Extraperitoneal Approach

Concerns of potential intraperitoneal complications (bowel injury, uroperitonitis, and ileus) led investigators to develop extraperitoneal approaches to laparoscopic radical prostatectomy (7). The initial report, by Raboy et al. (13), described a single extraperi-toneal laparoscopic radical prostatectomy that duplicated the open retropubic radical prostatectomy as described by Walsh and Donker (21). Subsequent reports from Belgium and Germany have demonstrated the feasibility of the antegrade extraperi-toneal approach (7,22-24). First the bladder neck is incised, the vasa deferentia and seminal vesicles are dissected through the bladder, and dissection is taken distally toward the apex of the prostate.

The theoretical advantages are the absence of peritoneotomy and therefore lesser risk of bowel injury, peritoneal irritation, and a quicker development of the Retzius' space. However, the drawbacks are a reduced and less ergonomic working space and a potential for increased tension at the urethrovesical anastomosis due to the limited bladder mobilization. Additionally, the extraperitoneal approach does not provide an accurate dissection of the seminal vesicles, which given the proximity of the neurovascular bundles and inferior hypogastric plexus may be relevant if a nerve sparing approach is planned.

0 0

Post a comment