Classically, an 8- to 10-cm lower midline incision is used. This allows access to the extraperitoneal retropubic space and the pelvic lymph nodes. The incision should commence over the superior aspect of the pubic bone and travel cranially. The skin and subcutaneous fat is incised and the rectus sheath opened along the linea alba. To facilitate identification of the linea alba, a retractor can be used at the apex of the incision with cranial retraction; the linea alba can then easily be palpated. The recti muscles can be parted in the midline with blunt dissection to create an extraperitoneal space which can give excellent access to the retropubic space of Retzius. Typically, the insertion of the recti abdominis muscles are divided with electrocautery to their attachment to the pubis. Blunt dissection is again performed to free the perivesical and periprostatic alveolar tissue from the pelvic side wall, and the external iliac artery and vein should be visualized bilaterally. A self-retaining retractor of appropriate size should be used; we prefer the Balfour or Bookwalter retractor for this incision.

It is possible to perform this operation through a standard Pfannenstiel incision although a randomized controlled trial did not demonstrate significant differences in need for postoperative analgesia and time to recovery compared with a standard vertical laparotomy (8). The Pfannenstiel incision may restrict access to the immediate retropubic space and make lymphadenectomy more difficult, although it allows for concomitant inguinal hernia repair.

Current National Comprehensive Cancer Network (NCCN) guidelines recommend the performance of pelvic lymph dissection in men with a predicted probability of lymph node metastasis greater than or equal to 2% (9).

The decision to perform standard versus extended pelvic lymph node dissection remains primarily driven by surgeon preference because the number of lymph nodes resected does not appear to affect disease-specific survival in men without positive nodes (10). In addition, a conversation should occur preoperatively with the patient with high-risk disease about his preferences regarding prostatectomy in the event that positive lymph nodes are found; if the patient would elect to forgo prostatectomy in the setting of metastatic disease, the pelvic lymph nodes should be sent for frozen section.

The surgical template for extended pelvic lymph node dissection extends from the bifurcation of the common iliac artery superiorly, the femoral canal inferiorly, and the obturator nerve and vessels and the hypogastric artery posteriorly. The standard template differs by exclusion of the lymphatic tissue overlying the hypogastric artery. Only those lymph nodes medial to the hypogastric vein should be removed and arterial branches from the external iliac, and obturator arteries should be preserved as these may supply the corpora cavernosa. Care should be taken to clearly identify, preserve, and avoid excessive traction to the obturator nerve.

An often underrated step is the removal of fat and areolar tissue from the anterior surface and apex of the prostate in order to facilitate precise identification of relevant anatomy. This is best achieved by the use of a combination of blunt dissection with a peanut swab and limited use of electrocautery superficially when veins are encountered from prostatic apex to the bladder neck.

The endopelvic fascia is incised sharply or with electrocautery in the groove between the levator ani muscles and the lateral border of the prostate (Fig. 31.2). This groove can be clearly visualized with medial retraction of the prostate using a sponge stick. Inside the fascia, the lateral surface of the prostate is covered by a smooth membrane overlying the lateral portion of the Santorini plexus. Strands of the levator ani muscles are gently dissected off the prostate to the level of the urogenital diaphragm using a peanut swab. There is often a small vein just lateral to the puboprostatic ligaments, and this should be cauterized adjacent to the prostate. The endopelvic fascia should be opened from the apex to the base of the prostate, taking care to avoid the deeper veins of the DVC. There is often debate whether the puboprostatic ligaments should be divided or preserved at this point. If the decision is made to divide the puboprostatic ligaments, they should be divided close to the pubis to facilitate access to the dorsal vein complex (DVC) (Fig. 31.3).

The DVC and urethra can be gently retracted medially allowing access to the plane between DVC and urethra. If the DVC is difficult to access, an atraumatic clamp such as a Babcock or Allis may be used to grasp the DVC (but not the urethra). Lifting this clamp anteriorly will open the space between DVC and urethra, facilitating subsequent suture placement. The fibers of the striated distal urethral sphincter should be observed wrapping around the urethra as part of the complex. A 2-0 absorbable suture on a CT-1 needle is typically used to suture ligate the DVC (Fig. 31.4). The needle should be pushed straight through the notch between the DVC and urethra as distally as can be placed and rotated only after the needle tip emerges on the opposite side. A simple ligation will usually suffice, but some surgeons advocate a figure-of-eight suture for control of a broader DVC or improved hemostasis. Occasionally, it may be useful to pass the needle through the periosteum of the posterior pubis just anterior to the DVC. If the suture is then tied, it will both control the DVC and anchor it to the periosteum, facilitating underrunning of any bleeding points after transection. A 3-0 absorbable suture on a 5/8 or UR needle is an excellent tool for dealing with bleeding in this area.
A second caudal (Fig. 31.4) or “back-bleeding” suture on the anterior surface of the prostate (Fig. 31.5) may be used and is often best applied in a running inverted V over the anterior surface of the prostate for hemostasis. Once ligated, the DVC should be divided initially with a curved dissecting scissors, electrocautery, or scalpel (Fig. 31.6), allowing the curve to guide over the apex to the urethra just distal to the prostate. Lateral dissection around the urethra should be kept to a minimum to avoid the NVB at this point.