Access in Laparoscopic Radical Prostatectomy

Laparoscopic radical prostatectomy represents a continuously evolving technique with no more than 6000 patients treated in Europe. As in the open retropubic approach different technical modifications have been introduced. Principally four different approaches can be distinguished: (i) transperitoneal descending prostatectomy with initial dissection of the seminal vesicles (Montsouris technique), (ii) transperitoneal ascending prostatectomy (Heilbronn technique), (iii) extraperitoneal descending technique (Brussels technique), and (iv) extraperitoneal ascending technique (modified Heilbronn technique).

Recently, comparable surgical results between extraperitoneal and transperitoneal laparoscopic radical prostatectomy have been published by experienced centers (23-25). However, there was no consensus: some authors (24,26) emphasized the advantages of the extraperitoneal approach (i.e., no bowel lesion, ileus, and peritonitis) and concluded that this technique is superior to the transperitoneal access. Other authors (25) could not find significant differences between both techniques and stated this as a "false debate."

According to the authors' experience comparing transperitoneal and extraperi-toneal laparoscopic radical prostatectomy, there was no significant difference between extraperitoneal and transperitoneal approaches using the Heilbronn technique regarding all important parameters (27). In addition to the preference and experience of the individual surgeon, previous abdominal surgery, gross obesity, and requirement of simultaneous inguinal hernia repair may be considered as selective indications for extraperitoneal laparoscopic radical prostatectomy (Table 7).

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