Surgery in MotionIntrafascial Nerve-Sparing Endoscopic Extraperitoneal Radical Prostatectomy
Introduction
Laparoscopic radical prostatectomy (LRP) and retropubic radical prostatectomy (RRP) are well-established procedures for the management of localized prostate cancer. The functional and oncologic results of both techniques are comparable [1], [2], [3], [4], [5], [6], [7], [8].
The initial experience (2002) with extraperitoneal endoscopic radical prostatectomy (EERPE) revealed surgical and oncologic results similar to those of transperitoneal LRP combined with the complete avoidance of the intraperitoneal complications while preserving the advantages of the minimally invasive surgery and retropubic approach [6], [7], [9]. The technique has undergone various refinements and modifications to achieve higher standards of efficacy [10].
The understanding of the anatomy of the bladder neck, urethra, and the neurovascular bundle (NVB) provided the base for the performance of the nerve-sparing EERPE (nsEERPE) and the most recent intrafascial nsEERPE, which resulted in improved potency and early continence [10], [11], [12], [13].
Section snippets
Patient positioning and trocar placement
The positioning of the patient, trocar placement, and the preparation of the preperitoneal space has been described in detail in previous reports [9], [10], [11], [12], [13]. In short, the patient is placed in a supine position with a 10° head-down tilt. The trocar placement is shown in Fig. 1. The preparation of the space of Retzius begins with an incision in the infraumbilical crease laterally to the midline and carried down to the posterior rectus sheath where a balloon trocar is inserted
Results
The intrafascial nsEERPE was performed in 150 consecutive patients by several surgeons. Cystography was performed 5 d postoperatively and if satisfactory (no paravasation), the catheter was removed. The perioperative patient data are summarized in Table 1. Patients older than 70 yr underwent surgery because of their overall good health and minimal comorbidities. Conversion and transfusion rates were 0% and 1.3%, respectively. The mean operative time was 131 min.
Continence was defined as no need
Discussion
The understanding of the anatomic structure of the NVB and the cavernosal nerves is of great interest due to the need to preserve the nerves necessary for erection and consequently to improve the potency-related functional results after RP. Efforts are being made to unify the existing terminology of the anatomic structures surrounding the prostate [11], [14], [15], [16], [17], [18].
Costello et al recently showed that most of the NVB descends posteriorly to the seminal vesicle. The nerves pass
Conclusions
Intrafascial nsEERPE is a further evolution of the current nsEERPE. The initial results are promising, with oncologic results similar to any other RP technique and favorable functional outcomes.
Conflicts of interest
The authors have nothing to disclose.
Acknowledgments
The authors gratefully acknowledge the assistance of Mr. Jens Mondry (Director Moonsoft, Germany) in preparing Fig. 1, and Mr. Gottfried Müller in preparing Fig. 2, Fig. 3, Fig. 4, Fig. 5.
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