The endoscopic extraperitoneal radical prostatectomy (EERPE): technique and initial experience

Abstract

Using the experiences of the extraperitoneal (endoscopic pelvic lymphadenectomy and inguinal hernia repair) and the transperitoneal approach (laparoscopic radical prostatectomy), we developed a totally extraperitoneal approach to endoscopic radical prostatectomy. In view of the favourable short-term outcome, we describe the technique of totally extraperitoneal endoscopic radical prostatectomy (EERPE) as a now standardised procedure. After creating the preperitoneal space by balloon dissection, five trocars were placed in the hypogastrium, allowing immediate access to the space of Retzius. The surgical technique of EERPE replicates the steps of the classical retropubic descending radical prostatectomy with slight modifications. The procedure starts with exposing the Retzius space and pelvic lymph node dissection. After that, the endopelvic fascia and the puboprostatic ligaments are incised, followed by ligating the Santorini plexus. The actual prostate dissection is similar to the open descending approach: bladder neck dissection, freeing of the seminal vesicles, transsectioning of the prostatic vesicles (with or without preserving the neurovascular bundles) and, finally, apical dissection. A water-tight urethrovesical anastomosis is performed with interrupted sutures. There were 20 patients who underwent EERPE. Mean operating time was 170 min with no conversion. No major complications occurred. Only one patient required a blood transfusion. The catheter could be removed on postoperative day 6 (n = 17) or on postoperative day 12 (n = 3). Final pathologic evaluations were 4 stage pT2a, 10 stage pT2b, 5 stage pT3a, and 1 pT3b. Surgical margins were negative in 17 patients. By avoiding entry into the peritoneal cavity, therefore, obviating intra-abdominal complications, such as bowel injury, ileus, or intestinal adhesions, the extraperitoneal endoscopic access provides a safe and minimally invasive approach to the prostate, combining the advantages of minimally invasive laparoscopy and retropubic open prostatectomy.

Technique of laparoscopic (endoscopic) radical prostatectomy

“…This method replicates the steps of a classical retropubic descending radical prostatectomy, with slight modifications, and has been described and illustrated elsewhere in detail [8].…”

“…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].…”

“…The introduction of extraperitoneal guidance as an aid to radical prostatectomy by Raboy et al [4] 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.…”

“…2). Second, the preperitoneal space is further developed by a balloon trocar inserted tangentially to the [8]. cutaneous plane towards the pubis.…”

“…This dissection is taken on both sides to a point just cephalad to the urethra, to mobilize the prostate completely. [8].…”