Abdominal Access, Insufflation, and Trocar Placement

For a transperitoneal approach, pneumoperitoneum is established using either a Veress needle inserted at the base of the umbilicus or an open Hasson technique. Following initial trocar placement, CO₂ insufflation pressure in general is maintained between 12 and 15 mm Hg. Secondary trocars are then placed under laparoscopic view. For RALP, an example of a trocar configuration is shown in Figure 103–3A. A 12-mm trocar is initially placed at or slightly above the umbilicus for insertion of the stereo endoscope. In a morbidly obese or very tall patient, infraumbilical camera placement may be preferable. Three 8-mm metal robotic trocars are used by the working robotic arms of the surgeon while the assistant provides retraction, suction, and irrigation and passes clips and sutures via the 12-mm and 5-mm trocars placed along the patient’s right side. The surgeon controls camera movement by depressing a foot pedal and using brief, simultaneous arm movements to affect camera positioning and rotation. Endoscopes with either angled (30-degree) or straight-ahead (0-degree) viewing are available and interchangeable at various portions of the procedure. In general, most surgeons use the 0-degree endoscope lens throughout the operation; however, some surgeons prefer to switch to the 30-degree down lens when approaching the bladder neck, NVBs, and apical dissection. Figure 103–3B depicts the trocar configuration for LRP. The surgeon stands at the patient’s left side and operates through the two pararectus trocars while one or two assistants use the lateralmost trocars. The endoscope is held and controlled by an AESOP robotic arm or surgical assistant through the umbilical trocar.

Figure 103–3 Trocar configuration for robotic-assisted laparoscopic prostatectomy (A) and laparoscopic radical prostatectomy (B).

Extraperitoneal Approach

For an extraperitoneal approach, a 1.5-cm incision is made at the level of the umbilicus and dissection is carried out down through the anterior rectus sheath. Using blunt finger dissection, a space is created immediately anterior to the posterior rectus sheath and underlying peritoneum. A trocar-mounted balloon dilator device (PDB Balloon, Covidien Autosuture, Mansfield, MA) is inserted into the preperitoneal space anterior to the posterior rectus sheath and advanced down to the pubis along the midline. Using a 0-degree, 10-mm endoscope inserted through the balloon trocar, approximately 500 mL of air is inflated to develop the space of Retzius under laparoscopic view (Fig. 103–4). Secondary trocars are then inserted as described previously under laparoscopic view. The operation then proceeds in the exact manner to that of the transperitoneal anterior approach.

Figure 103–4 Creation of working space for extraperitoneal pure laparoscopic or robotic-assisted radical prostatectomy using a trocar-mounted balloon dilator device.

Pros and Cons of Extraperitoneal versus Transperitoneal Approach

In a retrospective comparison between extraperitoneal versus transperitoneal LRP, Hoznek and colleagues (2003) found that the mean operative time was shorter with the extraperitoneal approach (169.6 vs. 224.2 minutes, P < .001) with the greatest time saved during access to the space of Retzius. They suggested that time to full diet was less with the extraperitoneal versus the transperitoneal LRP approach (1.6 vs. 2.6 days, P = .002) because the peritoneum had not been violated and postoperative ileus was minimized. Eden and colleagues (2004) found a statistical significant advantage in operative time, hospital stay, and return of early continence favoring patients undergoing extraperitoneal versus transperitoneal LRP, postulating that earlier return to urinary control may be secondary to less bladder dissection and, perhaps, less bladder dysfunction as compared with transperitoneal LRP. Most studies, however, have found little or no difference in operative time and perioperative outcomes between transperitoneal and extraperitoneal approaches (Cathelineau et al, 2004a; Erdogru et al, 2004; Brown et al, 2005b; Atug et al, 2006).

With an extraperitoneal approach, the simultaneous laparoscopic management of concurrent inguinal hernias using prosthetic mesh is feasible (Stolzenburg et al, 2003). Simultaneous inguinal herniorrhaphy has also been reported during transperitoneal LRP (Allaf et al, 2003); however, proper coverage of the mesh prosthesis is necessary using peritoneal flaps, omentum, or a second absorbable mesh to reduce the risk of direct contact between the mesh and bowel with subsequent fistula. The extraperitoneal technique may be preferable in patients with previous extensive abdominal surgery or morbid obesity. With the extraperitoneal approach, the peritoneum acts as a natural barrier, minimizing the potential for bowel injury and preventing the bowels from falling into the operative field and obscuring the surgeon’s view. Furthermore, this approach helps to confine any urine leak that may occur from the vesicourethral anastomosis within the extraperitoneal space. One limitation with the extraperitoneal approach is the reduced working space as compared with the relatively larger working space of the peritoneal cavity gained with transperitoneal access. This is especially relevant when a well-meaning assistant attempts to clear the operative field of blood or smoke. Suctioning can evacuate CO₂ gas and rapidly collapse the already limited extraperitoneal working space, thus significantly compromising visualization. A second limitation to the extraperitoneal approach is in patients with a prior history of laparoscopic extraperitoneal mesh herniorrhaphy because the retropubic space is often obliterated, making attempts at extraperitoneal access challenging. Lastly, higher CO₂ absorption has been reported with extraperitoneal versus transperitoneal insufflation, requiring a higher minute volume to compensate for hypercarbia and associated acidosis (Meininger et al, 2004). Overall, whether to use an extraperitoneal or transperitoneal approach for LRP or RALP is largely a matter of surgeon preference and experience and there is no consistently demonstrated advantage for either approach.

Developing the Space of Retzius

Following abdominal access and trocar placement for the transperitoneal anterior approach, the pelvic contents are inspected (Fig. 103–5) and adhesions are lysed if present. The initial step is entry and development of the space of Retzius. The bladder is dissected from the anterior abdominal wall by dividing the urachus high above the bladder and incising the peritoneum bilaterally immediately lateral to the medial umbilical ligaments using monopolar electrocautery. The presence of prevesical fatty alveolar tissue confirms the proper plane of dissection. Applying posterior and cephalad traction on the urachus, the retropubic space is rapidly developed with a combination of blunt and sharp dissection along the relatively avascular plane within the space of Retzius (Fig. 103–6). Lateral dissection of the bladder is carried out down toward the crossing of the median umbilical ligament and vas deferens in order to ensure optimal mobility of the bladder and to minimize future tension at the vesicourethral anastomosis. The fat overlying the prostate is removed using sharp dissection and electrocautery as needed, and the superficial branches of the DVC coagulated using bipolar electrocautery.

Figure 103–5 Initial transperitoneal view detailing the relevant landmarks within the male pelvis. NVB, neurovascular bundle.

Figure 103–6 Division of urachus and entry into the space of Retzius. Cephalad traction on the urachus with the left hand helps to identify the fatty alveolar tissue immediately anterior to the bladder, which marks the proper plane of dissection.

At this point, visible landmarks include the anterior aspect of the bladder and prostate, puboprostatic ligaments, endopelvic fascia, and pubis (Fig. 103–7). The endopelvic fascia and puboprostatic ligaments are sharply divided, exposing levator muscle fibers attached to the lateral and apical portions of the prostate. These fibers are meticulously and bluntly dissected from the surface of the prostate exposing the deep DVC and urethra at their confluence with the apex of the prostate. Electrocautery is avoided if possible to minimize thermal damage to the external sphincter and nearby NVBs.

Figure 103–7 Retropubic view of the bladder and prostate following entry into the space of Retzius. The fatty tissue overlying the anterior aspect of the prostate has been removed, exposing the puboprostatic ligaments, superficial and deep dorsal venous complex, and endopelvic fascia.

Accessory pudendal arteries traveling longitudinally along the anteromedial aspect of the prostate are easily recognized during LRP and RALP. Attempt at preservation of these arteries is important for erectile function because in some men these arteries may be the dominant source of arterial blood supply to the corpora cavernosa (Nehra et al, 2008). These accessory arteries can usually be preserved, although separation of the artery from the prostatic apex can be somewhat challenging. Most commonly, though, careful and meticulous dissection allows enough mobilization of the artery away from the deep DVC and prostatic apex that both good anatomic dissection of the prostatic apex and preservation of the accessory vessel are feasible.

Ligation of the Deep Dorsal Venous Complex

As with open surgery, different methods have been described for control of the DVC. A common observation, though, is that the profuse bleeding, which is sometimes encountered during open surgery, is not usually problematic because of the tamponade effect on venous bleeding offered by the pneumoperitoneum. In fact, some techniques involve simple cutting of the DVC with or without the use of electrocautery and placement of a suture only if necessary. Typically, there are one or two small arteries in the DVC. Most described techniques use placement of an absorbable suture for hemostasis before initiation of the surgical dissection of the prostate. During RALP, the ProGrasp forceps can be used for fixed cephalad retraction of the prostate and bladder to achieve optimal exposure of the DVC and prostatic apex before DVC ligation. Similar retraction can be applied by the surgical assistant during LRP. The deep DVC is suture ligated using a 0-polydioxanone suture or polyglactin suture as close to the pubis and as far from the prostatic apex as possible (Fig. 103–8). Securing the DVC as far away from the prostatic apex as possible can help minimize iatrogenic entry into the prostatic apex during later division of the DVC. The needle is passed beneath the DVC and anterior to the urethra. An alternative method to DVC ligation is the use a laparoscopic linear stapling device, which ligates and divides the DVC all in one step (Ahlering et al, 2004b; Nguyen et al, 2008). Regardless of the method used, it is important to avoid damage to the anterior urethral sphincter muscle from placing the sutures or staples too deep. With most techniques, the DVC is not divided until later in the operation and immediately before prostatic apical dissection and division of the urethra. A back-bleeding suture may be placed along the anterior base of the prostate to help identify the contour of the prostate and to aid in subsequent bladder neck identification and transection.

Figure 103–8 Ligation of the deep dorsal venous complex. A suture is passed from right to left, ligating the dorsal vein as distal as possible from the apex. Inset demonstrates the proper passage of the needle immediately anterior to the urethra.

Bladder Neck Identification and Transection

Proper identification of the bladder neck during RALP and LRP can be initially challenging due to the lack of tactile feedback in delineating the precise margin between the prostate and bladder. Several maneuvers are helpful in identifying the proper plane of dissection and in minimizing inadvertent entry into the prostate. First, visual identification of the point of transition of the prevesical fat to the anterior prostate can serve as a guide. Second, intermittent and repetitive caudal retraction of the urethral catheter balloon can help identify and confirm the transition between bladder neck and prostate. Third, using a forceps to grasp and retract the dome of the bladder in a cephalad direction results in “tenting” of the bladder neck at its attachment to the prostate. Lastly, further confirmation of this margin between the bladder and prostate is made by a bimanual “palpation” or “pinch” of the bladder neck using the tips of two robotic or laparoscopic instruments.

