RU2774776C1 - Method for ligating the dorsal vascular complex of the penis and isolating the apical part of the prostate gland during robot-assisted laparoscopic radial prostatectomy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely urology and andrology. The parietal peritoneum is opened, access to the prevesical space is formed, the prostate gland is isolated, it is cut off from the bladder neck, the seminal vesicles and ducts are isolated, the prostate gland is cut off from the urethra. After cutting off the prostate gland from the neck of the bladder, the posterior surface of the prostate gland, seminal vesicles and adjacent parts of the vas deferens are isolated. The vas deferens are coagulated proximally and crossed, the seminal vesicles are isolated completely, the prostate gland is isolated from the surrounding tissues along its own capsule from the back and side surfaces while maintaining Dennonvelier's fascia. The vascular pedicles of the prostate gland are clipped or coagulated and cut off at the base, then further dissection of the lateral surfaces of the prostate gland is performed with or without preservation of the neurovascular bundles, after which it is carried out alternately, independently from the left-right or right-left from the periphery to the center, a phased selection and ligation of the vessels of the dorsal vascular complex of the penis, wherein after each ligation the vessels are dissected and the apex of the prostate gland is sequentially isolated in a bloodless surgical field.

EFFECT: method allows to reduce the risk of intraoperative complications, reduce the duration and volume of blood loss, as well as optimize surgical access to the apical part of the prostate gland.

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Description

The invention relates to medicine, namely to surgery, and can be used in robot-assisted laparoscopic radical prostatectomy in the treatment of prostate cancer.

A known method of robotic-assisted laparoscopic radical prostatectomy (Patel V. R. et al. Robotic-assisted laparoscopic radical prostatectomy: the Ohio State University technique //Journal of robotic surgery. 2007., T. 1. No. 1.,. C. 51- 59, https://https://link.springer.com/article/10.1007/s11701-007-0018-х), including opening of the parietal peritoneum, formation of access to the prevesical space, opening of the intrapelvic fascia, ligation of the dorsal vascular complex of the penis , followed by isolation of the prostate gland, cutting it off from the bladder, isolation of seminal vesicles and vas deferens, cutting off the prostate gland from the urethra, imposition of urethrocystoanastomosis.

However, the operation to remove the prostate by a known method is associated with excessive tissue trauma, including the urethra and its external sphincter, when ligating the dorsal vascular complex of the penis.

There is also known a method of robot-assisted laparoscopic radical prostatectomy (Hoshi A. et al. Dorsal vein complex protective technique for intrafascial nerve-sparing laparoscopic radical prostatectomy / Anternational Journal of Urology. - 2013. - T. 20. - No. 5. - C 493-500), including opening the parietal peritoneum, forming access to the prevesical space, opening the intrapelvic fascia, isolating the dorsal vascular complex of the penis without prior ligation, isolating the prostate gland, cutting it off from the bladder, isolating the seminal vesicles and ducts, cutting off the prostate glands from the urethra, followed by the imposition of urethrocystoanastomosis.

The disadvantage of this method is the high risk of intraoperative blood loss, as well as, due to blood loss, deterioration of visualization when the apical part of the prostate is exposed, which in turn increases the incidence of complications and the risk of having a positive surgical margin in the apical part of the prostate, respectively.

The objective of the present invention is to create a method for ligating the dorsal vascular complex of the penis and isolating the apical part of the prostate gland during robot-assisted laparoscopic radical prostatectomy in the treatment of prostate cancer, which makes it possible to prevent the development of intraoperative complications, including blood loss, by stepwise ligation of the vessels of the dorsal vascular complex of the penis.

The technical result achieved by the invention is to prevent the development of intraoperative complications, the duration and volume of blood loss, as well as to optimize the surgical access to the apical part of the prostate gland, which, in turn, will lead to a decrease in the frequency of a positive surgical margin in the area of resection of the apical part of the prostate, improvement oncological outcomes, and increasing the efficiency of achieving early urinary continence, due to the exclusion of trauma to the external urethral sphincter during ligation of the dorsal vascular complex of the penis before the prostate is exposed.

The claimed technical result is achieved by the fact that in the method of ligating the dorsal vascular complex of the penis and isolating the apical part of the prostate gland during robot-assisted laparoscopic radical prostatectomy, including opening the parietal peritoneum, isolating the bladder, prostate gland through the prevesical space, cutting off the prostate gland from the neck of the bladder bladder, excretion of seminal vesicles, coagulation and intersection of the vas deferens, cutting off the prostate gland from the urethra, and its removal, while preserving the intrapelvic fascia, puboprostatic ligaments, pubo-perineal muscles and Dennonvelier fascia, after cutting off the prostate gland from the bladder neck, is carried out alternately, independently from the left - right or right-left, gradual isolation and ligation of the vessels of the dorsal vascular complex of the penis, while, after each ligation, the vessels are cut off and the apical part of the penis is sequentially isolated prostate gland in a bloodless surgical field.

Unlike analogues, the sequential, step-by-step isolation and ligation of the vessels of the dorsal vascular complex of the penis, followed by their cutting off, allows the operation to be performed in a practically bloodless surgical field, thereby providing good visualization in the surgical field zone when the apical part of the prostate gland is isolated. This, in turn, makes it possible to prevent the development of intraoperative complications by reducing the risk of intraoperative blood loss, to reduce the frequency of a positive surgical margin in the area of resection of the apex of the prostate, and to improve oncological outcomes. In addition, it allows you to highlight the urethra and the external urethral sphincter without trauma, to increase the efficiency of achieving early urinary retention.

The present invention is illustrated by illustrations, where:

in fig. 1 - shows a photo of the anterior surface of the prostate after providing access to the dorsal vascular complex of the penis;

in fig. 2 - shows a photo of the initial stage of the isolation of the dorsal vascular complex of the penis (after changing the instruments);

in fig. 3 - a photo of the stage-by-stage ligation of the vessels of the dorsal vascular complex of the penis is presented, cutting off the dorsal vascular complex of the penis in a blunt and sharp way;

in fig. 4 - a photo of the prostate bed after its removal is presented.

The method is carried out as follows.

The operation is performed using a Da Vinci robot, under endotracheal anesthesia (ETN), the patient is placed on his back and laparocentesis is performed at the upper or lower paraumbilical point. Through this access, an optical trocar is inserted and carboxyperitoneum is produced. Next, 3 working da Vinci trocars and an assistant port are inserted laterally to the left and right of the midline according to the standard technique. During the operation, the patient is positioned in the Trendelenburg position (with the cranial end lowered and the caudal end elevated). Docking of the da Vinci robotic surgical complex is performed (comparison of trocars with manipulators of the patient console of the robotic complex). With the help of a robot assistant, the anterior wall of the parietal peritoneum below the navel is opened and access is made to the prevesical (Retzian) space. Allocate the ventral surface of the prostate and bladder, while not opening the intrapelvic fascia, without crossing the puboprostatic ligaments and without ligating the dorsal vascular complex of the penis at this stage (Fig. 1). The next step is to cut off the prostate gland from the neck of the bladder, after which the posterior surface of the prostate gland, seminal vesicles and adjacent parts of the vas deferens are isolated. The vas deferens coagulate proximally and cross, the seminal vesicles are completely isolated. The prostate gland is isolated from the surrounding tissues along its own capsule (pseudocapsule) from the posterior (dorsal) and lateral surfaces, with Denonvelier's fascia preserved. The vascular pedicles of the prostate gland are clipped or coagulated and cut off at the base. Then, further dissection of the lateral surfaces of the prostate gland is performed, with or without preservation of the neurovascular bundles. Produce a phased ligation of the dorsal vascular complex of the penis. The robotic instruments are changed (Fig. 2) in such a way that a needle holder is located in the robotic manipulator No. 1, monopolar curved scissors are in the robotic manipulator No. 2, and a fenestrated clamp is in the robotic manipulator No. 3).

With the help of a fenestrated clamp, the prostate gland is grasped and traction is created in the opposite direction from the area where the dissection and dissection of the tissue will be performed. With the help of curved scissors, a phased dissection of the dorsal vascular complex of the penis is performed in a blunt and sharp way, if bleeding occurs, ligating this part of the complex under visual control using a needle holder, using the "V-loc" suture material, followed by cutting off this area and moving on to the next (FIGS. 2 and 3). Ligation of the vessels of the dorsal vascular complex of the penis with their further cutting off is carried out alternately, independently from the periphery to the center, step by step, further highlighting the apical part of the prostate and urethra. Thus, in stages and in a bloodless surgical field, the apical part of the prostate gland and the membranous urethra are isolated, separating the latter from the dorsal vascular complex of the penis (figure 4). Then the prostate gland is cut off from the urethra and placed in a special laparoscopic evacuator. After careful hemostasis of the bed of the removed prostate, a vesicourethral anastomosis is formed using absorbable suture material, with a continuous suture on a Foley catheter 18 Ch. The urethral catheter is replaced with a similar one, the tightness of the anastomosis is controlled by introducing 100 ml of saline through the catheter into the bladder. The next step is the anterior reconstruction of the small pelvis. A drainage tube (PVC) is installed in the small pelvis to the area of the vesicourethral anastomosis through the counterperture. Desufflation of carbon dioxide is carried out from the abdominal cavity, the drug is removed through one of the incisions where the endoports were located, after which interrupted sutures are applied to the trocar wounds on the skin.

