Early posterior dissection – Exposure of seminal vesicles and development of a plane between the prostate and rectum
Some surgeons use a posterior approach for dissection of the seminal vesicles and identification of the plane between the prostate and rectum. This step is performed using a 0° lens. The bowel is pulled superiorly and the rectum identified. The peritoneal reflection is incised in the midline, and blunt dissection is used to identify the ampulla of the vas and the seminal vesicles. Care should be taken to stay in the midline, as the insertion of the ureters in the trigone of the bladder occurs laterally. The vasa can then be dissected and divided bilaterally. The peritoneal reflection is divided slightly more laterally; the seminal vesicles are then encountered.

The seminal vesicles are then freed inferiorly and laterally and the vessels at the tip are divided bilaterally. By retracting the vasa and the seminal vesicles superiorly, the plane between the posterior prostate and the rectum can be easily developed under direct visualization. This plane is carried caudally to the prostatic apex. Care is taken to avoid lateral dissection because of the proximity to the neurovascular bundles. After this plane is well developed, attention is again turned to the development of the extraperitoneal space.

Some surgeons do not routinely use the posterior approach initially and instead dissect the seminal vesicles with anterior traction after separating the bladder neck from the prostate.

Development of the extraperitoneal space
This step is performed using a 30° upward-looking lens. A transverse peritoneal incision is made extending from the left to the right medial umbilical ligament and extended in an inverted U-shaped manner to the level of the vasa on either side. The vasa can also be divided at this point to aid in bladder mobility. The extraperitoneal space is developed after the medial and median umbilical ligaments are transected, allowing the bladder, prostate, and bowel to drop posterior and the remainder of the operation to be performed extraperitoneally. Some authors fill the bladder to help identify the planes of dissection and to aid in dropping the bladder posteriorly.

Lymph node dissection
A 0° lens is used for optimum visualization, and 1:3 scaling is used for lymphadenectomy. Lymphadenectomy is performed at the surgeon’s discretion if the preoperative serum prostate-specific antigen (PSA) value exceeds 10 ng/mL, the biopsy Gleason score is greater than 6, or more than 50% of the biopsy cores are positive for cancer. The anatomic boundaries of the limited bilateral pelvic nodes dissection include the iliac artery superiorly, the obturator nerve inferiorly, the ilac bifurcation cranially, and the obturator fossa caudally. The nodal package is sent for frozen-section analysis only if the nodes appear grossly enlarged.

Exposure of prostatic apex and endopelvic fascia
The 0° lens with 1:3 scaling is used for this part of the dissection. This endopelvic fascia is incised after the prostate is retracted medially with the da Vinci cautery scissors or hook. The fascia is incised from the urethra distally to the prostatovesical junction proximally. Blunt dissection allows sweeping of the levator muscle from the lateral surface of the prostate. Dissection is carried distally until the urethra, with the surrounding puboperinealis muscle, is exposed.

Dorsal vein stitch
The nonscaled setting is used for this step. A figure-of-eight stitch is placed around the dorsal venous complex using a 6-inch, 1-0 polyglactin suture on a CT-1 36-mm taper needle. An additional suture is placed midway between the apex and base of the prostate for traction and rotation of the prostate during posterior dissection.

Retroapical dissection and release of the neurovascular bundle
The plane behind the prostatourethral junction is developed using a combination of blunt and sharp dissection. This dissection helps enormously to precisely identify the posterior apical margin of the prostate at the time of detachment of the specimen.

Bladder neck transection
The assistant provides vertical traction on the prostatic suture, and the anterior wall of the bladder is incised until the Foley catheter is observed. The assistant then retracts the catheter to provide countertraction as the posterior bladder wall is cut. Sparing of the bladder neck is possible but uncommon. The bladder neck incision is elliptical so that the posterior lip is slightly longer than the anterior lip. This maneuver aids in visualization of the posterior suture line during anastomosis. Using the da Vinci bipolar forceps, the surgeon grasps the cut end of the posterior bladder neck in the midline and gradually dissects it away from the prostate. The anterior layer of Denonvilliers aponeurosis (fascia) is then exposed and incised, exposing the vasa and seminal vesicles.

If the seminal vesicles were previously released, the plane is easily entered. However, if the surgeon did not elect to use an initial posterior approach, at this point, the left assistant retracts the posterior lip of the prostate anteriorly while the fourth robotic arm depresses the bladder posteriorly to provide a clear operative field for dissection of the seminal vesicles and vas deferens. The vasa are transected, and the seminal vesicles are skeletonized, avoiding damage to the neurovascular bundles.

Once the seminal vesicles are freed, the left assistant retracts the seminal vesicles anteriorly. At this point, the posterior layer of Denonvilliers aponeurosis can be observed between the two lateral prostatic pedicles. This fascia is incised close to the prostate, and a plane between the prostate anteriorly and the rectum posteriorly is developed. The plane of dissection leaves the most posterior layer(s) of Denonvilliers aponeurosis on the rectum. This dissection is carried down to the apex of the prostate.

Control of the lateral pedicles and the veil of Aphrodite (preservation of the neurovascular bundles)
The lateral pedicles at the prostate vesical junction are controlled using Hem-o-lock clips and/or bipolar coagulation.12 The clips are applied close to the prostate, and the pedicle is divided between them. Once the dissection enters the plane between the prostatic fascia medially and the levator fascia laterally, electrocautery is avoided and the anterior nerve-sparing dissection proceeds using sharp cutting with scissors and blunt dissection using the grasper. This dissection proceeds distally to the puboprostatic ligaments.

Several authors have also advocated a completely cautery-free or athermal dissection of the lateral pedicles to avoid any inadvertent damage to the neurovascular bundle. This can be achieved with laparoscopic bulldog clamps and oversewing of the neurovascular bundle for hemostasis. Although results of this technique have not been validated in large series, minimizing the use of cautery or other thermal hemostatic instruments during dissection near the neurovascular bundle seems prudent.

Incision of the dorsal venous complex and urethra
This is the final step of the dissection. Using a 0° lens with 1:3 scaling, the dorsal venous complex is incised tangentially to the prostate to avoid capsular incision. A plane between the urethra and dorsal venous complex is gently developed to expose the anterior urethral wall. The Foley catheter is reinserted and used to identify the anterior surface of the urethra at the urethroprostatic junction. The anterior wall of the urethra is transected with the scissors a few millimeters distal to the apex of the prostate. The posterior wall of the urethra and the rectourethralis muscle are cut under direct vision. The freed specimen is then examined for adequacy of resection margins and is placed in a specimen-retrieval bag.

Urethrovesical anastomosis
Urethrovesical anastomosis is performed using a hybrid tied suture, which consists of two 3-0 Monocryl sutures (one dyed and the other undyed) tied to each other to form a double-ended suture on RB-1 needles, each 6 inches long. Some authors advocate the use of a similarly constructed Vicryl suture, although this suture may prove to be more difficult to tighten prior to ligation.

The initial throw is placed outside in the bladder at the 5-o'clock position, and the dyed suture is pulled through so that the knot lies securely on the outside wall of the bladder posteriorly. The dyed suture is then used as a running stitch to suture the posterior bladder wall to the urethra. The dominant hand is used for the urethral pass, and the nondominant hand is used for the vesical pass. Approximately 5-6 throws are made posteriorly, with the assistant placing slight tension on the suture, if necessary. At the corner, the surgeon reverses the suture within the bladder lumen and passes the suture outside-in on the urethra.

The post suture ends at the 11-o'clock position and is held on traction by the left assistant to prevent loosening of the stitch. The undyed suture is then used to perform the anterior part of the urethrovesical anastomosis extending from the 5-o'clock position to the 12-o'clock position. The two sutures are then tied to each other to complete the anastomosis. The bladder is irrigated with 200 mL of saline to look for any leaks. Any leaks are reinforced with sutures. A new 20F indwelling Foley catheter is placed, and the balloon is filled with 30 mL. The specimen is retrieved and ports closed.

Robotic Extraperitoneal Approach
In 2001, Abbou et al, from Hopital Henri Mondor, Creteil, France, published their technique using a completely robotic extraperitoneal approach.4 The patient is placed supine in a 15° Trendelenburg position. A 3-cm horizontal incision is made 1 fingerbreadth below the umbilicus, and the preperitoneal space is entered. A blunt port Hasson canula is placed, and the preperitoneum is insufflated to 18 mm Hg. The space of Retzius is developed by blunt dissection using a conventional laparoscope until the pubic symphysis is reached. A 5-mm port is then placed in the midline 2 fingerbreadths above the symphysis to further develop the retropubic space. The right and left extraperitoneal robotic instrument ports are placed 4 cm below the camera port at the pararectal line. Two additional assistant ports are placed on the right side, the first at the level of the umbilicus above the right robotic instrument port and the second to the right and in line with the right robotic instrument port.

The procedure essentially follows the same steps of the robotic prostatectomy described above, but the dissection is entirely extraperitoneal. The Creteil group uses a 2-0 polyglactin on a 26-mm needle for the dorsal venous stitch and a 3-0 polyglactin on a five-eighths circle tapered cutting needle for the running vesicourethral anastomosis.

Laparoscopic Transperitoneal Approach
The widely used transperitoneal approach is the Montsouris technique described by Guillonneau and Vallancien from the Institut Mutualiste Montsouris, University Pierre et Marie Curie, Paris, France.13 The patient is placed supine with the arms at the sides and the legs spread apart and in an extreme Trendelenburg position. One surgeon and one assistant perform the operation, with a right-handed surgeon standing on the left side of the patient. The Montsouris group uses the AESOP voice-controlled robot to hold the telescope.

Five ports are placed in a diamond configuration, (1) a 10-mm telescope port at the umbilicus, (2) a 10-mm port at the McBurney point, (3) a 5-mm port at the midpoint between the umbilicus and the pubis symphysis in the midline, (4) a 5-mm port at the midpoint between the left anterior superior iliac spine and the umbilicus, and (5) the final 5-mm port at the right pararectal line at the level of the umbilicus. The abdomen is initially inspected, and a pelvic lymphadenectomy is performed, if required.

The procedure is begun with incision of the peritoneal fold between the rectum and bladder and the dissection of the seminal vesicles posteriorly. The seminal vesicles are retracted anteriorly, and the Denonvilliers aponeurosis is incised. The dissection is carried distally to the level of the rectourethral muscle, separating the prostate anteriorly from the rectum posteriorly. Attention is then directed anteriorly, and the peritoneum is incised to enter the space of Retzius, thereby causing the bladder to fall posteriorly. The endopelvic fascia is incised, and the levator muscle is pushed laterally to free the prostate gland. This is followed by ligation of the dorsal vein. The next step is incision of the bladder neck.

Finally, the lateral pedicles are dissected, and the urethra is transected to free the prostate gland with the seminal vesicles. The final step of the surgery is construction of the urethrovesical anastomosis. The Montsouris group performs the anastomosis with interrupted 3-0 resorbable sutures on a five-eighths needle. A total of 8 sutures are placed. Finally, a drain is placed and the ports closed.

The advantages of the transperitoneal approach include familiarity with anatomy, adequate space for dissection, and the presence of several reference points to aid the surgeon in orientation. Maximum mobility of the bladder is achieved in this approach, which helps provide a tension-free urethrovesical anastomosis.

Disadvantages of the transperitoneal approach include communication of the anastomotic site to the peritoneal cavity with the potential for peritoneal urine leak and ascites. The transperitoneal approach also increases the risk of bowel injury, ileus, and adhesions.

Rassweiler et al from Klinikum Heilbronn, University of Heidelberg, Heilbronn, Germany, published a modification of the transperitoneal technique.6 They used a W-shaped port placement with 5 ports placed initially transperitoneally. The sixth port is placed in the right lower abdomen after access to the space of Retzius. The dissection is started distally, with incision of the endopelvic fascia, ligation of the dorsal venous complex, and transection of the urethra. The Foley catheter is held and pulled cephalad for retraction. The prostate is dissected starting distally and progressing proximally with division of the Denonvilliers aponeurosis to separate the rectum posteriorly. The lateral pedicles are clipped, and the neurovascular bundles are spared.

Once this part of the procedure is completed, the dissection shifts to the bladder neck, which is transected. The Foley catheter is then used as a loop retractor, and the vasa and seminal vesicles are dissected off the posterior bladder. Finally, urethrovesical anastomosis is performed with a 15- to 17-cm 3-0 polydioxanone suture on an RB-1 needle using 5 interrupted sutures at the 6-o'clock position, followed by sutures at the 5-, 3-, 7-, and 9-o'clock positions, respectively.

Laparoscopic Extraperitoneal Approach
This approach was first described by Raboy, from Staten Island University Hospital, Staten Island, New York, in 1997 as a simulation of the open retroperitoneal approach to the prostate. The patient preparation, position, and draping are similar to the transperitoneal technique except that a steep Trendelenburg position is unnecessary.

A 1-cm infraumbilical incision is made and carried down to the preperitoneal space, which is bluntly dissected, and a Hasson canula is placed in this space. The extraperitoneal space is then developed by either blunt dissection using additional trocars or by using a visual balloon-dilating trocar or Gaur balloon dilator. Once the space is developed, the steps of the surgery mimic those of the transperitoneal approach except that the seminal vesicles and vas are dissected after the bladder neck is transected.

Theoretical advantages of this approach include its feasibility in patients who have undergone extensive abdominal surgeries and its minimal associated risk of bowel injury. The peritoneum acts as a self-retractor for the intestines, thus obviating the need for steep Trendelenburg positioning. Reports of simultaneous inguinal hernia repairs using prosthetic mesh have been published. The most significant limitation of this approach is the lack of adequate space for dissection and suturing. Also, because the peritoneal and urachal attachments of the bladder are not divided, tension at the urethrovesical anastomosis is a concern. As a result, the extraperitoneal approach should be performed only by experienced laparoscopic surgeons.

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