The anterior bladder is divided horizontally using monopolar electrocautery along the midline until the urethral catheter is identified. The anterior bladder neck incision should not be carried too laterally because branches of the bladder pedicle are often encountered, resulting in unwanted bleeding. The balloon is decompressed, and the tip of the urethral catheter is brought through the anterior bladder neck opening and lifted anteriorly with the assistant applying counter traction externally at the penile meatus to suspend the prostate.

The posterior bladder neck is inspected for the presence of a median lobe and to locate the ureteral orifices. If a vertical drop-off of the posterior bladder neck mucosa is noted, this would suggest the absence of a median lobe. Alternatively, if a mass effect from a large median lobe is identified, further exposure may be required to visualize beneath the protruding median lobe and identify the posterior bladder neck. The median lobe is lifted anteriorly using either the ProGrasp forceps or the surgical assistant. The posterior bladder neck is horizontally divided with monopolar electrocautery, staying along the midline to avoid bleeding from the lateral pedicles (Fig. 103–9). Dissection is carried out in a 45-degree downward angle to avoid entry into the base of the prostate, as well as creating a buttonhole in the posterior wall of the bladder. In case of a prior TURP, the bladder neck margin is less evident and often distorted as a result of prior resection and scarring. Careful inspection is made of the posterior bladder neck paying specific attention to the location of the ureteral orifices because they are often found close to the posterior bladder neck margin. Attempt at bladder neck sparing should be avoided in post-TURP and median lobe cases. When in doubt, the posterior bladder neck should be divided slightly more proximally in these particular cases so as to avoid inadvertent entry into the prostate gland.

Figure 103–9 Division of the posterior bladder neck. An assistant or ProGrasp forceps is used to grasp and elevate the urethral catheter anteriorly, providing exposure to the posterior bladder neck. Dissection is carried out along the midline, avoiding bleeding from the lateral pedicles.

Dissection of the Seminal Vesicles and Vasa Deferentia

Following bladder neck transection, the seminal vesicles and vasa deferentia are individually identified, dissected, and divided, avoiding electrocautery if possible to prevent damage to the nearby NVB (Fig. 103–10). One unique distinction between the transperitoneal anterior and retrovesical approach is in dissection of the seminal vesicles and vasa deferentia. During a transperitoneal retrovesical approach, the initial step of the operation is complete dissection of the vasa deferentia and seminal vesicles deep within the cul-de-sac. Following abdominal access, the vasa are dissected from lateral to medial toward their confluence at the ejaculatory ducts. The seminal vesicles are found immediately lateral to the vasa and are dissected free from the nearby NVB using hemoclips while avoiding the use of thermal energy (Fig. 103–11). With the dissection of the seminal vesicles and vasa now completed, once the bladder neck is divided from the prostate, these structures are simply grasped and brought through the opening. This retrovesical approach to the seminal vesicles and vasa deferentia is particularly useful in cases of a median lobe where identification and dissection of these structures by the anterior approach may be more challenging due to the protruding median lobe.

Figure 103–10 Dissection of seminal vesicles and vasa deferentia via the transperitoneal anterior approach. The seminal vesicles and vasa are identified and dissected within the opening created between the posterior bladder neck and prostate following division of the bladder neck. Hemoclips are used in lieu of electrocautery to avoid thermal injury to the nearby neurovascular bundles (NVB).

Figure 103–11 Dissection of the seminal vesicles and vasa deferentia via the transperitoneal retrovesical approach. The vasa and seminal vesicles are identified as the initial step in this approach deep within the retrovesical space. The neurovascular bundles (NVB) are dissected off of the seminal vesicles in an antegrade direction from the tip toward the base using hemoclips.

Development of the Plane between the Prostate and Rectum

Separation of the posterior prostate from the anterior rectal wall is a key surgical maneuver to avoid rectal injury but also to permit adequate identification of the prostatic pedicles and establish the medial border of the NVB. Development of this plane in an antegrade fashion is a maneuver often unfamiliar to surgeons experienced with open surgery but one that is rapidly adaptable to laparoscopic and robotic approaches. Anterior retraction of the vasa deferentia and seminal vesicles by either a surgical assistant or the robotic ProGrasp forceps helps with identification of the proper plane for the initial dissection (Fig. 103–12).

Figure 103–12 Development of the plane between the prostate and rectum. As the assistant or ProGrasp forceps is used to apply anterior traction on the seminal vesicles and vasa deferentia and downward traction on the rectum, a transverse incision is made in Denonvilliers fascia below the seminal vesicles, and blunt dissection is used to develop a plane between the posterior prostate and the rectum. Inset demonstrates the direction of dissection toward the prostatic apex.

Denonvilliers fascia is an inferior extension of the peritoneal cul-de-sac that lies between the prostate and rectum. With an intrafascial or interfascial dissection, Denonvilliers fascia can be separated from the posterior prostate by careful blunt and sharp dissection. The separation can be carried all the way to the prostatic apex and laterally to the prostatic pedicle. The proper surgical plane is relatively avascular. When a wider margin of tissue is desired on the posterior prostate such as in cases of palpable disease, Denonvilliers fascia should be sharply incised just posterior to the junction of the seminal vesicle and the prostate. This allows immediate entry into the anterior perirectal fat plane of dissection. Good visualization can be achieved as the dissection proceeds distally toward the apex staying between Denonvilliers fascia anteriorly and the anterior propria fascia of the rectum posteriorly.