Using the proposed method (stage-by-stage ligation of the dorsal vascular complex of the penis and isolation of the apical part of the prostate gland) in the urology clinic of the V.A. Almazov” performed a number of robot-assisted laparoscopic radical prostatectomy. The possibility of carrying out robot-assisted laparoscopic removal of the prostate according to the proposed method is confirmed by a clinical example of such an operation.

Clinical example:

Patient R, 77 years old. Date of receipt 11/13/2019

Diagnosis: Prostate cancer pT2aN0M0. PSA level - 8 ng / ml. Results of multifocal prostate biopsy: acinar adenocarcinoma in 4 columns, Gleason score 3+3=6 (histological report from B-58873-34892/18 dated 03.12.18). According to the results of magnetic resonance imaging of the small pelvis, the volume of the prostate gland was 134 cm3, signs of extracapsular extension of the tumor, lesions of the seminal vesicles, and lymph nodes were not detected.

According to osteoscintigraphy, there were no signs of secondary damage to the bones of the skeleton. A robot-assisted laparoscopic radical prostatectomy was performed.

Under ETN, in the position of the patient lying on his back, laparocentesis was performed at the upper paraumbilical point, carboxyperitoneum was applied. Trocars da Vinci are installed in typical locations. Abdominal revision revealed no pathology. Access to the prevesical space was made through the anterior wall of the parietal peritoneum. After dissection of the anterior surface of the bladder neck and prostate, the prostate was cut off from the bladder neck. The posterior and lateral surfaces of the prostate gland, seminal vesicles, adjacent sections of the vas deferens were isolated. Then performed the intersection and coagulation of the vascular "legs" of the prostate. After further exposure of the lateral and posterior surfaces of the prostate gland, a change of robotic instruments was made (in the robotic manipulator No. 1 there is a needle holder, in the robotic manipulator No. 2 - monopolar curved scissors, in the robotic manipulator No. 3 - a fenestrated clamp). Performed a phased selection and ligation of the vessels of the dorsal vascular complex of the penis alternately on each side from the periphery to the center, and further isolation of the apical part of the prostate, in accordance with the description of the method. The prostate gland is cut off from the urethra, immersed in a laparoscopic evacuator. Imposed cystourethroanastomosis on the Foley catheter 18 Ch. With the introduction of 100 ml of saline into the cavity of the bladder through the catheter, the anastomosis is hermetic. Hemostasis control. Performed anterior reconstruction of the small pelvis. Hemostasis - dry. Drainage into the small pelvis, removed in the right iliac region. Desufflation. Stitches for wounds. Aseptic stickers.

The postoperative period was uneventful. The drainage was removed on the 2nd day after the operation. On the 7th day of the postoperative period, cystography was performed, according to which the vesicourethral anastomosis was hermetic, the urethral catheter was removed. Independent urination restored. There is immediate retention of urine. The sutures were removed on the 7th day. The patient was discharged from the hospital on the 8th day of the postoperative period.

The advantages of the proposed method over the prototype method are that, unlike the methods described above (with and without ligation of the dorsal vascular complex of the penis), in the course of the modified RARP developed by us, a phased isolation and ligation of the dorsal vascular complex of the penis occurs, i.e. the extraction of the apical part of the prostate gland and urethra does not occur simultaneously on the right and left, but its right and left halves are gradually isolated, during the dissection of the tissue with its possible dissection with scissors in the event of bleeding, this zone is stitched with a precision "V-loc" thread, which ensures reliable hemostasis even in the case of dissection of the thread itself, since the thread retains tension due to the peculiarity of its structure. This modification of robot-assisted radical prostatectomy reduces the risk of intraoperative complications, in particular blood loss, improves oncological outcomes due to the creation of a bloodless surgical field, precise exposure of the apical part of the prostate with a minimal risk of a positive surgical margin, as well as functional results due to ligation of the dorsal vascular complex of the penis in situ, aiming that it compares favorably with analogues.

Claims (1)

A method for ligating the dorsal vascular complex of the penis and isolating the apex of the prostate gland during robot-assisted laparoscopic radical prostatectomy, including opening the parietal peritoneum, forming an access to the prevesical space, isolating the prostate gland, cutting it off from the bladder neck, isolating the seminal vesicles and ducts, cutting off the prostate gland from the urethra, characterized in that after cutting off the prostate gland from the neck of the bladder, the posterior surface of the prostate gland, seminal vesicles and adjacent parts of the vas deferens are isolated, the vas deferens are coagulated proximally and crossed, the seminal vesicles are isolated completely, the prostate gland is isolated from the surrounding tissues along its own capsule from the back and side surfaces with the preservation of Dennonvelier's fascia, the vascular legs of the prostate gland are clipped or coagulated and stopped at the base, then yes further dissection of the lateral surfaces of the prostate gland with or without preservation of the neurovascular bundles, after which it is carried out alternately, independently from the left to the right or from the right to the left from the periphery to the center. dissect and sequentially allocate the top of the prostate gland in a bloodless surgical field.

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