Robotic Assisted Laparoscopic Prostatectomy in Bordeaux

Waving the technology flag

Urology has always been at the forefront of surgical technology embracing new science as it arrives, from the Hopkins telescope as the forerunner to all endoscopic surgery, to the latest scarless, single-port, minimally invasive surgery. Bones from Star Trek may have had some interest in orthopaedics but I believe his first love was urology! Admittedly, that conclusion is precarious at best, but there is no doubt that, as a surgical specialty, we have a very rich history that we can be proud of. It was with this in mind that I jumped at the opportunity to go and work with the great Richard Gaston at the St Augustin Clinic in Bordeaux.

Gaston was the first urologist in Europe to do laparoscopic radical prostatectomy; the procedure was first done by Ralph Clayman’s group several years earlier, but they had concluded that it was technically too difficult. Gaston pioneered laparoscopic radical prostatectomy and is now pioneering new approaches with robotic assisted laparoscopic prostatectomy (RALP). This was a huge opportunity for me – yes it was 6 months in a foreign country where I didn’t speak the language very well and yes my wife and 2 children would only be able to come for 3 months, but my enthusiasm seemed to jump every hurdle as it arrived.

However, it was also unpaid with no income for 6 months, and that was a problem! I wrote to various drug companies, charities and organizations, but times were difficult and funds not forthcoming. Fortunately, The Urology Foundation was very generous in their time and financial support, donating £3,000 to my cause. They have also continued to give me advice and encouragement since I returned from Bordeaux, for which I am very grateful.

Robotic assisted laparoscopic prostatectomy in the UK and France

Approximately 80% of robotic prostatectomies are carried out in the USA, whereas the UK has been comparatively slow in its uptake of this new procedure. There are currently about 20 robots in the UK and several more ordered, but centres doing significant volumes are still limited. The St Augustin group in Bordeaux has already performed over 3000 robotic procedures, and Gaston has developed a new approach for RALP which is tension free, with Santorini plexus preservation. Basically this means removing the prostate with a thin layer of surrounding tissue and leaving everything else behind, at the sides and in front of the prostate, while minimizing trauma to the surrounding tissues. The functional and histological results, although still in small numbers, seem very encouraging.

Surgery in its ultimate art form

Bordeaux has a wealth of experienced surgeons, including Thierry Piéchaud who ran the European Association of Urology robotic course this year, Jean-Luc Hoepffner, Camille Mugnier and Denis Rey. It was amazing to watch these surgeons operate with their regular assistants, as they were so sure of each other’s movements and approach to the procedure that the instruments seemed to dance purposefully around each other in concentrated silence. This was surgery in its ultimate art form. One time when I was assisting Gaston and he had completed a nervesparing laparoscopic radical prostatectomy skin to skin in 47 minutes, he turned to me and said charismatically, ‘Justin if you want to learn to go fast you have to learn to go slow’. Such were the sometimes limited but always memorable conversations in theatre.

Then there were the theatre nurses, from whom I learnt just as much and who are undoubtedly the most experienced theatre nurses that I have ever had the privilege to work with: Monica who primarily assists Gaston has assisted at over 5,000 prostatectomies, about 2,000 more than Gaston himself, and Natalie is also fantastic. Both gave very generously of their time to teach us, and luckily for me they both speak excellent English.

A truly international fellowship

There were three fellows in total; Clovis from Brazil, Tasos a Greek who lived in Italy, and myself from Belfast originally and living in the southwest, a truly international group! I am a 6th and final year urology SpR on the Southwest rotation and, before going to Bordeaux, I had already received good training in laparoscopic surgery and had performed several laparoscopic nephrectomies.

I had also experience of laparoscopic suturing in pyeloplasties and radical prostatectomies, and these skills certainly aided the learning process in Bordeaux.

At St Augustin three theatres were used in parallel between the surgeons. Lists started at 8am every day and finished usually around 6pm. Then the consultants would do their outpatients lists, often finishing around 9 or 10pm. We three fellows shared the ward rounds and assisted at a second hospital when there were laparoscopic cases there, so there was always plenty of surgery to get involved with.

When I first arrived we made a plan on what I hoped to achieve and by the end of the 6 months I had performed every step of a laparoscopic radical prostatectomy, and was performing operations that I had not seen before I went to Bordeaux, such as laparoscopic subcapsular prostatectomies for benign disease and laparoscopic sacrocolpopexies for prolapse-related incontinence.

This experience was beyond my expectations, but St Augustin wasn’t just about operating; there were plenty of other opportunities to get involved. They ran several laparoscopic and robotic courses while I was there and, as the common language was often English, I was asked to chair a couple of the live surgery sessions for them, which I really enjoyed and it was a great learning experience. Afterwards we had a fantastic dinner in a 19th century château.

The walls were all stained black from 200 years of alcohol in the air according to the château proprietor! There was also a weekend course on the south coast of Spain, where people were still swimming in the sea in October, and another weekend course in a ski resort where I presented our audits of 10 years of laparoscopic cystectomies at St Augustin.

The visit in numbers: