Robot-assisted laparoscopic radical prostatectomy ...gpgu.org/wp-content/uploads/2018/03/13-Cristophe-Assenmacher.pdf · •First of all I want the thank Dr Nelson Menezes ... •When

Robot-assisted laparoscopic radical prostatectomy

Posterior approach

Called

Retzius-sparing approach

08/02/2018 1Ch.F. Assenmacher

Challenging

• 10 years experience : conventional approach

• Functional & oncological results

– Comparable to the literature

08/02/2018 Ch.F. Assenmacher 2

Why ?

• Early continence

• Anatomical elegance


•

•Jorge Fonseca,

•Head of department Urology,

•Champalimaud Fondation


Learning curve

• Full time video (Aldo Bocciardi)

• Step by step

• 1° procedure 04/02/2017 (Belgium)

• 2° procedure same day



Functional results

• Better early continence

• Pad-free continence rate

X 5


•BUT !


Surgical margins

• Higher rates ??

• Unexpected location compared to conventional approach

• Less with experience


Moving or not ?

• Real benefit : functional results

• Bladder neck dissection

• Reduce surgical margin


• Let’s see the technique


Step 1 :Seminal vesicles & deferens

(Montsouris technique)


Step 2Posterior dissection


Step 3aLeft postero-Lateral dissection

N-V preservation


Step 3bSame step

without preservation


Step 4Left antero-lateral dissection

N-V preservation


Step 5Bladder neck


Step 6Anterior dissection


Step 7 Apical dissection


Step 8Urethral suture


Step 9Peritoneal closure


• Thank you.


• Dear colleagues, dear friends, • First of all I want the thank Dr Nelson Menezes

who invited me today for his 1st Symposium of oncologic Urology.

• I also want to thank my friend Jorge Fonseca and his fantastic team, without whom I would not be here today.

• I was asked to give you a little speech about a new technique without any scientific claim

• Just a few personal tips and comments


Why ?

• Moving from a well standardised anterior approach to a new one was really challenging.

• From 11/2007 to 02/2017 I performed +-900 RARP with good oncological and functional results (compared to the literature)


Why ?

• Thanks to Jorge Fonseca who lighted the fact that early continence was spectacularly better, he convince me to change the technique.

• He gave me a full time video of Aldo Bocciardi when performing his new technique at the “Challenges in Laparoscopy and Robotics” the 18 February 2016 at Champalimaud Foundation in Lisboa.


Learning curve

• After having watched several times this excellent video and studying every surgical time, step by step, I decided to go on and perform my first case in 02/2017 in Belgium.

• This has been so satisfactory, that the second patient that day, previously planned for a conventional RARP, benefited also the Bocciardi technique.


Functional results

• As our patient results come in and considering other published results using the technique, it’s becoming clear that this technique, known as a Retzius-sparing radical prostatectomy, is transforming patient results for continence and potency.

• That means that the pad-free continence rates are now more that 5 times better than they were before.


What about surgical margins?

• When the technique was first described by Aldo Bocciardi, we could often hear, in the European urological community, that the main argument against the technique was the highest rates of surgical margins.

• I dare say, at the beginning, there were more SM on unexpected area. Especially anteriorly, between the Santoriny plexus and the prostate.

• With experiences, these SM occurred less and less frequently


Mandatory to move ?

• In my mind, the patient benefits in terms of early continence and probably potency are significant.

• These arguments justify to spend time and energy in a better understanding and subsequently a better anatomical dissection of the bladder neck.

• This is the key point to reduce the SM rate, especially in its anterior part when posteriorly approached.

• The risk for SM in all other parts of the prostatic dissection (apical, basal, posterior, …) seems to be the same than by de conventional approach. No reason to be different!


Documents

Robot-assisted laparoscopic radical prostatectomy ...gpgu.org/wp-content/uploads/2018/03/13-Cristophe-Assenmacher.pdf · •First of all I want the thank Dr Nelson Menezes ... •When