,7% 62,7% 45% From Peter Albers BJU Int 1 0 0 , 10 5 0 – 10 5 4, 2007

  43. Antegradedissection • Traction on Seminalvesicles Injury to the nerves

  44. From Stolzemburg European Urology 51 ( 2 0 0 7 ) 629–639

  45. Detrusor 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. Myers UROLOGY 59: 472– 479, 2002

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