Step 1 Access to the Preperitoneal Space

A midline 3 cm incision is made transversally 1 cm inferior to the umbilicus. The subcutaneous tissue is divided down to the anterior rectus fascia. The anterior rectus fascia is then incised transversally to identify the inner borders of the rectus muscles separated by the linea alba. The index finger is introduced medially under the rectus muscle and along the posterior rectus sheath (Fig. 1). A blunt finger dissection is performed to create a space extending superiorly from the level of the skin incision to the lateral border of the rectus muscle. This space is limited caudally by the arcuate line of Douglas, posteriorly by the posterior rectus sheath, anteriorly by the posterior fibers of the rectus muscle and medially by the linea alba (Fig. 2). The same step is performed on the other side. At this stage, two spaces are created under each rectus muscle and separated by the linea alba.

The linea alba is then incised in contact with the anterior rectus fascia (Fig. 3). The disruption of linea alba is continued by the index finger as far as possible toward the symphysis pubis. At the end of the blunt finger dissection, a large preperitoneal space is created.

Step 2: Trocar Placement

Trocars No. 1 and No. 2 are inserted under digital guidance laterally to the rectus muscles (Fig. 4). A Hasson canula (Bluntport®a) is inserted into the initial subumbilical incision and secured with stay sutures (trocar No. 3). Insufflation is initially performed at 18 mmHg. A conventional 0° laparoscope is placed in trocar No. 3.

Under laparoscopic vision, the incision of the linea alba is completed to the symphysis pubis. The Retzius space is opened and the prevesical space is developed laterally. The anterior aspect of the bladder, the pubic arch and the external iliac vessels are visualized. Development of the preperitoneal space is then performed laterally to the epigastric vessels, easily identified on the posterior aspect of the rectus muscles (Fig. 5). On both sides, the space is completed between the spermatic cord and the epigastric vessels in contact with the abdominal wall. The peritoneum is forced back. Under vision, trocars No. 4 and No. 5 are inserted in the iliac fossa 3 cm inside the anterior

FIGURE2 ■ End of finger dissection: index finger can move in a large preperitoneal space.

FIGURE2 ■ End of finger dissection: index finger can move in a large preperitoneal space.

FIGURE3 ■ Incision of linea alba in contact with the anterior rectus fascia.

FIGURE 4 ■ Trocar positioning: No. 1, No. 4, No. 5, and No. 6: 5-mm trocars; No. 2: 12 mm (Versaport®b); No. 3: 12-mm trocar (Bluntport).

superior iliac spine (Fig. 4). Insufflation pressure is lowered to 12 mmHg and table is set in a 20° Trendelenburg position.

The two previous steps, i.e., space creation and trocar insertion, can be performed more efficiently and quickly using the balloon-trocar. As such, the initial incision and the digital dissection between the rectus muscles and their posterior sheath are done the same way as described above. Then, the balloon-trocar is inserted on the left side; the tip of the trocar is directed toward the anterior superior iliac spine, and the balloon is inflated with approximately 3 L of air. Under laparoscopic control, the symphysis pubis, the epigastric vessels, and the spermatic cord are clearly seen. The same maneuver is repeated on the right side. Then, a 12-mm trocar is placed through the umbilical incision and the secondary trocars are inserted under laparoscopic control after insufflation.

FIGURE 5 ■ Development of the extraperitoneal space laterally to the epigastric vessels.

FIGURE 5 ■ Development of the extraperitoneal space laterally to the epigastric vessels.

An accessory obturator vein is often found near the pubic arch, which may either be preserved or divided between hemostatic clips.

Step 3: Pelvic Lymph Node Dissection

Pelvic lymphadenectomy is performed if indicated. The technique is identical to pelvic lymphadenectomy performed during radical retropubic prostatectomy, with identical anatomical landmarks. The dissection of the inner border of the external iliac vein is bilaterally extended from the pubic arch to the vas deferens.

An accessory obturator vein is often found near the pubic arch, which may either be preserved or divided between hemostatic clips.

All tissues medial to the external iliac vein are dissected. The vein is then retracted laterally and dissection is completed to visualize the lateral wall of the pelvis. More posteriorly, the obturator nerve is exposed. The strip of lymph node tissue, starting distally with the lymph node of Cloquet is divided between clips in contact with the pubic arch. The lymphatic tissue with obturator nodes is then pulled upward with a locking grasper. The proximal dissection is performed as far as possible in order to include hypogastric nodes. An endoscopic bag is passed through trocar No. 2. The two specimens are placed in the bag and sent for frozen section analysis.

