Dr J.-U. Stolzenburg, University of Leipzig, Department of Urology, Liebigstraße 21, 04103 Leipzig, Germany. e-mail: firstname.lastname@example.org
During the last decade laparoscopy has become a standard technique available to the urologist, through constant technological advances and refinements. The progress of laparoscopic/endoscopic techniques allows the indications for this surgery to include complex oncological procedures like radical prostatectomy. Since the first description of laparoscopic radical prostatectomy (LRP) in the early 1990s the technique has undergone significant technical modifications. Transperitoneal LRP is now a standard procedure and can be used successfully and reproducibly, giving results comparable with those from the open retropubic procedure. Despite many advantages, transperitoneal laparoscopy is associated with potential intraperitoneal complications. Because of the limitations inherent in the transperitoneal route, a totally extraperitoneal endoscopic radical prostatectomy (EERPE) has been developed. The totally extraperitoneal endoscopic access provides a safe and minimally invasive approach to various urological procedures, including prostatectomy. This technical improvement completely obviates intra-abdominal complications. EERPE combines the advantages of minimally invasive laparoscopy and the open retropubic approach. We review the surgical techniques of LRP and EERPE, and highlight the indications, contraindications and outcomes.
Laparoscopic surgery has continued to expand dramatically since the initial report of this minimally invasive method for cholecystectomy. The overwhelming benefits with this new kind of surgery have persuaded surgeons to manage other commonly encountered disorders laparoscopically. The development of new technologies in laparoscopy has also improved the treatment of patients with various urological diseases. Urological laparoscopic techniques, originally introduced for diagnostic and ablative genitourinary procedures, have been expanded to use in ablative and reconstructive procedures like radical prostatectomy. Laparoscopic radical prostatectomy (LRP) was first described by Schüssler et al. . Although feasible and reproducible, that group were unable to define a clear advantage over the standard open retropubic approach for continence, length of hospital stay or convalescence. Notably, the mean operative duration was 9.4 h in nine patients. Since this first description the technique has been modified and refined. Groups in France refined the technique and reduced the mean operative duration to 3–4 h [2,3]. Raboy et al.  reported the first case of radical retropubic prostatectomy through an entirely extraperitoneal endoscopic approach (EERPE). LRP is now standardized and the steps of the procedure are more clearly defined. At several centres, including ours, LRP/EERPE has been refined to a point where it is offered as a first-line treatment for localized prostate cancer.
INDICATIONS AND CONTRAINDICATIONS FOR LRP AND EERPE
Laparoscopy is associated with increased intra-abdominal pressure caused by the capnoperitoneum. This may lead to a reduction of the venous blood flow to the right atrium, and to a decrease in cardiac output. In addition, CO2 pressure may be high; thus the intra-abdominal pressure of CO2 should be maintained at 10–15 mmHg during laparoscopy.
Associated with the increased intra-abdominal and intrathoracic pressure, there are absolute contraindications for laparoscopy, e.g. serious cardiac conditions (intracardiac shunts, severe aortic or mitral valve insufficiency), and high intracranial and intra-ocular pressures (risk of intracranial or retinal haemorrhage). Cardiac insufficiency or severe obstructive lung disease are relative contraindications depending on the individual situation of the patient .
Previous (multiple) abdominal surgery leads to the formation of intra-abdominal adhesions, which can be extensive, making trocar placement and further operative steps very demanding or even dangerous. Thus previous extensive transabdominal surgery is a contraindication for LRP. In contrast, EERPE avoids these problems because it uses a totally extraperitoneal approach.
THE SURGICAL TECHNIQUE OF LRP
After the first description of LRP the technique was modified and refined, e.g. a team in Bordeaux introduced the transperitoneal dissection of the seminal vesicles. To date, Guillonneau and Vallancien  have published the largest series of LRP. Between 1998 and 1999 they developed the ‘Montsouris technique’, which is now accepted as a feasible and reproducible procedure, and used by an increasing number of groups in Europe and the USA, with slight modifications. In experienced hands, there are no specific anatomical contraindications to LRP or EERPE, e.g. TURP, bladder neck incision, neoadjuvant androgen deprivation or even morbid obesity [7,8].
