Laparoscopic Prostatectomy

Despite the fact that open retropubic prostatectomy (RRP) is widely considered the preferred treatment for organ-confined prostate cancer, laparoscopic radical prostatectomy (LRP) has become standard therapy for organ-confined prostate cancer and is growingly conducted at selected centers worldwide.

In the 1990s, Schuessler, a non-academic, performed the first LRP with the help of two endourologists with laparoscopic renal surgery experience. These pioneers were able to do nine LRP surgeries with success but discovered no advantage over open prostatectomy. The procedure was lengthy and complicated, with an abnormally long operative time. In comparison to RRP, the researchers indicated that the technique provided no benefit.

Guillonneau et al. published a step-by-step technique for transperitoneal LRP in 1998. Guillonneau and colleagues produced a series exhibiting significant improvements in postoperative convalescence after significantly refining the procedures at Montsouris in France. The operation was proven to be practical, but more importantly, despite the steep learning curve.

Various European teams have contributed to the general experience using this technique since then. Even skilled laparoscopists in the United States were skeptical of LRP. Gill and Zippe, who specialized in renal laparoscopic surgery at the time, were among the first to start a laparoscopic pelvic surgery program.

LRP gained popularity after 1997 and, in some facilities, became the surgical strategy of choice for the treatment of localized prostate cancer due to its benefits. The most encouraging benefits observed appear to be the lower blood loss and transfusion rate related to the laparoscopic method, as well as a shorter hospital stay, decreased catheterization time, improved pain control, and a faster return to daily activities.

Laparoscopic Radical Prostatectomy

LRP stands for laparoscopic radical prostatectomy, which is a type of prostatectomy for prostate cancer. Unlike the original open surgery, it does not require a large incision and instead makes use of fiber optics and downsizing.

Radical Prostatectomy, both laparoscopic and open, removes the entire prostate and reconstructs the urethra to reattach to the bladder. The methods for accessing the deep pelvis and producing operating views differ between laparoscopic and open radical prostatectomy. As opposed to open prostatectomy, laparoscopic prostatectomy does not require the use of retractors and does not require the abdominal wall to be separated and stretched throughout the procedure.

Laparoscopic Prostatectomy Indications

Patients with medically localized prostate cancer (stages T1 and T2), no signs of metastases either clinically or radiographically (Computer Tomography, and bone scan), a low PSA level (less than 10 ng/mL), a Gleason score of 7, and age 70 or younger are eligible for LRP.

Laparoscopic Prostatectomy Contraindications

Previous abdominal and/or perineal surgical procedure (such as transurethral resection of the prostate (TURP), pelvic surgery, laparoscopic inguinal hernia repair), history of irradiation to the prostate, morbid obesity, large prostate size (e.g., >100g), and/or androgen insufficiency may complicate organ surgical resection and make the procedure more difficult, but these features are not contraindications for laparoscopic prostatectomy.

Active peritoneal inflammation, uncorrectable bleeding tendency, or incapacity to tolerate general anesthesia due to significant cardiac impairment, akin to open surgery, are all specific and absolute contraindications to laparoscopic prostatectomy.

Laparoscopic Prostatectomy Preparation

Bowel Preparation and Prophylaxis

Normally, no bowel preparation is provided. Patients should not eat or drink anything for at least six hours before surgery because they will be under general anesthesia. The fasting period begins at midnight the night before surgery. Good hydration, compression elastic stockings on the lower limbs, and low-molecular-weight heparin are used in thromboprophylaxis. On-call to the operation room, a single intravenous dose of a 3rd generation cephalosporin and low molecular weight subcutaneous heparin are administered. The night before surgery, patients who are hospitalized the day before surgery are given 4000 units of low molecular weight heparin, which is continued every day until the patient is discharged from the hospital. Crossmatch and blood type are identified.

Informed Consent

Patient information is why informed consent is so important. Patients undergoing LRP should be informed of the possibility of open surgery conversion, as well as the possibility of bleeding, transfusion, and infection. Impotence, incontinence, and incisional hernia as consequences must also be discussed with the patient, as well as the complications of general anesthesia.