Step 4: Incision of the Endopelvic Fascia and Dissection of Santorini's Plexus

The fatty tissue is swept cephalad and lateral from the endopelvic fascia and from the anterior surface of the prostate. At this point, the superficial dorsal vein is coagulated and divided. On both sides, the endopelvic fascia is incised toward the puboprostatic ligaments laterally to its line of reflection. The levator muscle attachments are peeled off the prostate and the apical dissection is performed to identify Santorini's plexus. The puboprostatic ligaments are then divided in contact with pubic arch to facilitate dissection of the Santorini's plexus. The apical dissection is then started to identify the posterior limits of the plexus and the urethra.

Step 5: Transection and Preservation of the Bladder Neck

The bladder neck is identified by palpation of the supple bladder in comparison to the solid prostate. A second suture is passed and secured around the superficial tissue at the base of the prostate, and a long tail is left for retraction. A sixth trocar is inserted (Fig. 4) and a toothed grasper is placed on the stitch for upward traction of the bladder neck (Fig. 6). The anterior aspect of the bladder neck is incised at the limit between the muscular fibers of the detrusor and the prostatic capsule. When the bladder is opened, the catheter balloon is deflated, and the catheter pulled out through the opening. The grasper is now placed on the tip of the catheter. Counter traction is achieved by securing the catheter with a Kelly clamp placed just beyond the urethral meatus. In this manner, the assistant exposes the posterior edge of the prostate and the posterior bladder neck.

Transection of the bladder neck is completed. A locking grasper is placed on the posterior bladder neck, which is retracted cephalad, exposing the anterior layer of Denonvilliers' fascia (Fig. 7).

FIGURE 6 ■ Suspension of the base of the prostate and section of the anterior bladder neck.

FIGURE 7 ■ Division of the posterior bladder neck from the anterior layer of Denonvilliers' fascia, which is incised transversally.

FIGURE 6 ■ Suspension of the base of the prostate and section of the anterior bladder neck.

FIGURE 7 ■ Division of the posterior bladder neck from the anterior layer of Denonvilliers' fascia, which is incised transversally.

Step 6: Dissection of Seminal Vesicles

The anterior layer of the Denonvilliers' fascia is incised transversally to allow the visualization of the vasa deferentia (Fig. 7). The vasa deferentia are dissected, clipped, and divided. The vascular pedicle for each structure is selectively clipped and sectioned. After division of each vas deferens, upward traction on the distal portion of the vas allows exposure of the seminal vesicles. Two large arteries supplying each seminal vesicle from the lateral side are typically identified. These are clipped and divided in a position immediately adjacent to the seminal vesicles. As dissected, each seminal vesicle is grasped and pulled anteriorly (Fig. 8). With anterior traction on the seminal vesicles, the prostatic pedicles are exposed.

Step 7: Transection of Prostatic Pedicles and Preservation of Neurovascular Bundles

To optimize transection of prostatic pedicles and neurovascular bundle preservation, the visceral prostatic fascia and the lateral edge of the posterior Denonvilliers' fascia are incised in contact with prostatic capsule. Incision of the posterior layer of Denonvilliers' fascia reveals prerectal fat and provides a safe plane of dissection (Fig. 9). Hemostasis of prostatic pedicles is performed near the bundles with clips, and near the prostatic capsule with bipolar electrocautery. The plane between the neu-rovascular bundles and prostatic capsule is opened after transection of the pedicles. Small capsular arteries, which are divided in a position immediately adjacent to the prostatic capsule after being controlled with clips, are the last attachments of the bundles. Dissection is extended to the prostatic apex. The vasa deferentia and the seminal vesicles are grasped and retracted anteriorly. Incision of posterior Denonvilliers' fascia is completed medially and dissection of the prostatorectal plane is performed into the rectourethral muscle behind the prostate.

Step 8: Section of Santorini's Plexus and Section of Urethra

One assistant grasps and retracts the suture at the base of the prostate cephalad to put the apex on tension. The margin between the urethra and dorsal vein complex is identified and a figure-eight stitch is placed around the Santorini's plexus. The plexus is sectioned perpendicularly. The plane between the plexus and the urethra is then developed caudally in an oblique manner. The anterior urethral wall is incised and the Foley catheter is visualized (Fig. 10). The catheter is pushed through the anterior ure-throtomy to open the urethral lumen and expose the posterior wall. The assistant retracts and rotates the prostate successively to each side and places the suction tip under the rectourethralis muscle and above the rectum. This maneuver allows a good exposure of the posterior lip of the prostatic apex, optimizing the section of posterior urethral wall and rectourethralis muscle and reducing the risk of positive posterior margins. After incising the urethra and the rectourethralis muscle, the freed prostate is placed in an endoscopic bag. The specimen is extracted through the slightly enlarged infraumbilical port site.

FIGURE8 ■ Exposition of the prostatic pedicles.

FIGURE8 ■ Exposition of the prostatic pedicles.

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