PATIENT AND SURGEON POSITIONING
In LRP the patient is placed in the dorsal supine position with a 15–25° head-down tilt, with his arms resting against the body. The surgeon and one assistant on each side of the patient perform the operation. The video monitor on the top of the laparoscopic tower is placed at the bottom of the operating table, as close as possible to the surgeon's eye level. A voice-controlled robotic system, another surgical assistant, or the scrub nurse, may serve as the optical/camera system (0°) operator. A Foley catheter is inserted to facilitate continuous drainage of the bladder.
There are different ways to place the first trocar. The safest technique to insert the 12 mm optical trocar is a mini-laparotomy within the umbilicus. We prefer to insert a Verress needle, followed by insufflation with carbon dioxide. After completing the capnoperitoneum with a pressure of 12–15 mmHg, a retractable trocar is introduced.
Four other trocars are placed under direct visual control; a 12-mm trocar in the left iliac fossa, a 5-mm trocar in the right iliac fossa ≈ 4 cm medial to the anterior superior iliac spine, a 5-mm trocar in the right iliac fossa on the lateral margin of the rectus abdominis, and a 5-mm trocar in the midline between the umbilicus and the pubis. This 5 mm trocar can also be placed in the left iliac fossa on the lateral margin of the rectus abdominis, depending on the preference of the operator.
After inspecting the abdomen for abnormalities, the procedure starts with incision of the peritoneum along the vasa deferentia down to the posterior aspect of the prostate. The vasa deferentia are identified and dissected towards the prostate. The seminal vesicles can be identified after dissecting the vasa deferentia up to the ampulla in a slightly lateral and caudal direction. The dissection should be kept in the midline close to the seminal vesicles and the prostate to avoid rectal or ureteric injury. The seminal vesicles are then dissected anteriorly, laterally and posteriorly. It is important to mobilize the seminal vesicles completely before dissecting Denonvillier's fascia and mobilizing the prostate.
Denonvillier's fascia is divided horizontally just behind the posterior aspect of the prostate and the seminal vesicles. The rectum is pushed off the posterior portion of the prostate. The procedure begins in the midline, is continued to the lateral aspect of the prostate and taken as far as possible towards the apex of the prostate. At this step of the procedure it can be helpful to use a rectal bougie to assist in identifying the fascia and the rectum.
The operation is now continued by incising the parietal peritoneum between the medial umbilical ligaments and developing the space of Retzius. The pubic arch and the symphysis are widely exposed. The incision of the peritoneum is continued in the lateral direction of the external iliac vessels. We prefer to dissect the pelvic lymph nodes at this step because of the better visualization of the anatomy of the pelvis. The endopelvic fascia is then incised on both sides toward the puboprostatic ligaments. The levator ani muscle is mobilized by blunt dissection only. In this way, the complete lateral aspect of the prostate can be dissected.
An important part of the procedure is ligating Santorini's plexus, with a polyglactin suture placed on the anterior portion of the prostate. A second separate suture of Santorini's plexus towards the symphysis may be used in some cases to improve haemostasis. The dorsal venous plexus is divided later, after bladder neck dissection, to avoid unnecessary (back) bleeding.
BLADDER NECK DISSECTION AND DISSECTION OF THE LATERAL SURFACE OF THE PROSTATE
The bladder neck can be easily identified after removing the pre-vesical fatty tissue. Traction of the Foley catheter helps to identify the border between the mobile bladder neck and the solid prostate. After dissecting the bladder neck at the 12 o’clock position the catheter is pulled up into the retropubic space. The dissection is now continued straight to the retrovesical space. The bladder neck is incised at the 6 o’clock position, and the seminal vesicles and the vasa deferentia brought into the operating field after dissecting the anterior layer of Denonvillier's fascia. This step of the procedure is important because it makes the circumferential dissection of the bladder neck and of the prostatic pedicles easier. While dissecting the prostatic pedicles the neurovascular bundles can be carefully preserved using fine bipolar forceps. Dissection must be extended to the point where the bundles enter the pelvic floor musculature.
