Operative Technique

The laparoscopic surgical approach to the seminal vesicles was first described by Kavoussi and Clayman in 1993 as a method for freeing up the seminal vesicles at the time of laparoscopic pelvic lymph node dissection immediately prior to a perineal prostatectomy (37). This transabdominal laparoscopic approach has subsequently become one of the initial steps of laparoscopic radical prostatectomy (38).

Pneumoperitoneum is obtained with a Veress needle or via an open technique. Either a 10-12 mm umbilical port is placed. Kavoussi originally described a five-port fan configuration for trocar placement with a 12 mm trocar just below the umbilicus, two 10 mm trocars lateral to the rectus muscle just caudal to the umbilicus and two 10 mm trocars just lateral to the rectus muscle approximately 2 cm above the superior iliac crest (36). We have found four ports to be adequate for laparoscopic seminal vesicle surgery with a 10-12 mm port just below the umbilicus, two 5 mm ports just lateral to the rectus sheath 2-3 cm below the umbilicus and a 5 mm port in the left lower quadrant just above the level of the anterior superior iliac crest (Fig. 3) (22). Larger 10-12 mm ports always can be substituted for 5 mm ports should instrumentation such as stapling devices, clip appliers, ultrasound probes, hernia staplers, or large fan retractors be necessary. If necessary, an additional fifth port can be placed in the right lower quadrant just above the anterior superior iliac crest or in the midline midway between the umbilicus and symphysis pubis as the surgeon sees fit.

The surgeon typically stands on the patient's left side while the assistant guides the camera and provides retraction or suctioning from the patient's right side. An AESOP robot or a fixed camera holder can also be used, which typically is placed through the umbilical port.

A full visual inspection of the abdomen is performed prior to addressing the seminal vesicles. Often, the colon overlies the area of the seminal vesicles and may need to be mobilized and retracted with either a fan or Jarit retractor. Upon reflecting the bladder anteriorly, the ureters can be visualized alongside the posterior surface of the bladder. Immediately inferior to the ureters the vas deferens enters into the prostate (Fig. 4).

The surgeon must carefully identify and stay away from the ureters. If there is any question as to their location or proximity to the seminal vesicles, an externalized ureteral stent can be placed via flexible cystoscopy to identify the ipsilateral ureter.

The size of the seminal vesicles can vary widely. A large congenital cyst may completely fill the pelvis whereas a seminal vesicle with a stone may be difficult to identify.

FIGURE4 ■ The seminal vesicles seen there through the peritoneal reflection are FIGURE5 ■ The surgeon typically stands on the patient's left the lowest ridge of tissue below the ureter side to dissect out the seminal vesicle, while the assistant and vas deferens. who is on the right directs the suction device.

FIGURE4 ■ The seminal vesicles seen there through the peritoneal reflection are FIGURE5 ■ The surgeon typically stands on the patient's left the lowest ridge of tissue below the ureter side to dissect out the seminal vesicle, while the assistant and vas deferens. who is on the right directs the suction device.

The neurovascular bundles responsible for erectile function travel lateral to the seminal vesicles. Sharp dissection rather than coagulation should be used in that area.

Following anterior retraction of the bladder, the peritoneum is incised transversely 2-3 cm above the rectovesical junction until the lateral border of the seminal vesicle is fully visualized. A longitudinal incision over the course of the seminal vesicle of interest is then made perpendicular to and crossing the previously made transverse incision. Acombina-tion of sharp and blunt dissection, clips, and cautious electrocautery is utilized to dissect the seminal vesicle caudally to its ampulla at the junction of the prostate (Fig. 5).

The neurovascular bundles responsible for erectile function travel lateral to the seminal vesicles (39). Sharp dissection rather than coagulation should be used in that area.

When identification of the seminal vesicle and its adjacent structures is challenging, injection of methylene blue or indigo carmine transperineally (13), transurethrally (19), or transvasal (13) helps to identify the seminal vesicle. To assist in identification of complex or large congenital seminal vesicle cysts Basillote advocates cannulating the ipsilateral ejaculatory duct with a 75cm three French ureteral catheter and injecting a mixture of contrast and indigo carmine so that additional flu-oroscopic and laparoscopic guidance is available (19). We have additionally found intraoperative laparoscopic ultrasonography of the seminal vesicle to be helpful. It may be necessary to open Denonvillier's fascia in some cases to get as close to the prostate as possible when clipping and transecting the seminal vesicle. Depending on the extent of dilation, the seminal vesicle can be taken at its junction with the prostate using a Weck clip, titanium clip, or endo-GIA stapler. For patients with large congenital seminal vesicle cysts desiring to bear children the vas deferens needs to be carefully identified and dissected free from the cyst. The vas deferens can occasionally be difficult to separate from the cyst wall. Leaving a narrow strip of the cyst wall on each side along the vas deferens helps minimize the chances of vasal injury (17). Other groups advocate clipping and transecting the vas deferens to facilitate complete resection of the cyst (13,15,18).

After the seminal vesicle has been resected, it can be removed using an endo-catch bag. For large symptomatic congenital cysts, intracorporeal drainage with a needle can facilitate its safe removal. If the surgeon chooses to reapproximate the peritoneum a hernia or universal stapler can be employed. Oral nutrition is resumed the night of surgery and the urethral catheter is removed once the patient is ambulatory. Discharge from the hospital typically occurs the day following surgery.

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