Journals / Türk Üroloji Dergisi/Turkish Journal of Urology / 2005 / Cilt: 31 - Sayı: 4
Initial results with laparoscopic radical prostatectomy (Heilbronn technique)
- Pages
- 547–554
- DOI
- —
Abstract
Introduction: Transperitoneal ascending laparoscopic radical prostatectomy (Heilbronn technique) includes an ascending part, with early division of the urethra and posterolateral dissection of the prostate, followed by incision of bladder neck and dissection of the seminal vesicles and vasa deferentia. Nowadays, laparoscopic radical prostatecomy (LRP) has been increasingly accepted providing similar functional and oncological results as open radical prostatectomy. We analyzed the results of our first experience with LRP using Heilbronn technique. Materials and Methods: In Heilbronn technique, the extraperitoneal LRP approach is similar to transperitoneal LRP, apart from high transection of the urachus and division of both lateral umbilical ligaments to reach the Retzius space and includes 7 steps: (I) incision of endo-pevic fascia on both sides, control of deep dorsal vein complex, (II) dissection of prostatic apex and the neurovascular bundles that were preserved according to oncological criteria, preoperative erectile activity and age, (III) division of urethra followed by posterior dissection of prostate, (IV) incision of bladder neck followed by (V) dissection of vesicula seminalis and vas deferentia combined with (VI) division of cranial pedicles of prostate and finally (VII) creation of urethro-vesical anastomosis with continuous sutures including reconstruction of bladder neck. The urethral catheter is removed on postoperative day 7 depending on the quality of the anastomosis according to cystographic assessment. The following parameters were also evaluated: preoperatively body mass index and hemoglobin level, perioperatively operative time, estimated blood loss, transfusion rate, postoperatively duration and amount of analgesic treatment, catheterization time, perioperative morbidities and complications, oncologic status (surgical margin). Subsequently, functional results on incontinence were also included in this analysis for 3 and 6 months postoperatively. Results: We performed LRP in 37 patients with organ confined prostate cancer (mean age: 62.4±6.3 years). Pelvic lymphadenectomy, bladder neck and neuro-vascular bundle-sparing dissection were performed in 38, 35 and 32 per cent of the patients, respectively. While mean urethro-vesical anastomosis time was 33.6±9.3 minutes, the mean operative time including anastomosis was 226.4±60.3 minutes. Whilst the reduction in hemoglobin level was 17.1%, blood transfusion rate was 10.8%. The mean hospitalization and urethral catheterization times were 4.3±1.5 and 11.5±5.6 days, respectively. No conversion to open surgery was necessary in either group. In the 1st patient postoperative re-intervention was required due to thermal effect of cautery on ileum. Conclusion: The Heilbronn technique was designed to copy the standardized technique of open anatomic radical prostatectomy starting with an ascending part, controlling Santorini's plexus and dividing the urethra and distal lateral pedicles of the prostate, followed by transection of the bladder neck and retrovesical access to the vesicula seminalis. Logically, this technique can easily be transferred without modification to extraperitoneal approach including identical surgical steps. In conclusion, in our opinion the technique of laparoscopic prostatectomy is transferable without loss of operative quality dependent on the concept of laparoscopic education. Taking this training concept into consideration the learning curve will only include the operating time but not the number of complications or the functional and oncological results of this procedure.
Özet
Ardışık olarak asendan LRP (Heilbronn tekniği) ile tedavi edilmiş olgularımızın operasyon verileri ve özellikleri, takip sonuçları beraberinde morbiditeleri ve erken kontinans oranları değerlendirildi. Klinik olarak organa sınırlı prostat kanseri belirlenen 37 hastaya (ortalama yaş: 62.4±6.3 yıl) asendan LRP uygulandı. Ameliyat öncesi hastanın vücut kitle indeksi, PSA değeri, transrektal ultrasonografide elde edilen prostat volümü, Gleason skoru ve ameliyat öncesi hemoglobin değeri değerlendirildi. Ameliyat sırasında ameliyat süresi, anastomoz süresi, yaklaşık kan kaybı, intraoperatif kan transfüzyonu yanında istenmeyen yan etkiler değerlendirildi. Ameliyat sonrası dönemde ise hastanede yatış süresi, analjezik miktarı ve süresi, üretral kateterizayon süresi değerlendirildi. Ortalama ameliyat süresi 226.4±60.3 dakika olup, veziko-üretral anastomoz süresi ortalama 33.6±9.3 dakika olarak gerçekleşti. Hastaların %38'ine pelvik lenfadenektomi, %32'sine sinir koruyucu yaklaşım uygulandı. Ortalama kan kaybı 443.7±127.8 ml olup, ameliyat öncesi hemoglobin değerine göre ameliyat sonrası değerdeki azalma %17 olarak belirlendi. Ameliyat sonrası dönemdeki ilk 24 saat içinde 12 hastada hiçbir şekilde analjezik ihtiyacı olmadı. Bu dönem içinde kullanılan ortalama narkotik analjezik miktarı 22.8±21.7 mg olup, ameliyat sonrası ortalama 4.3 günlük hastanede kalış döneminde kullanılan toplam narkotik analjezik miktarı 28.9±26.2 mg olarak gerçekleşti. Hastalarda ortalama üretral kateterizasyon süresi 11.5±5.6 gün olarak tespit edildi. Ülkemizdeki ilk önemli LRP serilerinden birisini oluşturan değerlendirmemizde elde edilen veriler, LRP'nin ülkemiz açısından gelecekte önemli bir cerrahi teknik olarak gelişeceğini göstermektedir. Özellikle laparoskopik cerrahi eğitiminin kalitesi ile bu gelişme oldukça hızlı bir uygulama alanının oluşmasında önemli yere sahip olacaktır.