100 Jens Rassweiler,1 Giovannalberto Pini,2 Marcel Fiedler,1 Ali Serdar Goezen,1 & Dogu Teber3 1 Department of Urology, SLK Kliniken Heilbronn, University of Heidelberg, Germany 2 Department of Urology, San Raffaele Turro Hospital, Milan, Italy 3 Department of Urology, Klinikum Karlsruhe, University of Heidelberg, Heidelberg, Germany In the United States more than 70% of radical prostatectomies are robot assisted using the da Vinci device. In Europe, there is skepticism concerning the spread of robotic systems, based on unfavorable experiences in orthopedics and cost pressures [1]. In Germany and Italy, 25% of radical prostatectomies are performed by laparoscopy. The advantages of this approach include reduced access trauma, less pain and bleeding, and lower transfusion rates [2, 3]. Furthermore, all robot‐assisted techniques are based on laparoscopy. In 1992, Schuessler et al. attempted the first laparoscopic radical prostatectomy (LRP) [4]. However, his technique did not provide any advantages over retropubic radical prostatectomy (RRP) [5]. In 1995, Raboy et al. published a case of extraperitoneal LRP [6]. Richard Gaston (personal communication, 1998) pioneered LRP in 1997, followed by Guillonneau, Vallancien, and Abbou, who popularized the transabdominal access to seminal vesicles [7–10]. In 1999, Rassweiler et al. developed a retrograde technique similar to RRP [11, 12]. In the following years, several groups revisited the French technique [13–16], and in 2000, Bollens et al. revisited the extraperitoneal approach [17]. In 2002, a survey in Germany and Switzerland revealed that 15% of departments performed LRP, but that only 5% did more than 15 cases per year [18]. In 2004, 19.2% of German departments were offering LRP [19]. In 2005, a multicenter study including 5800 patients treated by 50 surgeons was published [20]. In the United States, Gill and colleagues was one of the few groups establishing a program of laparoscopic pelvic surgery [21]. Menon et al. initiated the change when hiring Vallancien and Guillonneau to establish LRP at his institution [22]. Perhaps more importantly, he invested in the da Vinci system and managed to perfect robot‐assisted laparoscopic prostatectomy (RALP). Although RALP has led to a significant decrease in the use of classical LRP within the last decade, particularly in the United States, in Europe, about 25% of all prostatectomies are performed laparoscopically, 35% robot assisted, and 40% still by open technique [23, 24]. Moreover, recent technical improvements including 3D high‐definition (HD) or even ultra‐HD video‐technology, the use of an ergonomic chair, and instruments providing six degrees of freedom have significantly reduced the ergonomic difficulties of the procedure [25–27]. Accordingly, LRP has yielded excellent oncologic outcomes, even in advanced stages [28, 29]. There is still a continuous role for LRP [24, 30] since no study has yet proven any substantial inferiority in oncologic and functional results. Indications include men with localized prostate carcinoma and a life expectancy greater than 10 years [30]. All patients with stage less than T3, Gleason score less than 8, and prostate specific antigen (PSA) less than 10 ng/ml are candidates for nerve preservation. Those with suspected extracapsular invasion (T3) or perineural invasion in core biopsies should not undergo nerve‐sparing surgery (Table 100.1). Table 100.1 Criteria for nerve sparing. PSA, prostate specific antigen. Previous transurethral resection of the prostate, abdominal or pelvic surgery, laparoscopic hernia repair, pelvic irradiation, and gross obesity can add to surgery complexity, and such patients should be approached only after considerable experience [28, 31, 32]. Absolute contraindications are abdominal wall infection, generalized peritonitis, bowel obstruction, and uncorrected coagulopathy. Despite early descriptions by Walsh et al. and a recent consensus paper by Walz et al. [33–35], there is still no consensus on the nomenclature of all described anatomical structures. Therefore recently, the European Association of Urology (EAU) Section of Uro‐Technology (ESUT) proposed a uniform nomenclature [36]. In general terms, descriptions/nomenclatures are either surgical, anatomical, or eponymical, but some authors use different terminologies (Table 100.2). The anatomical description is defined according to the Federative Committee on Anatomical Terminology’s Terminologia Anatomia, International Anatomical Terminology published in 1998 [37]. Usually, surgeons describe their technique based on the “surgical terminology,” using terms translated from Latin. One example would be the term “endopelvic fascia” instead of “fascia pelvis parietalis.” Eponymical descriptions are based on the name of the first surgeon or anatomist publishing an article on the relevant anatomical structure, such as the “plexus Santorini” or “Denonvilliers’ fascia” [38, 39]. In addition to this, some authors use different terms to describe important structures, such as the “paraprostatic or periprostatic fascia” instead of “levator fascia” or “fascia levatoris ani” [40]. Table 100.2 Summary of existing anatomical descriptions of relevant anatomy during radical prostatectomy. Modified from Rassweiler et al. [36]. Walsh et al. described three layers covering the anterolateral surface of the prostate [33, 34]: the prostatic fascia overlaying the prostatic capsule and levator fascia (fascia diaphragmatica pelvis superior). Both fasciae fuse laterally to form the lateral pelvic fascia covered by the endopelvic fascia (fascia pelvis parietalis) reflecting off the transversalis fascia (Figure 100.1). This area is also described as the tendinous arch of the pelvis. Posteriorly, there are two layers: Denonvilliers’ fascia (prostato‐seminal‐vesicular fascia; septum retrovesicale) and the prostatic capsule. The neurovascular bundles run along the posterolateral part of the prostate between levator and prostatic fascia and contain branches from the inferior vesical arteries running medial to cavernosal nerve branches originating from the pelvic plexus. These vessels enter the capsule through the prostatic fascia. Some authors describe the levator fascia also as the periprostatic or parapelvic fascia [40]. Figure 100.1 Anatomical basis of the prostate: fascial anatomy of the prostate according to Walsh et al. [33]. For preservation of continence, the course of intrapelvic branches of the pudendal nerve is more relevant than the course of neurovascular bundless [41]. N. pudendus has three branches: (i) nervi rectales inferiors, (ii) nervi perinealis, and (iii) nervus dorsalis penis. The perineal rami support the penile muscles (m. bulbospongiosus, m. ischiorectalis, m. ischiocavernosus) and the striated urethral sphincter. Lesions of perineal branches lead to incontinence. A., V. and N. pudendus enter the small pelvis through the foramen ischiadicus minus, then follow the canalis pudendalis (Alcock’s canal). Finally the nerve divides medially into its three branches. The perineal rami supporting the striated urethral sphincter run underneath the levator fascia (fascia diaphragmatica pelvis superior). The urethral sphincter apparatus consists of the horseshoe‐shaped rhabdosphincter and smooth‐muscle longitudinal and circumferential lissosphincters [35]. In addition, the prostate is connected laterally to the urethra by thickened fascial band components (Walsh’s pillars, Müller’s ischioprostatic ligaments). Anteriorly, puboprostatic (pubovesical) ligaments suspend the urethra. For preservation of the puboprostatic collar it is important to keep this part completely intact (Figure 100.2). Posteriorly, the sphincter apparatus is supported by the median fibrous raphe and rectourethralis muscle. In addition, the striated sphincter is flanked by thickened anteriomedial edges of the anterior levator ani muscle (i.e. urogenital hiatus), forming an incomplete sling behind the urethra. On contraction they forcefully propel the prostate and prostatourethral junction upward and forward, enabling quick cessation of urination. Figure 100.2 Concept of preservation of puboprostatic collar according to Takaneda et al. [58]. The precise anatomy of the bladder neck and its effect on continence is still unclear. In the