Heilbronn laparoscopic radical prostatectomy - Technique and results after100 cases

Introduction: In 1999, Guillonneau and Vallancien presented a refined appro ach of a descending laparoscopic radical prostatectomy which based mainly o n the primary access to the seminal vesicles and an improved suturing and k notting technique. Based on our own experience reconstructive laparoscopy a s well as with open retropubic radical prostatectomy we have used a combine d ascending/descending technique similar to open surgery. In this paper we want to describe our approach, and to present the initial results with the Heilbronn technique. Materials and Methods: A transperitoneal approach is used with a W-shaped a rrangement of the trocars (13-mm umbilical port, 2X10 mm medial, 2X5 mm lat eral ports). After the exposure of the Retzius' space and control of the do rsal vein complex the urethra is incised and the distal pedicles of the pro state ( the neurovascular bundle) are transsected. We now pull the apex ven trally and start with the incision at the bladder neck followed by a transv esical access to both, vasal deferentia, and seminal vesicles. The gland is entrapped in the Extraction Bag((R)). After accomplishing the posterior wa ll of the urethrovesical anastomosis with five interrupted sutures, the fol ey catheter is placed into the bladder and the bladder neck is closed. Now the prostate is extracted via the umbilical incision. From March 1999 to Ju ne 2000, we have performed 100 cases (48 pT2-, 47 pT3- and 5 pT4 tumors). T he mean preoperative PSA was 26.8 (1.4-75.5) ng/ml. Two tumors were grade 1 , 72 grade 2 and 26 grade 3. Median Gleason score was 6 (3-9). All specimen were inked and examined according to the Stanford protocol. Postoperative continence was evaluated using a questionnaire monitored by a colleague who was involved in surgery. Results:We had 5 conversions (rectal injury, difficult dissection, adhesion , 2x bleeding at the dorsal vein complex). The mean operating time was 278 (180-500) min., the transfusion rate 31%. One patient required reinterventi on due to bleeding from the right obturator fossa. 95% of the patients did not require any analgesia on the second postoperative day. Positive margins were found in 17% of the patients, of which 12 had a PSA nadir to a value of less than 0.1 ng/ml within 3 weeks after surgery. In 82 patients, the an astomosis was tight after removal of the catheter, median catheter time was 8 (6-30) days. 4% developed a stricture at the anastomotic site which coul d be treated by laserincision. On discharge 33% were continent, after 6 mon ths 81%, whereas only 2 patients still suffer from grade II stress incontin ence at 9 months. Conclusions. Laparoscopic radical prostatectomy is feasable but requires la paroscopic expertise. Its learning curve is still ongoing. Morbidity is low , oncological control is similar to results of open surgery, functional res ults are promising. Copyright (C) 2001 S. Karger AG, Basel.