After completely mobilizing the prostate in the lateral, anterior and posterior directions, Santorini's plexus is then divided. After this the urethra is sharply incised directly and caudally of the apex of the prostate, and the catheter visualized inside the urethra. We avoid coagulating the urethra, especially with monopolar electrical current, to preserve the external sphincter muscle. Finally, the whole prostate with the attached seminal vesicles is dissected. The complete specimen is temporarily placed in the paracolic space.
A water-tight urethrovesical anastomosis is made with interrupted sutures, or it can be made with a running suture. It is not necessary to evert the bladder mucosa. In the ‘Montsouris technique’ a metal Benique catheter with a depressed tip helps to guide the needle into the urethra. The first suture is placed at the 5 o’clock position, running inside-out at the urethra and outside-in at the bladder neck. The second suture is placed in the same way at the 7 o’clock position. Both sutures are tied intraluminally. Then four sutures are placed at the 4, 8, 2 and 10 o’clock positions; these sutures are tied outside the lumen. The final sutures are placed at the 1 and 11 o’clock positions.
LEAVING THE ABDOMEN
At the end of the procedure a 20 F drainage catheter is placed into the retropubic space, and finally the prostate is placed into a sterile endobag. The specimen is then removed via the umbilical incision or through McBurney's incision. The initial 10/12 mm port incision is enlarged, depending on the size of the prostate.
MODIFICATION OF THE TECHNIQUE
The ‘Heilbronn technique’ is a mixture of the ascending and descending approach, which requires six ports . The procedure includes primary access to the space of Retzius, and high transection of the urachus and lateral umbilical ligaments, thereby avoiding the second peritoneal incision to dissect the vasa deferentia and the seminal vesicles within the small pelvis. The seminal vesicle dissection is part of the descending section at the end of the prostatectomy. Furthermore, the dorsal vein plexus is divided immediately after ligation. This technique may be responsible for the high transfusion rate of 30% and the relative long duration of 4.5 h, reported by Rassweiler et al.  in a series of 180 patients.
There are different techniques to preserve the nerve bundles during LRP and EERPE. In the ‘Montsouris technique’ the neurovascular bundles are systematically preserved using precise bipolar coagulation. We think that there is a considerable risk of thermal and electrical injury of the neurovascular bundles and the branches of the pelvic plexus, which are situated between the rectum and the urethra, with bipolar coagulation. We currently use ultrasonic cutting devices for nerve-sparing prostatectomy during the following steps; dissecting the tips of the seminal vesicles, isolating the nerve bundles, dividing the prostatic pedicles, and transecting the lateral and dorsal circumference of the urethra. However, to date, systematic studies and definite results are lacking; these issues must be addressed in future studies.
FEASIBILITY AND LEARNING THE PROCEDURE
We do not share the view that LRP as a laparoscopic procedure is itself associated with significantly increasing the operative duration [10,11]. However, LRP requires significant laparoscopic expertise and takes 50–100 cases to be fully mastered. Guillonneau et al.  reported a mean operative duration of 268 min for the first 50 cases, 245 min for the next 50 and 180 min for the last 350 in a series of 567 patients. In the same series there were 12 conversions to open surgery in the first 50 cases, two in the next 50 and none in the last 467. After our initial experience with 70 LRPs the mean operative duration, including lymph node dissection, was 155 min in the subsequent 70 EERPEs. There were no conversions to open surgery and no re-interventions . However, LRP and EERPE are very recent techniques; in this respect the previous duration compares favourably with standard open retropubic approach, which has been modified and refined many times over two decades.
THE RESULTS OF LRP AND EERP
The three goals in radical prostatectomy are cancer control, and preservation of continence and potency. Although the rate of positive surgical margins is not an ideal variable to evaluate cancer control it is currently the only one available, as long-term data (i.e. PSA progression) are not yet published. Because dissecting the prostate in LRP and EERPE mirrors open prostatectomy and is within the same tissue layer, the positive surgical margin rate for LRP, EERPE and open prostatectomy are expected to be equivalent. Guillonneau et al.  reported an overall rate of positive surgical margins of 13.7% (4.2% pT2a, 13.9% pT2b, 31.2% pT3a, 42.8% pT3b). Rassweiler et al.  reported a rate of positive surgical margins in pT2 tumours of 2.3%, in pT3a of 15% and in pT3b of 34%. These results compare with those of other smaller series . In our experience with EERPE the rate of positive surgical margins for pT2 tumours was 6.1% and for pT3 29.4% . Randomized prospective long-term studies are important to compare the oncological outcomes of these different surgical techniques.
The incontinence rate after open radical prostatectomy is quite variable among series and depends largely on the definition of continence. Early continence results after LRP and EERPE are encouraging. Rassweiler et al.  reported continence rates of 54% after 3 months, 74% after 6 months and 97% after 12 months. Using the strict definition ‘no protection day or night’ Guillonneau and Valancien  reported a continence rate of 73.3% at 6 months after surgery; 15% of patients were still wearing pads as a precaution and 11.6% needed> 1 pad/day. The continence rate of the EERPE is comparable with LRP; 72% after 3 months and 90% after 6 months .
In theory, both LRP and EERPE have a possible advantage in preserving the neurovascular bundles, as a result of the magnification and better visualization. However, the follow-up of existing series is too short and includes too few patients for definitive conclusions to be drawn about the preservation of potency. Guillonneau and Valancien  were able to preserve the neurovascular bundles in 20 of 120 patients during LRP, and Bollens et al.  in seven of 50 during EERPE. Interestingly, both groups reported a potency rate of 43–45% at 3 months after surgery.
As yet there are no data on port-site metastases after LRP and EERPE, which are a concern in all minimally invasive procedures for malignancies.
COMPLICATIONS OF LRP
The complications of radical prostatectomy may be classified as general, arising from the anatomy the pelvis (like rectal or ureteric injury) and specific, associated with the technique (transperitoneal or extraperitoneal), e.g. adhesion formation, ileus or small bowel injury.
The rate of ureteric injury in LRP is low and varies from none  to 1.4%  in series with> 100 patients; it may be especially prevalent with the transperitoneal technique, if the posterior peritoneal incision for seminal vesicle dissection is too high and the ureter is mistaken for the vas deferens.
The rectum can be injured during retropubic and perineal prostatectomy, and this is not specific to the route to the prostate. The rate of rectal injury has been reported to be 0.005–0.5% in open retropubic prostatectomy [18,19]. Guillonneau et al.  reported rectal injuries in eight of 567 cases (1.4%) in LRP; this can happen during two steps of the procedure, i.e. during incision of the posterior layer of Denonvilliers’ fascia if it is not incised close enough to the posterior surface of the prostate, and during apical dissection, when attempting to develop the plane between the rectum and Denonvillier's fascia.
The formation of adhesions is a well recognized consequence of any intra-abdominal or transabdominal surgical procedure. Postmortem studies show clearly that the most common cause of peritoneal adhesion is previous intra- or transperitoneal surgery . In pelvic surgery, adhesions forming after laparotomy were reported in up to half the patients . In a prospective analysis of 210 patients undergoing laparotomy, who previously had one or more abdominal operations, Menzies and Ellis  found that 93% had intra-abdominal adhesions that were a result of their previous surgery. The formation of adhesions is an adaptive response to localized peritoneal injury, depending on the size of the peritoneal incision. Compared with open laparotomy, the amount of peritoneal trauma and adhesion formation caused by laparoscopic procedures is significantly less. Pattaras et al.  reported a rate of 22.2%, mostly minor, adhesions in patients who had had previous urological laparoscopic surgery. However, to date the prevalence of significant adhesions after LRP has not been systematically investigated.
Our experience with two open surgical revisions in 70 patients after LRP showed extensive bowel adhesions. The small intestine was adherent to the abdominal wall and to the urethrovesical anastomosis. Therefore, the transperitoneal approach of LRP may potentially be associated with small-bowel obstruction or chronic abdominal or pelvic pain. In addition, the option of adjuvant radiation therapy for local recurrent disease may be limited because of the potential small bowel complications.
During transperitoneal laparoscopic dissection constant insufflation with CO2 is essential for optimal visualization and to avoid intestinal burns from cautery. Vallancien et al.  drew attention to the use of concomitant unipolar and bipolar coagulation pedals in the shadow of the operating table, which is associated with a risk of unintentional bowel injury. Bowel perforations as a result of laparoscopy are rare but serious events, occurring in ≈ 1.3 per 1000 procedures . If not immediately recognized and treated, symptoms of acute abdomen develop after 2–5 days, usually requiring emergency intervention. Fahlenkamp et al.  evaluated the complications of 2407 laparoscopic procedures in four German centres and reported 20 visceral lesions, 12 of them associated with monopolar electrocautery.
The transperitoneal approach to the extraperitoneally located prostate is also associated with potential risks of intraperitoneal complications. Even in the hands of the most experienced laparoscopic surgeons there can be significant intraperitoneal complications. Guillonneau et al.  reported intraperitoneal complications in 1.8% of 567 patients after LRP; six patients with ileus (one re-operated), two with ileal injury (two re-interventions), one with sigmoid injury (one re-intervention), five with haemoperitoneum (five re-interventions) and one with uroperitoneum (treated by percutaneous drainage).
THE EXTRAPERITONEAL APPROACH
Increasing experience at many medical centres, coupled with technological advances, have led to advanced urological procedures being undertaken laparoscopically. Most newly described laparoscopic procedures on retroperitoneal structures have used a transperitoneal approach, e.g. transperitoneal nephrectomy or pyeloplasty. In these cases the transperitoneal route offers the advantages of familiarity of the approach and increased working space. However, in urological pelvic surgery, the extraperitoneal approach is equal to or even better than the transperitoneal approach . Thus, the extraperitoneal endoscopic pelvic lymph node dissection is an easy and elegant way for surgically staging prostate cancer [28–30].
Retroperitoneoscopy has the distinct advantage of remaining outside the peritoneum and therefore preventing the complications associated with intraperitoneal dissection. The introduction of extraperitoneal guidance as an aid to radical prostatectomy by Raboy et al.  resulted in an intensive effort to apply this technique routinely. To date two teams have reported the feasibility and reproducibility of EERPE [8,16].
Different terms have been reported to characterize the LRP/EERPE. Laparoscopy is defined by the Greek origin of the words ‘λαπαρος= soft’ and ‘λαπαρ⇐= the (empty) space between the ribs and the hips’. Therefore, laparoscopy means the inspection of the intraperitoneal organs with the magnification of the laparoscope. Transperitoneal LRP is actually a laparoscopic technique. The EERPE modification uses a totally extraperitoneal approach to the prostate, completely avoiding access to the intraperitoneal cavity. Therefore, this is not strictly a laparoscopic technique, using the word ‘λαπαρ⇐’. EERPE is therefore an endoscopic technique using laparoscopic instruments.
THE SURGICAL TECHNIQUE OF EERP
This method replicates the steps of a classical retropubic descending radical prostatectomy, with slight modifications, and has been described and illustrated elsewhere in detail .
POSITIONING THE PATIENT, PREPARING THE PRE-PERITONEAL SPACE AND PLACING THE TROCARS
Under general anaesthetic, the patient is placed in the dorsal supine position with a 20–25° head-down tilt (Fig. 1). Both arms must be well protected, positioned on the body of the patient. The surgeon stands to the left of the patient with an assistant opposite. The camera-holder stands behind the head of the patient. Despite the balloon trocar and the Hassan-type trocar for the optical system, there are no other instruments, compared with the transperitoneal laparoscopic procedure. We prefer a 0° optical system combined with a video system during the whole procedure.
Creating the pre-peritoneal space starts with a 15-mm incision in the infra-umbilical crease laterally to the midline, and carried down to the anterior rectus fascia. The anterior rectus fascia is incised and the rectus muscle fibres vertically separated by blunt dissection. First, the space between the rectus muscle and the posterior rectus sheath is bluntly developed by finger dissection (Fig. 2). Second, the pre-peritoneal space is further developed by a balloon trocar inserted tangentially to the cutaneous plane towards the pubis. The optical system is inserted into the balloon trocar to visualize the landmarks of the pre-peritoneal space during insufflation of the balloon (Fig. 3). The inferior epigastric vessels can always be identified ventrally.
After this the balloon trocar is deflated and removed. Stay sutures of 2/0 polyglactin are placed in the anterior rectus fascia, and the Hassan-type trocar placed just beneath the rectus muscle and anterior to the peritoneum. Carbon dioxide is introduced to 12 mmHg. Once the pre-peritoneal space has been developed, four trocars are placed as shown in Fig. 4 in the hypogastrium. The operator must complete the dissection of the pre-peritoneal space at both sides by separating, from outside to inside, the spermatic cord, the external iliac vessels, the pubic arch with Cooper's ligament, the symphysis, and caudally the bladder and the prostate (Fig. 5).
The endoscopic extraperitoneal orientation may not be familiar to many urologists. The basic principle of the procedure is to create a vacuous pre-peritoneal space through which the myopectineal orifice can be seen. Compared with the transperitoneal technique the working space in the extraperitoneal approach is limited. The thin peritoneum can easily be disrupted during the procedure. Thus a capnoperitoneum may develop, further limiting the working space, especially at the beginning of the procedure while creating the pre-peritoneal space. However, the good exposure of the organs of the pelvis itself is not limited by the capnoperitoneum. Closure of the peritoneal defect is only essential in cases with concomitant hernia repair.
PELVIC LYMPH NODE DISSECTION
Extraperitoneal pelvic lymph node dissection has become an established procedure for staging early carcinoma of the prostate. The limits of the staging lymph node dissections at both sides are: cranially, the bifurcation of the common iliac artery; laterally, the iliac vein and genitofemoral nerve; medially, the medial umbilical ligament; caudally, the pubic bone; and posteriorly, the obturator nerve. The prepared nodal packages are removed from the operative field through the 12 mm working trocar in the left iliac fossa.
EXPOSING THE PROSTATE AND BLADDER NECK, AND INCISING THE ENDOPELVIC FASCIA
The operation is now continued by preparing the whole Retzius space from the symphysis down to the apex of the prostate. It is important to drain the bladder completely during the procedure. The fatty tissue is swept gently from the anterior surface of the bladder neck, from the anterior surface of the prostate and the endopelvic fascia. The endopelvic fascia is incised on both sides toward the puboprostatic ligaments. The prostate is retracted medially by the assistant to free any fibres of the levator ani that remain attached to the prostate. After that the puboprostatic ligaments can be exposed and dissected, as shown in Fig. 6.
LIGATING SANTORINI's PLEXUS
Santorini's plexus is now clearly visible and is ligated with a polyglactin suture placed on the retropubic portion (Fig. 7). We prefer a double ligation; the first suture goes from right to left, the second from left to right. Ligating the plexus in the direction of the bladder neck is not necessary. Santorini's plexus is not divided immediately but during apical dissection.
BLADDER NECK DISSECTION
To dissect the bladder neck, a transverse incision is made from the 11 to the 1 o’clock position within the natural fold between the bladder and prostate, and the urethra is developed with sharp and blunt dissection (Fig. 8). We use bipolar forceps to control minor vessels. The urethra is incised, and the catheter pulled up into the retropubic space and fixed by the assistant in the direction of the symphysis. The dissection is now continued in the lateral direction. The magnification of the laparoscope helps to identify the plane between the bladder (mucosa) and prostate. At this point the assistant pulls up the ventral part of the prostate ventrally. In so doing, it is easy to identify the natural groove between the bladder mucosa and prostate in the dorsal direction. The transection of the posterior bladder neck is continued by sharp dissection. If the middle lobe of the prostate is large, identified by routine cysto-urethroscopy before surgery, inserting JJ catheters can be helpful but is not absolutely necessary to identify the ureteric orifices. Under normal conditions the ureteric orifices are far from the bladder neck incision.
FREEING THE SEMINAL VESICLES
The whole prostate is now fixed in the direction of the symphysis. Because of the traction on the prostate the anterior layer of Denonvillier's fascia is tensioned between the prostate pedicles. The anterior layer of Denonvillier's fascia covers the ampullae of the vasa deferentia and the seminal vesicles. Denonvillier's fascia is perforated horizontally in the midline and the ampullary portions of the vasa deferentia developed, cauterized and dissected (Fig. 9). The seminal vesicles can be identified in a slightly lateral and caudal direction. Both seminal vesicles are fully mobilized. Care is taken when dissecting near the tips of the seminal vesicles to avoid injuring the neurovascular bundles that are situated just lateral to the seminal vesicles.
INCISING DENONVILLIER's FASCIA AND SECTIONING THE PROSTATIC PEDICLES
It is important to mobilize the seminal vesicles completely before opening the posterior layer of Denonvillier's fascia and before starting the prostatic pedicle dissection. These structures can be exposed very well if the assistant lifts the seminal vesicles in the direction of the symphysis. The posterior layer of Denonvillier's fascia is perforated horizontally (Fig. 10). The prostate is bluntly dissected to the apex in the midline and laterally. The dissection is taken as far as possible towards the apex of the prostate and the urethra, and should be kept as close as possible to the prostate to avoid rectal injury.
The assistant now lifts the seminal vesicles ventrally and cranially, so that the prostate pedicles can be easily identified as two cords laterally. Both pedicles are systematically coagulated and divided close to the prostate. This dissection is taken on both sides to a point just cephalad to the urethra, to mobilize the prostate completely.
The laparoscopic magnification improves the visualization of the neurovascular bundles. If the prostate is small the neurovascular bundles can be completely dissected from the lateral aspect of the prostate before sectioning the prostatic pedicles, which makes the procedure safer. If large, sectioning the prostatic pedicles and preserving the neurovascular bundles is combined.
SECTIONING SANTORINI's PLEXUS AND APICAL DISSECTION
Santorini's plexus is sectioned at this step of the procedure. Once the apex of the prostate and the urethra have been fully mobilized, the urethra must be meticulously dissected. The external sphincter and the urethra are sharply divided from the apex of the prostate tangentially. The cutting line extends from ventrocranially to caudodorsally (Fig. 11) up to the catheter visible inside the urethra. The tip of the catheter is now brought into the operation field (Fig. 11, inlay), and the assistant pulls it up to expose the lateral and dorsal limit between the apex and urethra. The dissection of the urethra is now completed vertically. After completely detaching the prostate the gland is temporally placed in the lateral iliac fossa, between the spermatic cord and the abdominal wall.
A water-tight urethrovesical anastomosis is made with 5–9 interrupted sutures (Fig. 12), the number varying depending on the size of the opening of the bladder neck. We prefer an interrupted suture because it is more comfortable. The best way is to tie all sutures intracorporeally. All sutures are placed ‘outside-in’ at the bladder neck and ‘inside-out’ at the urethra, so that the sutures are always tied extraluminally. The first sutures are placed posteriorly, starting at the 7 o’clock position continuing to the 6 and the 5 o’clock positions. After the dorsal hemi-circumferential anastomosis has been made, the catheter is inserted to serve as a guide for the lateral and ventral sutures. The subsequent sutures are placed systematically at the 8, 4, 10, 2, 11 and 1 o’clock positions. The magnification of the optical system allows better visibility throughout the procedure. In our experience the urethrovesical anastomosis is completely tension-free in EERP and allows a catheterization time of 6–8 days.
At the end of the procedure, a 20 F Robinson drain is placed into the retropubic space, drawn into the abdominal cavity through the 5 mm port-site in the right iliac fossa. Finally, the prostate is placed in an endobag and removed via the trocar in the left iliac fossa, which is removed, and the incision enlarged to 3–4 cm, depending on the size of the prostate.
ENDOSCOPIC PROSTATECTOMY AND CONCOMITANT HERNIA REPAIR
Currently the use of prosthetic mesh placed pre-peritoneally through a transabdominal (transabdominal pre-peritoneal technique) or extraperitoneal route (totally extraperitoneal technique, TEP) has become common to treat inguinal hernias and has helped to reduce recurrence rates. The trend in laparoscopic/endoscopic surgery toward the TEP repair has shown it to be equally effective, with fewer complications [32–34]. Although the coincidence of prostate cancer and inguinal hernia has not been described in clinical studies, patients with both diseases are encountered in clinical practice. Especially in elderly men, the incidence of inguinal hernia is relatively high. Different authors reported a concomitant inguinal hernia repair during endoscopic extraperitoneal pelvic lymph node dissection [35,36]. In these studies, the rate of inguinal hernias was 12.9–18.3%. The goal of the procedure is an extraperitoneal approach to the defect, which allows direct access to the posterior inguinal anatomy. Therefore, all possible hernia defects are clearly visible.
There are different techniques to place the mesh into the pre-peritoneal space to cover all possible hernia defects. We prefer a standardized TEP technique, which uses the principle of tension-less hernia repair, overlaying the entire myopectineal orifice with one large piece of mesh [36,37]. The mesh is 10 × 15 cm; it is incised in the middle and a small hole cut into the mesh to provide sufficient space for the spermatic cord. The split within the mesh is covered by a flap (6 × 5 cm). The essentials of this technique are elevating the spermatic cord at the side of the inguinal hernia defect and placing the prepared polypropylene mesh around the spermatic cord, to cover the hernial orifices and the entire space from the symphysis pubis in the midline to the abdominal wall laterally (Fig. 13). No staples or sutures are necessary for fixing the mesh; the mesh is anchored and fixed to the abdominal wall by intra-abdominal pressure alone.
Closing the peritoneal defect after placing the mesh is essential to avoid exposing the mesh to the intra-abdominal organs. Direct contact of the mesh with the bowel must be avoided. To close the large incision of the anterior peritoneum in LRP is extremely difficult or impossible using the laparoscopic route. Thus, the laparoscopic repair of inguinal hernias with the mesh technique is technically difficult. To date there are no reports of concomitant inguinal hernia repair with the mesh technique during LRP.
EERPE maintains the peritoneal integrity during the procedure and therefore, this approach for radical prostatectomy easily allows concomitant inguinal hernia. Our experience with 70 EERPE have shown that inguinal hernias, including bilateral and recurrent hernias, can be repaired at the end of the procedure within an acceptable operating time and with low morbidity . The operative duration of EERPE is prolonged by a mean of < 15–25 min. In these patients there were no additional complications in the hernioplasty group and no hernia recurrences. However, the follow-up is too short to draw firm conclusions about the development of recurrent hernias.
RECENT TECHNOLOGICAL DEVELOPMENTS
The VISERA® video system (Olympus, Tokyo, Japan) is a state-of-the-art endoscopic imaging device including digital imaging and movie recording capabilities which can be individually configured. To avoid any loss of image quality critical interfaces were reduced by introducing camera heads with integrated video adapters, and video laparoscopes with ‘chip-on-the-tip’ technology. In addition, the sensitivity was enhanced (≈ 30% better than in preceding models) and different levels for exposure areas, enhancements and colour modes created. All these adjustments can be stored by individual pre-setting. The VISERA laparoscopic system projects ‘reality’ onto the monitor screen and transfers it to digital-to-digital recorded data for easy reproduction.
A few surgical robotic systems have been developed, two of them (DaVinci®, Intuitive Surgical Inc., Mountain View, CA; and Zeus®, Computer Motion Inc., Goleta, CA) recently introduced into clinical routine in various centres worldwide. While clinical experience is limited to date, some groups regard the assistance of robotic systems for LRP to be a useful additional technological tool available to the experienced laparoscopic surgeon . The acceptance of these systems will ultimately depend on their ability to advance surgical performance, improve patient safety and reduce costs. Surgical robotics has the potential to open new horizons for surgical practice .
CONCLUSIONS AND OUTLOOK
Minimally invasive surgery in urology has had a decade of progress; while some laparoscopic/endoscopic procedures have become the standard of care, making the conventional open approach obsolete, others are an equal alternative depending on the indication, individual situation of the patient, and the expertise and preference of the surgeon. Even such a technically demanding oncological procedure as radical prostatectomy, only a few years ago considered to be technically not as feasible by many urologists, is now being used routinely in more centres. Although only long-term oncological results will define the role of minimally invasive radical prostatectomy, and the technical modifications and refinements, the available data are encouraging and promising. The future is bright for minimally invasive surgery in treating localized prostate carcinoma; these techniques will continue to be developed and are here to stay.