The laparoscopic radical prostatectomy and robotic

English version

• Cardiac Medico-Surgical Department
• Digestive Disease’s Department
• Mother-child department
• Ophthalmology
• Orthopaedic surgery
• Thoracic
• Urology
  • Collaboration networks
  • The Medical Staff
  • Inpatients department
  • Treated Diseases

This technique is performed in the department of urology where it was started in 1998. It is actually the reference technique.

The Technique

• After having started a transperitoneal approach the team has developped a retroperitoneal way-undergeneral annesthesia, the retroperitonum is dissected with a balloon and the four other trocars are placed in the iliac fossas. The optic is connected to a vocal commanded robot.
• When indicated a lymphnode dissection is performed.
• The prostate and seminal vesicles are resected.
• The high-power views obtained on the video monitors allow a precise preservation sparing the neurovascular pedicles.
• Once the prostate has been removed, the bladder is manually sutured to the urethra with intracorporeal knots and with preservation of the striated sphincter.
• A succion drain is placed in the pelvis for 24-48 hours.
• A bladder catheter of 18 Fr is inserted and left 8 days.
• The all cost of laparoscopic radical prostatectomy (fees, drugs, imaging and laboratory tests) is 18.000 euros. Mean postoperative stay is 3 to 4 days.

The robotic operation
The team was a pioneer to develop robotic operation and particularly radical prostatectomy with the Da Vinci system (Intuitive Company).

The Results

3500 patients were operated between February 1998 and December 2007.

• Mean age: 57 years
• Mean PSA: 8,3 ng/ml
• Mean number of positive biopsies: 2,2
• Mean Gleason score: 6,5
• Mean weight of the prostate: 56 g
• Operating time: about 2 hours
• Mean intraoperative bleeding is currently 350 cc.
• Transfusion is currently required in 3% of cases.
• The conversion rate to open surgery is currently 0%.
• The hospital stay is 3 to 5 days in 90% of cases
• The mean duration of bladder catheterization is 8 days.
• Currently bladder catheter removal is done at home after the patient was discharged from hospital.
• Reduction of postoperative pain by means of laparoscopy results in pain scores on visual scales of less than 2 out of 10 on the first day.

Continence :
At one year, 83% and 90% at 2 years of patients do not wear permanent pads looking at the home questionnaire fulfilled by the patient himself.
1% underwent had an artificial sphincter after one year.

Potency :
Preservation of the neurovascular pedicles currently allows an increased erection rate. 80% of patients who have a pre-operative regular sexual activities with bilateral neurovascular sparing are potent at 18 months, using temporary help of a medication (Cialis).

• Patients who underwent previous abdominal or pelvic surgery can be operated on.

Carcinologic results :

• 85% of patients were PT2 and 15% were PT3.

At 5 years, globally 80% of patients with PT2 cancers are PSA free (no recurrence). Among the group of patients with PSA <10, gleason score <7 .88% of them have no recurrence at 3 years, at 5 years globaly 80% of patients are PSA free.

The Complications

• No death, 0,2% phlebitis, 0,1% embolism, and no other cardiovascular accident was observed in this series of 3500 patients.
• 17 millimetric rectal injuries were observed and were sutured laparoscopically. A temporary colonic diversion was done in 2 patients. One ileal burning required a 2nd operation and 0,2% recto-urethral fistula were observed and treated surgically.
• Partial bipolar coagulation of an obturator nerve induced only transient sequelae lasting for a fortnight.
• Urine leak into the suction drainage were observed in 5% of cases, simply resulting in extension of the hospital stay by several days. 4 surgical revisions and 2 abdominal punctures were required in 4 patients (0.6%).
• 0,1 % ureters were cut and repaired laparoscopically and two were burnt partially requiring a ureteric stent in one case and a uretero-vesical reimplantation in other case.
• 0.3% of patient had a bleeding of an epigastric artery during placement of a trocar was observed.
• 1% of hematomas.
• 0,1% eventrations of the abdominal wall were detected.
• 0,4% wound infection, 0,5% stenosis of the vesico-urethral suture was observed in these 2200 patients.
• Globaly, 2,9% of patients underwent a second operation.
• No tumour seeding on the ports was observed.

Conclusions: Laparoscopic radical prostatectomy is a well standardised operative technique which allows less blood transfusion, a shorter hospital stay with less pain. Carcinological results are the same, and functional results such as continency are better in our hands than after open surgery with a quicker continence recovery. Potency is also better comparing with our previous results after open surgery.