transverse plane, the bladder neck is composed of two different muscles, the ventrolateral and dorsal longitudinal muscles, which are positioned in an oblique direction. When the bladder neck is examined in a truly transverse direction, there is a distinct circular muscle called the musculus sphincter vesicae, possibly representing the rationale for bladder neck preservation [36]. Both somatic pudendal nerve and autonomic branches of the pelvic plexus are involved in the urinary continence mechanism. Somatic motor innervation passes from the anterior horn of S2–4 segments and travels to the external sphincter via an intra‐ and an extrapelvic branch of the pudendal nerve. Additional intrapelvic extrapudendal nerve fibers from S2–3 pass lateral to the pelvic plexus and then continue along the dorsolateral surface of the rectum, until they disappear into the levator ani muscle and terminate in the urethral sphincter [40]. In addition to the efferent autonomic and somatic nerve fibers innervating the sphincteric musculature, intrapelvic afferents from the membranous urethra contribute to urinary continence. Intact afferents lead to a conscious sensation of urine entering the membranous urethra, inducing either a spinal reflex or voluntary contraction of the rhabdosphincter. These afferent fibers run in branches of the pelvic plexus and the intrapelvic branch of the pudendal nerve. Four approaches have been described: (i) transperitoneal descending with initial dissection of the seminal vesicles [8]; (ii) transperitoneal ascending [12]; (iii) extraperitoneal descending [42, 43]; and (iv) extraperitoneal ascending [44]. The patient lies in lithotomy position. A rectal balloon catheter is inflated with 40–60 ml of air. The operating table is placed in a 15–20° Trendelenburg (Figure 100.3a). A 16 Fr Foley catheter is inserted. Some authors prefer an incline of up to 30–40° [7]. A semi‐lunar or W‐shaped arrangement of 5 and 10 mm trocars is recommended (Figure 100.3b,c). Figure 100.3 Positioning of the patient and trocar arrangement for laparoscopic radical prostatectomy. (a) Lithotomy position. (b) Classic supine with adducted legs and 15–20° Trendelenburg and W‐shape arrangement (Heilbronn technique). (c) Semilunar arrangement according to Ukimura et al. [21]. Transperitoneal access is accomplished with a Veress needle (maximum pressure 15 mmHg). The peritoneum is incised over both seminal vesicles and the vas deferens are exposed and divided. Thereafter, the space of Retzius is developed by transection of the urachus after filling the bladder with 200 ml of saline. Extraperitoneal access uses a periumbilical incision followed by extraperitoneal blunt dissection of the space of Retzius (balloon trocar; Figure 100.4). The other ports are placed after establishing the pneumo‐extraperitoneum (maximum 12 mmHg). Figure 100.4 Balloon dissection of the space of Retzius under endoscopic control. (a) Schematic view. (b) Introduction of the telescope via the balloon trocar. Transferability of the transperitoneal access was demonstrated [10–14, 45–48]; however, the extraperitoneal descending technique is easier to learn, as reflected in the shorter operating times [20, 31, 42]. Eliminating the transperitoneal dissection of seminal vesicles may shorten operative time by 50 minutes [49]. Comparable surgical results between extraperitoneal and transperitoneal LRP have been published [20, 50–54]; some authors emphasize the advantages of the extraperitoneal approach (i.e. no bowel lesions, ileus, and peritonitis) [44, 49], whereas others found no differences [53, 54]. Table 100.3 Advantage and disadvantage of extraperitoneal versus transperitoneal laparoscopic radical prostatectomy. The antegrade technique starts at the bladder neck. The Foley catheter is used as a retractor to expose and cut the posterior wall of the bladder neck (Figure 100.5a). Subsequently, the vesicoprostaticus muscle is divided, exposing the vas deferens and seminal vesicles. Using the vas as a retractor, Denonvilliers’ fascia is incised to dissect the posterior surface of the prostate. Proximal pedicles are clipped and divided (Figure 100.5b). Following apical dissection the dorsal vein complex (DVC) is sutured and divided. Finally, the urethra is transected (Figure 100.5c). Figure 100.5 Antegrade technique of laparoscopic radical prostatectomy according to Ukimura et al. [21]. (a) Opening of the bladder neck and dissection of the vas deferens and seminal vesicles. (b) Dissection of the posterior surface and control of prostatic pedicles using the vas deferens as a retractor. (c) Division of the urethra. The retrograde technique starts at the apex with suturing and dividing of the DVC. Thereafter, the urethra is incised (Figure 100.6a). The Foley catheter is used as a retractor during prostatic posterior dissection (Figure 100.6b). Subsequently, it serves as a retractor to expose the bladder neck, which is incised to reach the vas and seminal vesicles and to control the proximal pedicles (Figure 100.6c). Figure 100.6 Retrograde technique of laparoscopic radical prostatectomy (Heilbronn technique). (a) Division of the urethra. (b) Posterior dissection using the Foley catheter as a retractor. (c) Bladder neck incision using the loop of the catheter as a retractor. Although the retrograde technique is more popular in open surgery [45, 55–57], laparoscopic and robotic surgeons favor the antegrade approach [15, 22]. The early control of prostatic pedicles and late division of the DVC ensure minimal bleeding. Long‐term continence exceeds 90% in most laparoscopic and robotic series; however, initially early continence (i.e. at three months) used to be still in the range of 40–50% [3]. Several strategies have been proposed [40, 58–65]: Recently, Takenaka et al. [58] introduced the strategy of preservation of the puboprostatic collar. We have added the preservation of the levator fascia to this strategy, yielding excellent short‐term continence results. Following lateral incision of the endopelvic fascia, the levator fascia is perforated, creating a dissection plane along the levator ani muscle (Figure 100.7). The levator (“periprostatic”) fascia is incised secondarily to perform an interfascial nerve‐sparing technique [66–69]. This approach also includes division of both puboprostatic ligaments and distal ligation of the DVC (Figure 100.8). Figure 100.7 Incision of the endopelvic fascia. Red arrows: without preservation of the levator ani fascia (conventional technique). Black arrows: with preservation of the levator ani fascia. NVB, neurovascular bundle. Figure 100.8 Division of the dorsal vein complex (DVC). (a) A 120° endodissector is placed over the prostatovesical junction. (b) Conventional technique: distal suturing and division of the DVC. (c) New technique: division of the DVC at the mid prostate. Following medial incision of the endopelvic fascia below the puboprostatic ligaments, the avascular plane between the levator and prostatic fascia is developed (Figure 100.7). Thus, the intrapelvic branch of the pudendal nerve remains covered by levator fascia. The DVC is sutured over the mid part of the prostate to preserve the puboprostatic collar. For division of the DVC a 120° endodissector is placed over the prostatovesical junction (Figure 100.8), rotating the prostate towards the urethra, and the anterior striated sphincteric complex is reached. The urethra is transected just distal to the verumontanum, preserving the rectourethralis muscle. Whenever indicated, we perform a bladder neck‐sparing technique. After dividing the bladder neck, the prostatovesicle muscle is incised close to the prostate to be used for posterior reconstruction of the anastomosis. If nerve sparing is contraindicated, the neurovascular bundles are clipped distal to the urethra using 10 mm titanium clips. No Hem‐o‐lok clips are used to avoid migration into the anastomosis. The proximal pedicles are clipped pararectally to minimize the risk of positive margins. Preservation of the neurovascular bundles can be performed using an antegrade or retrograde technique [69–71]. Antegrade dissection starts with the division of the proximal pedicle and release of the neurovascular bundles at the base of the prostate [8]. Finally, the bundles can be separated bluntly from the apex. The neurovascular bundles cannot easily be visualized without initially incising the levator fascia and developing the lateral neurovascular bundle groove [69]. Gill et al. proposed intraoperative transrectal ultrasound monitoring to identify the course of the neurovascular bundle [66]. Interfascial neurovascular bundle dissection uses the prostatic fascia as a visible landmark, starting with its separation lateromedially [31, 69]. Retrograde dissection reproduces the open technique with earlier release of the neurovascular bundles [70–72]. The space between the urethra and the neurovascular bundles is dissected bluntly until Denonvilliers’ fascia can be identified. The rectal balloon is inflated with 40–60 ml of air. The prostatic fascia is incised and small branches to the neurovascular bundles are controlled with 5 mm titanium clips (Figure 100.9a). The same is achieved during posterior dissection after incision of the urethra. Following division of the bladder neck, the course of the neurovascular bundles is visualized to exactly determine the clip position to control the proximal pedicle (Figure 100.9b). Figure 100.9 Retrograde nerve‐sparing technique. (a) Early release of the neurovascular bundles at the apex using 5 mm titanium clips. (b) Controlled division of the proximal pedicle. Table 100.4 Advantages and disadvantages of retrograde versus antegrade neurovascular bundle preservation during laparoscopic radical prostatectomy. All steps can be performed using either technique, and in the meantime hybrid techniques using steps of both approaches have been described [73]. Commonality exists with regard to accomplishing an interfascial dissection and early visualization of the neurovascular bundles, use of task‐specific instrumentation such as fine right‐angled and curved dissectors, and avoiding thermal energy during steps relevant to neurovascular bundle preservation [69, 71, 74]. The specimen is entrapped in the self‐opening extraction bag (Karl Storz, Tuttlingen, Germany) by pulling the purse‐string out onto the skin surface via the left 10 mm port. Thereafter, the port is reinserted parallel to the bag. For the urethrovesical anastomosis, the right medial port and left lateral port are used to provide an optimal angle (25–35°) between the instruments (Figure 100.10a). The anastomosis can be accomplished by the interrupted, continuous, or single‐knot technique [64]. Figure 100.10 Urethrovesical anastomosis. (a) Suturing using the right medial port for the needle driver to achieve an appropriate angle between the instruments. (b) Schematic posterior reconstruction according to Rocco and Rocco [65], with adaptation of the vesicoprostatic muscle to the rectourethralis muscle and posterior plate. B, bladder; NVB, neurovascular bundles; C, catheter; Pu, periurethral plate (prostate‐vesical muscle and central raphe); 1–4, position of stitches. (c) Rocco stitch. (d) Single‐knot technique according to van Velthoven using a bicolored suture. Urethral stitch (inside–outside). (e) Bladder neck stitch (outside–inside) at 4 o’clock. (f) Adaptation of the posterior part of the anastomosis using the winch principle. Rocco and Rocco reported significant improvement of early continence following adaptation of the prostatovesicle muscle to the rectourethralis muscle [65] (Figure 100.10a–c). However, Menon et al. did not find any advantage over a single‐knot technique alone [75]. Using the described technique, Rocco suture did not improve early continence. However, it did release tension on the anastomosis as well as the neurovascular bundles. Anastomosis is performed using two bicolored sutures (17 cm PDS 3‐0 and Biosyn; RB1‐needle) knotted together [76, 77]. At this stage it is important that the assistant pushes the perineum with the urethral stump towards the surgeon (“perineal push”). We start at the 6 o’clock position on the bladder neck, subsequently taking the posterior urethra. Once the posterior part of the anastomosis is accomplished, the sutures are pulled to adapt the bladder neck and urethra (winch mechanism) (Figure 100.10d–f). An 18 Fr catheter is inserted and the anastomosis is completed. In difficult situations, a special bougie allows insertion of a guidewire for safe placement of the catheter. Posterior bladder neck reconstruction is necessary when the orifices are close (<5 mm) to the resection line (i.e. in cases of a large mid lobe). Anterior reconstruction may become necessary when bladder neck preservation is not possible or indicated. Based on anatomical studies Tewari et al. promoted the anterior reconstruction of the dorsal vein plexus and the reattachment of the arcus tendineus and puboprostatic plate to the bladder neck [78]. Even if other authors could not confirm its positive effect on early continence [75], the concept of total reconstruction of the urethrovesical junction seems to be an appealing concept. Early continence may depend more on other factors, such as preservation of the levator fascia minimizing the trauma to the branches of the pudendal nerve, but total reconstruction of the urethrovesical junction has a significant impact on the healing process of the anastomosis. After placing the drainage tube via the right medial 10 mm port, the bag is extracted via the periumbilical incision. A systematic literature search using the terms “laparoscopic radical prostatectomy,” “ergonomics,” “comparative studies,” and “robot‐assisted radical prostatectomy” was performed in Medline, Embase, and Pubmed. Inclusion criteria were randomized controlled trials (RCT) or observational series and reviews of good quality. Primary outcome parameters focused on the impact of ergonomics on performance and learning curve of the different techniques. Secondary outcome parameters were functional and oncologic outcomes after radical prostatectomy. In Heilbronn, we have performed 3505 LRPs since March 1999, including 869 with da Vinci. Twenty‐seven comparative studies were identified: 23 compared LRP with RRP and 4 compared LRP with RALP: one randomized controlled trial [79]; 12 nonrandomized prospective studies [45, 54, 80–101]; seven retrospective studies compared to contemporary series [91–96]; and four retrospective studies using historical series as controls [97–100]. Furthermore, there are robust long‐term data from major centers as well as from recent meta‐analyses [2, 3, 56, 101–104]. Based on this, there is an increasing body of evidence that laparoscopic and robot‐assisted radical prostatectomy provide advantages with respect to surgical complications such as risk of transfusion and postoperative pain without deterioration of oncologic and functional outcomes [105, 106]. Comparison of early laparoscopic series to relevant contemporary series of RRP [8, 54, 56, 81, 86, 87, 92, 93] includes a major bias related to the different levels of surgical experience. Based on today’s training programs, about 50 cases are necessary to learn LRP [47, 50]. Increased operating times (180–330 minutes) was one of the criticisms leveled against LRP (compared to RRP, 105–197 minutes; Table 100.5A). However, Frede et al. showed a decrease in operative time from 332 minutes for the first 50 cases to 196 minutes for the last 50 cases after 1000 procedure [47]. Similar decrease in operating time was seen with the extraperitoneal approach [107, 108]. Nowadays, at experienced centers mean duration of the operation ranges between 150 and 200 minutes. Table 100.5A Comparison of intraoperative outcome following laparoscopic and retropubic radical prostatectomy: operating times. Meta‐analysis according to Ficarra et al. [3]. RRP, retropubic radical prostatectomy; LRP, laparoscopic radical prostatectomy; WMD, weighted mean difference. Compared to RRP, LRP demonstrated a significantly lower blood loss (189–1100 ml vs. 550–1550 ml) and transfusion rate in cumulative analysis (Table 100.5B). In one study comparing 1134 LRP versus 3458 RRP cases, the transfusion rate was 4% versus 55% [109]. The study by Hu also revealed a 20% transfusion rate for RRP versus 4% for minimally invasive techniques [110]. Table 100.5B Comparison of intraoperative outcome following laparoscopic radical prostatectomy and retropubic radical prostatectomy: transfusion rates. Meta‐analysis according to Ficarra et al. [3].
