Intrafascial Nerve-Sparing Endoscopic Extraperitoneal Radical Prostatectomy (nsEERPE)

 

Despite the different approaches for Radical Prostatectomy, the key for good results is the understanding of the anatomy. To visualize the anatomical structures of the pelvis, we developed this three-dimensional model of the lower urinary tract. Most important for autonomic innovation of the penis is the rhombically-shaped pelvic plexus. It is located close to the tips of the seminal vesicles. In Intrafascial Nerve-Sparing Radical Prostatectomy the pelvic plexus, the neurovascular bundle and the prostatic plexus, a distribution of nerve fibers on the lateral surface of the prostate, are preserved in order to obtain the neurovascular integrity.

 

Endoscopic Extraperitoneal Radical Prostatectomy, a strictly extraperitoneal procedure, is usually performed with the patient under general anesthesia. The initial step of the procedure is the creation of the extraperitoneal space. A 1.5 cm right infraumbilical skin incision is made, followed by an incision of the anterior rectus fascia. The rectus muscle is separated bluntly down to the posterior rectus fascia. Superficial to this fascia, finger dissection of the extraperitoneal space is performed, allowing placement of the balloon trocar. The balloon trocar is slowly inflated under constant visual control with the aid of a zero-degree telescope.

 

After the introduction of the optical Hassan trocar, a further four trocars are inserted into the extraperitoneal space, as shown on the diagram. Injury to the epigastric vessels can be caused during insertion of the trocar in the right pararectal line. This trocar position has to be varied medially or laterally by careful inspection of the abdominal wall by the laparoscope.

 

The prostatectomy starts with exposure of the anterior surface of the bladder neck, the prostate, and the endopelvic fascia. The superficial branch of the deep dorsal vein complex is fulgarated with bipolar forceps and divided. A sharp incision of the superficial fascia overlaying the prostate is performed as shown in the video. The main goal is to create the landmarks where further dissection will be performed later during the procedure. The incision is performed on the left side from the bladder neck toward the apex. A plane is developed between the prostate and its thin overlying periprostatic fascia. This maneuver is performed medially to the puboprostatic ligaments, leaving intact the puboprostatic ligaments, the periprostatic fascia and the lateral part of endopelvic fascia as a continuous structure. The development of the plane is then continued in an ascending fashion on the right side. When you are in the right plane you see the shiny surface of the prostatic capsule, which is easily detachable from the periprostatic fascia.

 

The next step is the bladder neck dissection. It is performed as a mixture of blunt and sharp dissection using the SonoSurg device to minimize blood loss. The bladder neck dissection is commenced from the ten to two o’clock position. This allows the identification of the longitudinal muscle fibers of the bladder neck. In bladder neck sparing procedures these longitudinal muscle fibers have to be carefully developed. When cutting the bladder neck, the assistant and the operator push the bladder dorsally. It is completely incised and the catheter is pulled out into the retropubic space and placed on traction. The dissection of the bladder neck is now continued laterally.

 

The posterior bladder neck is initially completely divided between the five to seven o’clock positions. The magnification of the laparoscope helps to identify the mucosa of the bladder. The mucosa is the key structure that leads our dissection. This will avoid any accidental, intraprostatic entry which may occur if the dissection is in too cordular (??? I couldn’t identify this word) a direction. Following complete dissection of the bladder neck the ampullae of the vasa deferentia have to be visualized. When both vasa deferentia are identified, the posterior bladder neck dissection is slightly extended laterally in both directions. The video now clearly shows the anatomical landmarks of the vasa deferentia.

 

The next step of the procedure is the dissection of both vasa deferentia and seminal vesicles. Once the right vas is dissected, the assistant grasps and pulls it contralaterally to facilitate the dissection of the seminal vesicle by the surgeon and vice-versa. Care is taken to avoid any injury to the pelvic plexus and the neurovascular bundle, which run in close proximity to the tips of the seminal vesicles.