Substantial bleeding typically suggests that the dissection may be too close to the prostate. If difficulty is encountered in establishing the proper plane of dissection, a new attempt can be directed to one side or the other of the initial entry point. Once the proper plane is entered, the dissection characteristically progresses rather smoothly. The rectal wall should be mobilized far enough laterally that there is sufficient separation for dissection of the NVB and prostatic apex.

Prostatic Pedicle Control

Various methods have been described for control of the prostatic pedicle. Some techniques use pure electrocautery, either monopolar or bipolar. Because of the propagation of thermal energy through tissue, which may result in damage to the nearby NVB, limitation of the use of electrocautery is advised even in the prostatic pedicle. Locking polymer Hem-o-Lok clips (Teleflex Medical, Research Triangle Park, NC) are commonly employed, but engagement of the clipping mechanism does require good delineation and thinning of the pedicle tissue so that the clipping mechanism will engage. This is best facilitated by adequate mobilization of the rectum and lateral prostate for identification of the prostatic pedicle. Application of a bulldog clamp to the pedicle with subsequent suturing after the specimen has been removed has also been described (Ahlering et al, 2005; Gill et al, 2005). Regardless of the method used, though, successful division of the prostatic pedicle in the correct anatomic location is an important step in avoiding positive margins and damage to the nearby NVB.

Preservation of the Neurovascular Bundle

Preservation of the periprostatic parasympathetic nerve fibers important for erectile function is one of the key and most difficult maneuvers during radical prostatectomy, regardless of surgical approach. Increasingly, it is recognized that the periprostatic nerves of significance have a more diffuse and highly variable course than previously believed (Costello et al, 2004; Takenaka et al, 2004; Lunacek et al, 2005), but there is a confluence of nerves along the posterolateral prostate commonly termed the NVB. Nerve tissue extends posteriorly around the prostate, forming a virtual hammock of nerves. In addition, nerve fibers can be identified in the periprostatic tissue along the more anterior portion of the prostate gland, although there is still debate about their relative contribution to erectile function. A well-performed, nerve-sparing radical prostatectomy takes all of these considerations into account and preserves as much periprostatic nerve tissue as possible.

The superb visualization of the periprostatic tissues with laparoscopic surgery has led to a greater appreciation of the periprostatic fascial layers. Although there is some confusion in the literature regarding the terminology used for the various fascial layers, an extra fascial dissection typically implies dissection laterally between the lateral prostatic fascia and the levator fascia and posteriorly between Denonvilliers fascia and the anterior propria rectal fascia. An interfascial dissection is carried out laterally between the prostatic fascia and the levator fascia and posteriorly between Denonvilliers fascia and the posterior prostate (Fig. 103–13). This is the preferred approach in patients with presumed organ-confined disease because it permits safe preservation of the cavernous nerves without violating the anatomic limits of the prostate gland and capsule. An intrafascial dissection is between the prostatic capsule and the prostatic fascia and leaves virtually no periprostatic tissue overlying the prostate. Although technically feasible, this approach may lead to a higher incidence of positive margins due to the relatively closer dissection to the prostate gland. Even though these fascial layers as described do have some true integrity for intraoperative identification, it is also well recognized that they can be multilayered.

Figure 103–13 Cross section of the prostate demonstrating the periprostatic fascial planes with respect to the location of the neurovascular bundles. The dashed line indicates the direction of interfascial dissection (i.e., between the levator and prostatic fascia) to accomplish a high anterior release of the neurovascular bundle from the prostate and establish the lateral neurovascular bundle groove. The solid line indicates the incision made for a standard release of the neurovascular bundle.

Damage to the NVB can occur because of direct incision, entrapment in a suture or clip, thermal injury, or traction. Some surgeons advocate release of the NVB from the prostate before mobilization of the specimen to help avoid traction injury. With the antegrade approach typically used for LRP and RALP, identification and at least partial release of the NVB along the lateral aspect of the prostate before controlling the prostatic pedicle can help drop the nerve tissue away from the gland and permit a more precise placement of sutures, hemoclips, or clamps on the pedicle while preventing inadvertent entrapment of the nerve bundles. To accomplish this, the levator fascia is first incised sharply along the anteromedial aspect of the midprostate entering into the interfascial plane of dissection (Fig. 103–14). Blunt dissection is carried out along the prostatic fascia in a posterolateral direction, thus partially releasing the lateral NVB and developing a visible NVB groove, which aids in precise hemoclip placement and division of the prostatic pedicle (Fig. 103–15). The ergonomics and scaled motion of the wristed robotic instruments are helpful in achieving this delicate dissection. During LRP, specially designed fine-tipped (0.8-mm) dissectors have been described to aid in NVB dissection and preservation (Su et al, 2004). Some discussion and debate has centered around how far anteriorly on the prostate the interfascial dissection of the nerve bundles should be performed. Whether high release (vs. standard release) preserves important nerves or simply allows for a physical handle to permit more precise, meticulous dissection and preservation of the true cavernous nerves located at the 5- and 7-o’clock positions without direct manipulation of these main nerve fibers is uncertain (see Fig. 103–13). However, there is a general consensus that thermal energy should be minimized and, ideally, completely avoided during dissection of the NVB. These microscopic postganglionic parasympathetic nerve fibers are highly susceptible to thermal injury as shown in both animal and human studies (Ong et al, 2004; Ahlering et al, 2005). Bleeding along the NVB is usually relatively minimal and may require no specific hemostatic measures. There may be small arteries or larger veins that require suturing with small tissue bites to avoid entrapment of adjacent nerves. Overdissection of the NVB at the prostatic apex should be avoided.

Figure 103–14 Entering into the interfascial plane of dissection for neurovascular bundle (NVB) preservation. The levator fascia is first incised along the anteromedial aspect of the midprostate, allowing entry into the interfascial plane of dissection.

Figure 103–15 Developing the interfascial plane of dissection. Using blunt dissection, the nerve bundle is partially released from the prostate in a posterolateral direction, forming a visible lateral neurovascular bundle groove. This step serves to delineate the prostatic pedicle and course of the nerve bundle and allow for precise placement of hemoclips, while avoiding nerve entrapment. NVB, neurovascular bundle.

Patients with extremely large prostate glands (especially those > 100 g) offer a unique challenge during preservation of the NVB. Maneuvering a large prostate gland in the tight confines of the bony pelvis can be challenging, especially during exposure of the prostatic pedicles and NVB. Effective exposure of tissues by the surgical assistant, as well as the fourth robotic arm, is critical and can optimize visualization during prostatic pedicle ligation and NVB preservation.

Apical Dissection

The prostatic apex is a common location for tumor involvement and the most common site of positive margins with radical prostatectomy. Further, the steps required for apical dissection are crucial to preservation of erectile function and avoidance of urinary incontinence. The visualization of the operative field and the ability to limit bleeding from the DVC facilitate apical prostatic dissection during LRP and RALP.

Up to this point in the operation, antegrade dissection has permitted complete mobilization of the lateral, base, and posterior prostate, leaving division of the DVC and urethra from the prostatic apex for last. It is critical to avoid entry into the anterior prostate during division of the DVC because this may result in an iatrogenic positive margin. Although the previously placed DVC stitch may become dislodged or divided during this step, further sutures to secure the DVC can be easily placed. Also, bleeding from the DVC during attempts at resuturing can be kept to a minimum by transiently increasing the CO₂ insufflation pressure to 20 mm Hg to improve the tamponade effect on venous bleeding. Once the DVC is divided, there should be good visualization of the prostatic apex and its junction with the urethra (Fig. 103–16). The anatomy of the prostatic apex is variable and should be carefully inspected before division of the urethra. As much urethral length as possible should be maintained, but an overlying anterior lip of prostate must be recognized, as well as posterior extension of prostatic tissue beneath the urethra. Nevertheless, leaving a small rim of urethra along the prostatic apex may be advisable to reduce the incidence of apical positive margins because this does not appear to have an adverse effect on the return of urinary continence (Borin et al, 2007). Sharp dissection with limited use of electrocautery is preferred during the prostatic apical dissection and division of the urethra so as to prevent thermal injury to the external striated sphincter and nearby NVBs.

Figure 103–16 Division of urethra. Following division of the deep dorsal venous complex, the anterior and posterior urethra is divided sharply without electrocautery. A small rim of urethra may be safely left on the prostate apex to avoid an iatrogenic positive apical margin. Great care must be taken to avoid damage to the nearby nerve bundles. NVB, neurovascular bundle.

Intraoperative Inspection of Prostate

Upon completely freeing the prostate gland and before entrapment of the specimen, the entire surface of the gland can be inspected laparoscopically to assess the adequacy of resection and integrity of the tissues covering the prostate specimen. If concern exists regarding a close surgical margin, additional tissue may be excised specific to the location of concern; however, with experience this should rarely be necessary.

Pelvic Lymphadenectomy

It is generally at this time that pelvic lymphadenectomy takes place because prior mobilization of the bladder allows for excellent exposure of the obturator lymph node region. The extent of pelvic lymphadenectomy remains controversial but can be tailored on the basis of patient-specific risk factors including prostate-specific antigen (PSA), clinical stage, and Gleason score. Technical description of laparoscopic pelvic lymphadenectomy follows later in this chapter.

Entrapment of Specimens

The prostate and pelvic lymph nodes are entrapped within a laparoscopic entrapment sack introduced into the abdomen by the surgical assistant through the 12-mm assistant trocar and stored in the abdomen until completion of the vesicourethral anastomosis.

Bladder Neck Reconstruction

The bladder opening is often slightly larger than the urethral lumen, but a parachuting effect can be achieved during the vesicourethral anastomosis that allows direct approximation of the bladder neck to the urethra. If the bladder neck opening is considerably larger than the urethra, a tennis racquet handle closure can be performed using absorbable suture either posteriorly or anteriorly to allow a better size match with the urethra. In the event of a large prostate gland, median lobe, or prior TURP, the bladder neck may often be disproportionately larger than the urethra and thus may require extensive reconstruction before performing the vesicourethral anastomosis. Often, in these circumstances, the ureteral orifices are located at or near the posterior margin of the bladder neck where they are at risk of injury or obstruction during suturing of the anastomosis. In such cases the ureteral orifices can be imbricated by placing a few interrupted sutures at the 5- and 7-o’clock position along the posterior bladder neck using 3-0 polyglactin or polydioxanone suture. This maneuver can help avoid inadvertent sutures passing through or near the ureteral orifices during the anastomosis while at the same time reduce the size of the bladder neck opening.

Posterior Support of the Vesicourethral Anastomosis

As a result of prostatectomy the posterior supportive layers of the bladder and prostate are divided, including the Denonvilliers fascia and its confluence with the posterior rhabdosphincter. Recent reports of attempts at reconstruction of these posterior supportive structures have suggested improvement in earlier postoperative return of urinary control (Rocco et al, 2007), whereas others have found no significant benefit (Menon et al, 2008). Reconstituting the posterior support to the anastomosis is accomplished by reapproximating the remnant Denonvilliers fascia and posterior bladder neck to the posterior rhabdosphincter beneath the urethra using a running continuous 2-0 poliglecaprone (Monocryl) suture before completion of the vesicourethral anastomosis (Fig. 103–17). Although the exact mechanism remains unclear, suggested mechanisms include re-establishment of the posterior anatomic support to the bladder and urethra improving urethral coaptation during voiding, reduced tension at the vesicourethral anastomosis, and increase in the functional length of the striated urethral sphincteric complex. Despite the ongoing debate on its effectiveness, many believe that this step at the very least reduces the distance between the bladder neck and urethra, thus facilitating completion of a tension-free vesicourethral anastomosis. Resuspension of the anastomosis and distal bladder neck to the arcus tendineus is used by some to restore anterior urethral support and preserve the vesicourethral angle (Tewari et al, 2007).

Figure 103–17 Modified Rocco stitch. Posterior support is provided to the vesicourethral anastomosis by reapproximating the remnant Denonvilliers fascia and posterior detrusor along the posterior bladder neck to the posterior rhabdosphincter using a running continuous 2-0 Monocryl suture.

Vesicourethral Anastomosis

With LRP, the vesicourethral anastomosis is one of the most difficult aspects of the procedure due to the challenges of performing laparoscopic suturing. The da Vinci surgical robot greatly facilitates suturing of the anastomosis due to the ergonomics of the wristed robotic instrumentation. Although interrupted sutures may be used for the anastomosis, van Velthoven and colleagues (2003) described a running suture technique, which distributes tension broadly across multiple points along the bladder and urethra. Typically, two separate sutures are tied together at their ends, each 6 to 8 inches in length. The anastomosis between the bladder and urethra begins posteriorly, leaving two needles to run progressively in an anterior direction on either side, finally ending at a single anterior tie. Dedicated mucosal eversion sutures at the bladder neck, commonly used during radical retropubic prostatectomy (RRP), are seemingly unnecessary with the excellent running mucosa-to-mucosa anastomosis achieved with LRP and RALP. Multiple sutures are first placed through the urethra and bladder before progressive cinching of the anastomosis by lifting each arm of the suture in an anterior direction (Fig. 103–18). Either an assistant or the robotic ProGrasp forceps can be used to grasp one arm of the suture to maintain tension and approximation of the posterior anastomosis while the surgeon reapproximates the contralateral side of the anastomosis using the second suture. The final urethral catheter is passed under direct vision immediately before completion of the anastomosis and the bladder is irrigated to make certain that there are no anastomotic leaks. Further sutures may be required if a leak is identified.

Figure 103–18 Running vesicourethral anastomosis. The posterior anastomosis is reapproximated after preplacing two to three sutures on either side and cinching the sutures by lifting anteriorly. Great care must be taken to avoid incorporating the neurovascular bundles (NVB) when placing sutures within the urethra.

Delivery of the Specimens and Exiting the Abdomen

Prior to undocking the robot and removal of the specimens, the pelvis and operative field should be carefully reinspected for bleeding under low insufflation pressure (<10 mm Hg). The bowel should be examined closely to make certain that there is no injury resulting from instrument exchanges. The string for the laparoscopic entrapment sack is transferred to the camera port site at the umbilicus and the abdomen is completely desufflated. The specimens within the laparoscopic entrapment sack are extracted intact through extension of the periumbilical trocar site. The fascial defect is then closed by open suture placement, and the skin defects are closed with a subcuticular absorbable suture or a skin adhesive. Closure of the fascial defect for the 5-mm trocar sites is generally not necessary. Due to the potential risk of a trocar site hernia, it is advisable to close the 12-mm trocar sites with a Carter Thomason fascial closure device, especially if a bladed (vs. dilating) trocar is used.

Operative Time

The duration of surgery is typically longer with LRP or RALP compared with open surgery, especially early in the surgeon’s experience. In fact, operating times are often used as a surrogate for assessing the “learning curve” with laparoscopic prostatectomy (Herrell and Smith, 2005). As both surgeon and operating team experience is gained, virtually all reported series have documented a substantial decrease in operative times that approach and in some series surpass those for open surgical techniques. At experienced centers of excellence with LRP, operative times less than 3 to 4 hours are common (Turk et al, 2001; Salomon et al, 2004; Stolzenburg, 2008). Similar findings have been observed with RALP. Inexperience of both the console surgeon and the tableside operating team can lead to lengthy procedures initially. Once experience is gained, operative times of less than 3 hours have been reported for the total procedure (Smith, 2004; Badani et al, 2007; Patel et al, 2008).

Postoperative Pain

One of the distinct advantages of laparoscopy for many surgical procedures (e.g., laparoscopic nephrectomy) is its minimally invasive nature resulting in less postoperative pain than comparative open approaches. For radical prostatectomy, however, this advantage seems to be less dramatic because RRP is performed through an infraumbilical muscle-splitting incision. In addition, relatively little pain occurs after radical perineal prostatectomy. Some series have shown decreased pain in patients undergoing either LRP or RALP compared with RRP (Menon et al, 2002; Bhayani et al, 2003). Other reports have shown no substantial difference in postoperative narcotic use or in patient-reported pain (Webster et al, 2005). The lack of a significant advantage for laparoscopic prostatectomy is attributable primarily to low pain scores even in the open surgical group.

Intraoperative Blood Loss

Because most of the blood loss that occurs during radical prostatectomy is from venous sinuses, the tamponade effect from the pneumoperitoneum helps diminish ongoing blood loss during LRP and RALP. Further, the antegrade approach used during LRP and RALP entails earlier control of the prostatic pedicles and late division of the DVC as compared with RRP, in which the DVC is divided early and the arterial supply to the prostate managed late in the operation. Thus the potential for ongoing bleeding is reduced during LRP and RALP as compared with open surgery. Both of these factors, as well as the excellent visualization with laparoscopy, account for the minimal blood loss reported in most series. Blood loss of less than a few hundred milliliters is routinely reported (Ficarra et al, 2009).

Perhaps the most meaningful parameter clinically is the proportion of patients requiring transfusion of homologous blood products. Most studies have shown a significant decrease in transfusion requirement for patients undergoing LRP or RALP compared with RRP (Tewari et al, 2003; Ahlering et al, 2004a). Others have shown no statistically significant difference if the transfusion requirement with RRP can be limited to only a few percent of patients (Farnham et al, 2006).

Hospital Stay

Over the past decade, hospital stay after radical prostatectomy has diminished remarkably regardless of the surgical approach. Some centers have reported a length of stay as short as 1 or 2 days after RRP (Holzbeierlein and Smith, 2000). With LRP and RALP, a hospital stay of only 1 day has become routine in many centers. Ileus and inability to tolerate a regular diet are the most common factors limiting early discharge. Pain control does not typically contribute to prolonged length of stay because parenteral narcotics are rarely required. With early discharge programs for radical perineal and RRP being commonly used at many centers within the United States, no distinct advantage exists for LRP or RALP, although discharge on the first postoperative day may be more easily accomplished routinely with the minimally invasive approaches.

Urinary Incontinence

Urinary incontinence after radical prostatectomy is usually manifested as stress incontinence secondary to intrinsic sphincter deficiency. Although more than 90% of patients ultimately regain good urinary control and do not require pads for incontinence in reports from high-volume centers (Walsh, 1998; Catalona et al, 1999), other studies have shown that a substantial proportion of patients may be bothered by some degree of stress incontinence (Fowler et al, 1993). The exact physiologic mechanisms that contribute to urinary control after radical prostatectomy are not entirely understood and are likely multifactorial. However, surgical technique is undoubtedly a contributing factor (Smith, 2002).

With LRP and RALP, visualization of the prostatic apex is typically superb. The minimal bleeding and magnification of the operative field allow precise dissection of the prostatic apex with limited trauma to the periurethral striated sphincter and genitourinary diaphragm. As mentioned previously, the ability to more reliably accomplish a tension-free, watertight anastomosis under the superior and direct visualization offered by laparoscopic approaches in theory favors LRP and RALP over open surgery. A common observation after radical prostatectomy, regardless of surgical approach, is that urinary incontinence improves substantially within the first 3 to 6 months after surgery and to some extent for another year or more. Therefore the time points at which data on incontinence are collected are highly influential. Differences exist whether the information is gathered by questionnaire, the physician, or an independent third party. Further, even though validated instruments for assessment of incontinence exist, the manner and location in which the data are collected can affect results. Although the method used to evaluate continence in reported series varies, the recovery of urinary continence is excellent at 1 year following LRP and RALP (Table 103–2). More recent reports of techniques that provide both posterior and anterior support to the vesicourethral anastomosis report even further improvements in urinary continence, especially at earlier time points (Tewari et al, 2007).

Table 103–2 Reported Urinary Continence Outcomes following LRP and RALP

Erectile Dysfunction

Preservation of erectile function after radical prostatectomy depends on precise and meticulous separation of the cavernous nerves within the NVB from the prostate gland (Walsh and Donker, 1982). The anatomic course of these nerves has been described but can be variable (Costello et al, 2004; Takenaka et al, 2004; Lunacek et al, 2005). Intraoperative localization using nerve stimulation has not been sufficiently accurate for clinical utility (Holzbeierlein et al, 2001). The principles and anatomic dissection for nerve preservation are the same regardless of surgical approach. It is still uncertain whether the magnified image of the operative field afforded by laparoscopy and the precision of the surgical instruments allows more anatomically accurate and less traumatic dissection of the NVBs, resulting in improved postoperative erectile function. As with incontinence, comparison of the published literature is difficult (Salomon et al, 2004). Differences in the method of assessment, definition of potency (e.g., spontaneous erections vs. intercourse), and patient selection complicate comparisons. In addition, the use of adjunctive therapies such as phospho-diesterase-5 inhibitors or vasoactive injections can substantially influence results. Also, in concordance with other nerve injuries, improvement in erectile function is a prolonged process that is ongoing for years after radical prostatectomy. Good results with erectile function after both LRP and RALP have been reported (Table 103–3). However, there are no published data that allow definitive conclusions about the relative merits of either LRP or RALP in avoiding erectile dysfunction compared with open surgical approaches. Nevertheless, the avoidance of hemostatic energy sources during NVB preservation and the performance of meticulous interfascial dissection and preservation of the cavernous nerves appear to be critical to optimizing postoperative recovery of potency.

Table 103–3 Reported Potency Outcomes following Bilateral Nerve-Sparing LRP and RALP

Anatomic studies indicate that the cavernous nerves in the NVB course posterolateral to the prostate and urethra. A technique during RALP for preservation of more anteromedial periprostatic fascia in addition to the conventional NVB regions has been reported to significantly improve potency outcomes (Menon et al, 2005; Savera et al, 2006). Although some neural tissue can be shown histologically to travel within the anterior and medial periprostatic fascia, the purpose and significance of these nerves and their relative contribution to erectile function remains uncertain. Nevertheless, the concept of optimizing both qualitative and quantitative preservation of nerve fibers traveling within the periprostatic fascial planes irrespective of whether they affect penile erections or urinary continence seems reasonable. In cases where wide excision of the nerve bundles is required, cavernous nerve grafting and nerve advancement have been described; however, the true merits of these techniques remain unclear (Martinez-Salamanca et al, 2007; Zorn et al, 2008).

Surgical Margins

The goal of radical prostatectomy is complete surgical removal of the entire prostate and its investing fascia, as well as the seminal vesicles. Because most adenocarcinomas of the prostate occur in the peripheral zone and approach the capsular margin, surgical technique can influence oncologic outcomes. Proper surgical dissection should allow negative margins with pathologic stage T2 tumors while also permitting complete excision and negative margins for some extracapsular lesions. Efforts to avoid urinary incontinence or erectile dysfunction by dissecting too closely to the prostatic apex or the posterolateral aspect of the prostate can compromise margins, regardless of the surgical approach. Once again, comparison of positive margin rates in reported series is difficult because of patient selection. Importantly, the method and detail of pathologic analysis of the surgical specimen can be highly influential in assessing surgical margin status. Some reports have used only biopsies of remaining tissue after removal of the surgical specimen to assess margin status, whereas others rely on step-sectioned routine or whole mount histology. According to the World Health Organization International Consultation Consensus Committee guidelines established for the pathologic analysis of prostatectomy specimens, whole mount histologic sectioning may miss areas of extraprostatic extension in 7% to 15% of cases and positive margins in up to 12% as compared with specimens analyzed by routine sectioning (WHO International Consultation on Prediction of Patient Outcome in Prostate Cancer, 2004). This finding is thought to be due to the relatively thicker slices required during sectioning of the prostate for whole mount technique as compared with the serial 3- to 5-mm slices used during routine sectioning.

In most series of LRP and RALP, positive margin percentages decrease with experience (Ahlering et al, 2004b; Salomon et al, 2004; Rassweiler et al, 2005). This implies that inexperience with the surgery accounts for positive margins in some cases. Sometimes, this may be from difficulty in identifying the proper anatomic plane of dissection between the bladder neck and the base of the prostate. The most common site of a positive margin, whether the operation is performed via open or laparoscopic approaches, is the prostatic apex (Touijer et al, 2005). Insufficient removal of prostatic tissue at the apex in an effort to optimize urethral length and avoid incontinence can result in positive margins even with tumors that do not pathologically violate the capsule (i.e., stage pT2). As mentioned previously in the surgical techniques section of this chapter, adhering to specific surgical principles can help reduce site-specific positive margins at the apex, bladder neck, and posterolateral regions of the prostate. Published rates of pathologic stage-specific positive margins for LRP or RALP are shown in Table 103–4.

Table 103–4 Reported Pathologic Stage-Specific Positive Margin Rates with LRP and RALP

The primary factor that determines the positive margin rate in a given series is patient selection. As discussed earlier, the method and detail of pathologic analysis is also influential. Evaluating positive margin rates from one series to another, then, is not necessarily a comparison of surgical technique. A more accurate technical comparison is analysis of the pathologic results in stage T2 tumors wherein a positive margin implies surgical violation of the prostatic capsule. Even in this circumstance, though, the methodology for pathologic sampling is important. Intrainstitutional comparisons from some studies have shown a reduced rate of positive margins with laparoscopic approaches compared with RRP. However, comparison of margin status between high-volume centers with operations performed by experienced surgeons has shown no definitive advantage for one surgical approach over the other in achieving negative surgical margins (Brown et al, 2003; Khan et al, 2005).

Biochemical Recurrence

Biochemical recurrence following prostatectomy may perhaps provide a more accurate assessment of oncologic control than margin status. Guillonneau and colleagues reported on their oncologic outcomes with 1000 consecutive LRPs performed over a 4-year period with a median follow-up period of 12 months (Guillonneau et al, 2003b). Their overall actuarial biochemical progression-free survival rate was 90.5% at 3 years. By pathologic stage, the rates were 92% for pT2a, 88% for pT2b, 77% for pT3a, and 44% for pT3b. Pavlovich and colleagues (2008) reported on 528 consecutive LRP patients with a mean follow-up of 13 months. The 3-year, actuarial, biochemical-free survival was 94.5% overall, 98.2% for pT2, and 78.7% for pT3 disease.

With regard to RALP, Badani and colleagues in 2007 reported on their large series of 2766 consecutive RALP patients with a mean follow-up period of 22 months. Their overall 5-year, actuarial, biochemical-free survival was 84% overall, 84% for pT2, and 66% for pT3 patients. It should be noted that their patient population included higher-risk patients than most reported series with a Gleason score of 7 or higher in 64% and a pathologic stage of pT3 or higher in 22% of their patients. In a retrospective comparison of biochemical recurrence between RALP and a contemporary series of RRP performed at a single center, no difference was found between the two groups after controlling for clinical and pathologic features (Schroeck et al, 2008). In the end, longer-term follow-up is required to compare the results of LRP and RALP with results of RRP from established and experienced centers of excellence.