Personnel and Arrangements

The operation theater team must have specific skills and training. A scrub nurse, circulating nurse, and surgical assistant make up the surgery team. A single surgeon is usually enough, however, a second assistant can help with tissue retraction. In order to complete this procedure, the scrub nurse must be well-versed in laparoscopic surgery.

The surgeon works on the patient's left side, while the first assistant is positioned on the surgeon's right side. The equipment table and the coagulation unit are situated on the patient's left side, while the laparoscopic trolley is put at the patient's feet. The scrub nurse is placed next to the patient's left lower extremity. Between the patient's feet and at the level of the doctor, the video monitor is placed.

Laparoscopic Prostatectomy Equipment

Even though they are more expensive, it is recommended to choose the best equipment. A good instrument will last longer and be more effective. The following list reflects preferences and is not intended to be comprehensive.

The following is a list of the necessary instruments for a laparoscopic prostatectomy:

• Foley catheter
• Long 5-mm trocars, including one with an insufflators
• 10-/12-mm trocars
• Long forceps
• Pair of unipolar forceps
• Large bipolar forceps
• A small bipolar forceps
• Needle holders
• Pledgets
• Rectal bougie
• Aspirator-irrigator
• Suture materials: they must be solid and must not form loops spontaneously;
• Lactomer 9-1
• Polyglactin 910
• Video equipment
• Video camera and monitor
• A rapid insufflators

Patient Positioning

The patient is in a supine position. Legs are partially abducted and inserted into padded receptacles. In arm padding, the arms are secured beside the torso. From the xiphisternum to the perineum, including the genital area, the abdomen is prepared. With both arms alongside the torso, the patient is tied to the table with adhesive tape. The lower extremities and thighs are likewise secured. With the 30-40°, the strapping must be secured enough to limit patient movement. During surgery, the Trendelenburg posture is used, although breathing should not be obstructed. To avoid elevating the abdomen while in the Trendelenburg position, the table's base must be placed below the patient's hip.

To prevent pressure ulcers, foam cushions are utilized to cushion the patient at all bone prominences. After the sterile drapes are in place, a Foley urethral catheter with a 10mL balloon is inserted. To decompress the stomach, a nasogastric tube is inserted. Skin preparation is done on the abdomen, pelvis, and genitalia in case an open surgery is indicated.

Anesthesia

LRP necessitates general anesthesia. Establishing correct pulse oximetry, intravenous access, and blood pressure gauge placement is required before patient positioning. Controlling CO2 insufflation and pneumoperitoneum complications like oliguria and hypercapnia is given special attention. The anesthesiologist and surgeon may need to make quick and ongoing modifications.

History of cerebral surgery or intracranial malignancies is an absolute contraindication. Respiratory failure, severe heart failure, and glaucoma are all relative contraindications.

Laparoscopic Prostatectomy Procedure

When trying the procedure, a thorough knowledge of the anatomical landmarks and their consequences for the patient's future quality of life is required. The umbilicus, anterior superior iliac spine, pubic symphysis, and lateral boundary of the rectus sheath are all normal anatomical features to consider when placing a trocar during any of the minimally invasive methods. These operations are often performed with 4 to 6 trocars arranged in a "W" or inverted fan arrangement. The prostate is routinely removed via an extension of the umbilical port site, and vesicourethral anastomosis is performed using either a continuous or interrupted suturing approach.

The transperitoneal (TP) or Montsouris 1 and extraperitoneal (EP) or Montsouris 2 techniques of minimally invasive prostatectomy have been reported. Each technique has its own set of benefits and drawbacks. Based on their previous expertise, each operator must select their favorite technique.