Laparoscopic Radical Prostatectomy
Introduction
Historical background
Indications and contraindications
Clinical stage
T1
When PSA is relatively low and the number of positive biopsies or the extent of biopsy involvement is limited
T2a
A contralateral nerve‐sparing procedure can be proposed
T2b
A nerve‐sparing attempt can result in positive surgical margins and give rise to local failure
Anatomy of the prostate
Different types of nomenclature and terminology
Anatomical structure (surgical nomenclature)
Anatomical description (anatomical nomenclature)
Eponymical description
Other description(s)
Pelvic fascia
Fascia pelvis parietalis
Endopelvic fascia
–
Levator fascia
Fascia levatoris
Outer layer of Walsh’s lateral pelvic fascia
Periprostatic fascia
Parapelvic fascia
Prostatic fascia
Fascia prostatica
Inner layer of Walsh’s lateral pelvic fascia
Posterior prostate visceral fascia
Septum rectovesicale
Denonvillers’ fascia
Prostato‐seminal vesicular fascia
Posterior prostatic and seminal vesicle fascia
Vesico‐prostatic muscle
Musculus vesico‐prostaticus
Anterior layer of Denonvillers’ fascia
Posterior longitudinal fascia
Rectal fascia
Fascia propria rectalis
Outer leaf/posterior layer of Denonvillers’ fascia
Dorsal vein plexus
Plexus venosus dorsalis penis
Santorini’s plexus
Dorsal vascular complex
Puboprostatic ligaments
Ligamenta puboprostatica
Pubovesical ligaments
Anterior prostate visceral fascia
Visceral endopelvic fascia
Anterior periprostatic fascia (covering detrusor apron and McNeal’s anterior fibromuscular stroma)
Fascial tendinous arch of plevis
Arcus tendineus fasciae pelvis
Puboprostatic collar (plus puboprostatic ligaments)
Puboperineal portion of levator ani
Musculus levator urethrae (hiatus urogenitalis)
Quick stop muscle of Gosling
Puboperinealis muscle
Rhabdo‐sphincter of urethra
Sphincter urethrae externus
Striated urethral sphincter
Lisso‐sphincter of urethra
Sphincter urethra internus
Intrinsic sphincter
Ischioprostatic ligaments
Walsh’s pillars
Posterior raphe
Musculus anoperinealis
Rectourethralis muscle
Periprostatic fascial anatomy
Course and branches of pudendal nerve
Anatomy of urethral sphincter apparatus and the bladder neck
Neurologic aspects of urinary continence mechanism
Operative techniques
Patient positioning and trocar arrangement
Access to the prostate
Extraperitoneal versus transperitoneal approach (Table 100.3)
Advantages extraperitoneal
No advantage one technique over the other
Advantages transperitoneal
No contact with bowel
Previous abdominal surgery
Fewer problems with urine extravasation
Gross obesity
Simultaneous inguinal hernia repair
Operating time
Morbidity
Complication rate
Positive surgical margin
Continence
Larger room
Less tension on anastomosis
Minimal risk of lymphocele in case of extended lymph node dissection
Routes of dissection
Retrograde versus antegrade technique
Technical aspects for early continence
Heilbronn technique for early continence (see Videos 100.1 and 100.2)
Conventional technique
Preservation of levator fascia and puboprostatic collar
Non‐nerve‐sparing technique
Nerve‐sparing techniques
Antegrade technique
Retrograde technique
Antegrade versus retrograde nerve sparing (Table 100.4)
Technique
Advantages
Disadvantages
Retrograde
Earlier identification of neurovascular bundles (NVB) (i.e. hemostasis at dorsal vein plexus)
Exposure of NVB during every step
Direct transfer of existing techniques of open radical prostatectomy
Technical difficulty
Late control of proximal pedicle
Antegrade
Early control of prostatic pedicle, resulting in minimal bleeding
Early control of seminal vesicle arteries
Better working angle for the instruments
Dissection proceeds along surgeon’s natural line of site
Later identification of NVB still covered by levator fascia (compensated by early incision of endopelvic fascia)
Suboptimal exposure of prostatic base during control of prostatic pedicles
Entrapment of the specimen
Urethrovesical anastomosis
Posterior reconstruction
Van Velthoven single‐knot technique (see Video 100.1)
Reconstruction of the bladder neck
Anterior reconstruction
Retrieval of the specimen
Results
Perioperative data
Operating times
Blood loss and transfusion rates
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