 

After completion of seminal vesicle dissection, both the surgeon and the assistant retract the seminal vesicles in a craniolateral direction, exposing Denonvillier’s fascia. In contrast to standard nerve-sparing prostatectomy, the fascia is not incised. The appropriate plane of intrafascial dissection can be found by stripping down the Denonvillier’s fascia from the prostatic capsule. The dissection is continued strictly in the midline as far as possible towards the apex of the prostate. At this point of the procedure the shining surface of the prostatic capsule is clearly seen medially and laterally. As shown in the diagram, during the initial fascial incision ventrolaterally, as well as during the blunt dissection of Denonvillier’s fascia, two planes are created to guide intrafascial nerve-sparing.

 

For prostatic pedicle dissection, the assistant elevates the seminal vesicles ventrally, allowing clear exposure of the prostatic pedicle. The prostatic pedicle must be clipped and cut step by step - it is not possible to include the entire pedicle within one clip. It is advisable to proceed with clipping and cutting in small steps directly on the surface of the prostatic capsule. At this point of the procedure, the SonoSurg device can only be used for blunt dissection, to avoid any thermal damage to the nerve structures. Again, the plane surface of prostatic capsule is clearly seen laterally, as well as posteriorly. When the main prostatic pedicle has been fully dissected, the remaining neurovascular bundle and the periprostatic fascia can be detached from the prostatic capsule, in most of the cases bluntly, as shown on the video. The prostate now becomes free from its surrounding fascias and neurovascular structures. The dissection is continued towards the apex on the surface of the prostatic capsule. When the dissection of the left side is completed, the same process is repeated on the right side. The surgeon uses the scissors with his right hand and the grasper with his left hand. The dissection is completed on both sides to free the entire posterior and posterior-lateral surface of the prostate.

 

After full mobilization of the apex of the prostate, the Santorini Plexus is ligated. A two-oh polisorb GS22, slightly straightened needle is used, and guided from left to right in the plane below the dorsal venus complex, and the plexus is thus ligated.

 

According to the anatomy of the urethra, the final apical dissection is a three-step procedure. The first step is the dissection of the dorsal venus complex and overlying connective tissue. This is performed from laterally to medially until full dissection is completed. For optimal access, the prostate should be pushed dorso-cranially.

 

The second step is the dissection of the junction between the striated part of the urethral sphincter and the apex of the prostate.

 

Finally, the inner smooth muscular layer of the urethra is separated. Dissection of the anterior urethra is then performed proximally, very close to the prostate, to preserve the urethra as long as possible. As soon as the urethral catheter becomes visible, the assistant retracts the catheter towards the synthesis. The verumontanum is now clearly visible. The dissection of the posterior urethra starts distally to the verumontanum. The final detachment of the posterior urethra is performed dorso-laterally, to avoid any injury to the neurovascular bundles and the rectum. The assistant retracts the seminal vesicle contralaterally, out of the pelvis and also pushes the prostate dorso-laterally. Then, the dissection is performed as a mixture of blunt and sharp dissection using the scissors.

 

When the prostate is completely dissected it is placed into an endoscopic retrieval bag. The video now shows the result of Intrafascial Nerve-Sparing Prostatectomy, leaving intact not only the neurovascular bundles covered by the periprostatic fascia, but also the endopelvic fascia and the puboprostatic ligaments.

 

A watertight urethrovesical anastomosis is now performed with eight to nine sutures. The first suture is placed posteriorly at an eight o’clock position. All stitches are performed outside-inside at the bladder neck and inside-outside at the urethra. The neck sutures are systematically placed at the seven, six, five and four o’clock positions, as shown in the diagram. Once the posterior anastomosis has been completed, the definitive silicone catheter is placed into the bladder. Two further sutures are placed at the three and nine o’clock positions. The anastomosis is finalized by two sutures placed at the eleven and one o’clock positions.

 

At the end of the procedure, the laparoscope should be inserted through the 12mm left lateral trocar, identifying any possible injury to the epigastric vessels. Finally, a sixteen French Robinson drain is placed through the 5mm right iliac foss support site.