The extraperitoneal method allows for quick access to the Retzius space while reducing intestinal problems and intra-abdominal organ injury. The open RRP is quite similar to the extraperitoneal technique. During laparoscopy, however, the anatomy of the pelvis and prostate is magnified, enabling the dissection of vital structures considerably more precisely. The risk of ileus or injury is reduced because no bowel is moved. Because the colon does not need to be retracted, less Trendelenburg positioning is required, which may result in enhanced anesthetic and cardiovascular factors. The limited retroperitoneal space may aid in venous tamponade, and there is little risk of intraperitoneal contamination. The biggest issue is the limited working space, however, with experience, this does not appear to be a significant disadvantage. Recent research comparing transperitoneal and extraperitoneal techniques, on the other hand, has found no significant differences. In obese patients, the extraperitoneal technique may be advantageous because it reduces the distance between the trocar insertion site and the operative area, and in patients who have had previous abdominal surgery because it avoids time-consuming adhesiolysis and reduces the risk of bowel injury.

Extraperitoneal Laparoscopic Prostatectomy

The operation's numerous steps are as follows:

• Access to the abdomen, insufflation, and port placement
• The retropubic space is dissected.
• On each side, the pelvic fascia is opened.
• Bladder mobilization
• The seminal vesicles are dissected.
• Neurovascular bundles are dissected.
• Retropubic blood vessels hemostasis
• The tip of the urethra is dissected and the urethra is sectioned.
• Vesicourethral anastomosis
• The surgical specimen is extracted and the abdominal wall is closed.

Transperitoneal Laparoscopic Prostatectomy

The procedure's various steps are the same as in extraperitoneal prostatectomy, although they are carried out in a different order:

• Positioning of the patient, trocar insertion, insufflation
• Dissection of pelvic lymph nodes
• Seminal vesicles and the interprostatorectal area are dissected.
• Dissection of the bladder and prostate lobes
• The bladder is opened and mobilized.
• Neurovascular bundles are dissected.
• Hemostasis of the retropubic vessels
• The apex of the urethra is dissected, and the urethra is sectioned. 
• Vesicourethral Anastomosis
• The prostate is removed and the incision is closed.

Guillonneau and Vallancien proposed the Montsouris technique 1, in which dissection begins at the rectovesical cul-de-sac. The sigmoid colon is cephalad pulled, and a transverse peritonectomy is made at the rectovesical cul-de-sac's (distal) peritoneal fold.

Bipolar cautery is used to move the seminal vesicles and vas deferens circularly. The fascia of Denonvilliers is opened to allow access to the pre-rectal plane. The bladder is then lowered posteriorly, the Retzius space is established, the dorsal vein is ligated, the bladder neck is transected, and the prostatic pedicles are incised while the neurovascular bundle is spared if needed. The urethra is transected, the prostate is excised, and the vesicourethral anastomosis is established.

When compared to the extraperitoneal method, the transperitoneal laparoscopic radical prostatectomy has the potential to provide more working space and less tension on the urethrovesical anastomosis. Moreover, the transperitoneal procedure is less technically difficult than the extraperitoneal procedure when conducting extended pelvic lymphadenectomy for high-risk prostate cancer patients.

What Happens During Laparoscopic Prostatectomy?

The surgeon will insert a tiny needle into the abdominal cavity just below the navel. A short tube connects the needle to a little tube that delivers carbon dioxide to the abdomen. Once the laparoscope is in position, this elevates the abdominal wall to offer the surgeon a better view.

After that, a tiny cut near the navel will be done. The laparoscope, which is attached to a video camera, is inserted through this incision. The image produced by the laparoscope is shown on video monitors beside the operating table for the surgeon to see.

The surgeon will examine your abdominal cavity thoroughly before the surgery to ensure that the laparoscopy technique is safe for you. The operation will be stopped if the surgeon notices scar tissue, infection, or abdominal disease.

If the surgeon determines that the procedure can be performed safely, additional tiny cuts will be made to get access to the abdominal cavity. To remove the pelvic lymph nodes, one of these tiny incisions may be expanded if necessary.

What Happens after Laparoscopic Prostatectomy?

At first, you will be on a liquid diet, and later you will be able to eat solid things. When you return home, you will eat a soft diet that excludes raw fruits and vegetables. A nutritionist can provide you with more detailed guidance.

Because the intestines are momentarily paralyzed after anesthesia and surgery, nausea and vomiting are frequent. The doctor may prescribe drugs to alleviate these symptoms, which should subside within a few days of surgery.

Starting the first day after surgery, you will be advised to get out of bed and walk as much as possible. After you go home, gradually increase the activities. You should not lift or push anything heavier than 30 pounds for the first 6 weeks after surgery, and you should avoid abdominal workouts like sit-ups.

Laparoscopic Prostatectomy Recovery

Knowing about basic self-care you may take at home can help you heal faster after a laparoscopic prostatectomy. Keep in mind that these are basic principles that may or may not apply to each patient. Always follow the doctor's particular post-treatment instructions.

If Steri-Strips are utilized, they may remain on the incision site for 9 to 15 days after surgery before being removed. After surgery, keep the wound clean and dry for a week. Consult your doctor about when you can wash or bathe. Do not go swimming until you've talked to the doctor about it at your follow-up visit.

Following the surgery, you will be given a prescription for pain medication. Extra Strength Tylenol can also be taken as prescribed by the doctor. For the first three days after the procedure, avoid taking aspirin or aspirin-containing products.

After the procedure, the area may look black and blue. In a few days, this will be gone. It's usual to experience numbness, stinging, or discomfort. Before starting any physical activity, speak together with your doctor.

After surgery, most men may drive again in 9 to 15 days. Consult your doctor for specific recommendations.

Laparoscopic Prostatectomy Complications

Operating Time

Laparoscopic radical prostatectomy has a reputation for taking a long time to perform. However, with practice, times have been observed to reduce. Guillonneau and colleagues found that the first 50 cases took 4.5 hours, the next 50 took 4 hours, and the last 140 cases took 3.3 hours. Currently, the average time is between 2 and 3 hours.

Blood Loss and Transfusion Rates

Prostate surgery is known for its high intraoperative blood loss and transfusion rates. Blood loss of 500 mL, 1 L, or more has been observed in open prostatectomy series. Excellent vision of the dorsal venous complex and a pressure effect from the carbon dioxide pneumoperitoneum's 15-mm Hg pressure limit blood loss during laparoscopy. In the studied series, the need for transfusion ranged from 1.5 percent to 30 percent.

Conversion to Open Surgery and Intraoperative Complications

Although the conversion rate from laparoscopic to open surgery is still low (0 to 3%), some facilities experienced a high conversion rate in their early years. The careful introduction of LRP is shown in the low conversion rates in all major series. Even difficult conditions, such as those following previous laparoscopic hernioplasty, can be addressed with experience.

We can extrapolate from the present research that there are 4 percent of intraoperative problems (rectal damage at 1.5 percent, ileal or sigmoid injury at 1 percent, epigastric arteries injury at 0.3 percent, bladder injury at 0.8 percent, ureteral injury at 0.3 percent, external iliac vein injury at 0.1 percent). Anastomotic leaks (10 percent), hemorrhagic complications (2 percent), urinary retentions (2.5 percent), and ileus were the most common early postoperative problems, accounting for 20 percent of cases (1.5 percent). Anastomotic stricture, phlebitis, embolism, thrombosis, urinary tract infections, neurological sequelae, fistulas, lymphorrhea, and trocar hernia, on the other hand, accounted for less than 1 percent of cases.

Cost Comparison of Laparoscopic Prostatectomy and Open Prostatectomy

Despite the minimally invasive nature of LRP, the procedure's operative durations have consistently been longer than those of retropubic radical prostatectomy, and the cost of disposable operation theater equipment has been higher, implying that LRP is more expensive than RRP. Given the enormous number of men diagnosed with prostate cancer who are likely to seek treatment, it is desired that treatment choices be not only successful but also cost-effective.

Conclusion

LRP is a safe procedure that produces early outcomes that are comparable to open surgery. The technique, however, necessitates considerable laparoscopic skills and comes with a steep learning curve. The laparoscopic method has several advantages, including reduced blood loss during surgery and probably a faster recovery period. To aid reduce operating time during the early experience, intracorporeal suturing abilities can be acquired and improved in the pelvic trainer.