Laparoscopic radical prostatectomy: transperitoneal approach

The description of the laparoscopic radical prostatectomy: transperitoneal approach covers all aspects of the surgical procedure used for the management of prostate cancer. Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: initial dissection of seminal vesicles, intrafascial dissection, specimen retrieval, vesicourethral anastomosis, end of procedure. Consequently, this operating technique is well standardized for the management of this condition.

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Laparoscopic   radical   prostatectomy:   transperitoneal   approach

Authors
T Piéchaud, C Saussine
Abstract
The description of the laparoscopic radical prostatectomy: transperitoneal approach covers all aspects of the surgical procedure used for the management of prostate cancer.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: initial dissection of seminal vesicles, intrafascial dissection, specimen retrieval, vesicourethral anastomosis, end of procedure.
Consequently, this operating technique is well standardized for the management of this condition.
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2006-02
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E-publication
WeBSurg.com, Feb 2006;6(02).
URL: http://www.websurg.com/doi-ot02en302.htm

Laparoscopic   radical   prostatectomy:   transperitoneal   approach

1. Introduction
Radical prostatectomy is used for the treatment of localized prostate cancer.
The first laparoscopic radical prostatectomy was described by Schuessler (Schuessler et al., 1992). However it was not until 1997 that the laparoscopic technique was standardized in a reproducible fashion. Since then, several experienced laparoscopic surgical teams have developed this minimally invasive procedure and have demonstrated its advantages (Guillonneau et al., 1999; Abbou et al., 2000; Abbou et al., 2001; Rassweiler et al., 2001a; Rassweiler et al., 2001b). There are now several series of laparoscopic transperitoneal radical prostatectomies providing preliminary results with regard to postoperative continence, recovery of erectile function and oncological outcome.
More recently, laparoscopic radical prostatectomy has been developed using robotic assistance (Pasticier et al., 2001).
2. Anatomy
• Anatomical relations
The anatomical relationships of the prostate are complex. Situated deep at the base of the pelvis, it is in contact with the following:
- muscular and aponeurotic structures (levator ani muscles, endopelvic fascia, Denonvilliers' fascia/rectoprostatic fascia);
- visceral structures (rectum);
- vascular structures (prostatic venous plexus);
- neurovascular structures (neurovascular bundles leading to ischiocavernous muscle);
- lower urinary apparatus (bladder neck, striated urethral sphincter).
The prostate is joined to the seminal vesicles, which are removed en bloc with the prostate. The distal part of the vesicles are in contact with the superior portion of the neurovascular bundles and the inferior vesical artery.
• Posterior relations
• General landmarks
The following structures are anatomical landmarks:
1. Retzius’ space;
2. Seminal vesicles;
3. Ductus deferens.
After incision of the anterior peritoneal leaflet of the rectovesical recess, the main landmarks are:
4. Anterior surface of rectal peritoneum (space of Douglas);
5. Denonvilliers’ fascia;
6. the rectum.
• Rectum
The anterior surface of the rectum constitutes the main anatomical relationship. Separated from the posterior surface of the prostate by a very thin fibrofatty area of loose connective tissue, it is easily freed with simple dissection. At the level of the prostatic apex, the lower part of the rectum becomes more closely adherent to the gland attached by a dense fibrous plane, in contact with the rectourethralis muscle.
1. Rectourethralis muscle
2. Neurovascular bundles
3. Rectum
• Denonvilliers’ fascia
CLICK ON THE BULLETS FROM BOTTOM TO TOP TO DISPLAY THE STRUCTURES CONSTITUTIVE OF THE PELVIC CAVITY
Denonvilliers’ fascia (rectoprostatic fascia) is thick. At the mid-perineal plane it is split into 2 leaflets (anterior and posterior). The space between these leaflets contains the seminal plexus and the spermatic ducts (seminal vesicle and ductus deferens). The incised posterior sheet remains attached to the rectum. The anterior surface of the rectum is protected by a layer of fat at the upper part of the plane of dissection.
• Seminal vesicles
Posteriorly, the seminal vesicles are in contact with subperitoneal fat. Anteriorly, they are separated from the fundus of the bladder by a fibrofatty tissue plane. Laterally, the essential relationships are found: emergence of the inferior vesical artery at the base of the seminal vesicles, and a series of lateral arterial branches supplying the vesicles.
There may be contact with the ureter, which is sometimes found near the summit of the vesicle.
1. Vesiculodeferential artery
2. Ureter
3. Ductus deferens
• Anterior relations
• Retzius’ space
The prevesical area of loose connective tissue (Retzius’ space) isolates the anterior surface of the bladder from the muscular wall. Its dissection runs laterally, on each side, to the pelvic fascial plane.
1. Retzius’ space
2. Bladder
• Pelvic fascia
The pelvic cavity is formed by the endopelvic fascia that covers the superior surface of the prostate. It must be incised to gain access for the dissection of the lateral surfaces of the prostate. At this level, the prostate gland is in close contact with the fibers of the levator ani muscle. Simple separation from these fibers will liberate the prostate laterally, to its apex.
1. Levator ani muscles
2. Pelvic fascia
3. Reflection of pelvic fascia
• Ligaments
The puboprostatic ligaments extend on each side, between the endopelvic surface of the pubic symphysis and the anterior apex of the prostate. They block access to the preprostatic (Santorini’s) venous plexus anteriorly and laterally, and therefore should be divided to enable dissection of the venous plexus.
1. Puboprostatic ligament
2. Levator ani muscle
3. Puboprostatic plexus (Santorini’s)
• Venous plexus
The preprostatic (Santorini’s) venous plexus is a rich venous plexus that extends anteriorly from the apical area of the prostate and ensures venous drainage from the penis. In laparoscopy, anatomical exposure is facilitated, and engorgement of the venous plexus is reduced as a result of the pressure from the pneumoperitoneum.
The striated urethral sphincter is separated from the apical prostate by a small length of the urethra. It is preserved during urethral division.
• Superolateral relations
• Bladder-prostate fixation
The bladder neck lies on the base of the prostate. There is a dissection plane between the bladder neck and the prostate that leads to the urethra. Dissection in this space completely mobilizes the bladder neck from the base of the prostate. This dissection reveals the beginning of the urethra. It can be isolated over a 1 cm length above its intraprostatic course.
• Neurovascular bundles
Essential for erectile function, the neurovascular bundles include the erectile nerves that run alongside the vessels leading to the corpora cavernosa. Several arterial branches supply the prostate.
1. Pelvic fascia
2. Arterial branches
3. Neurovascular bundles
4. Urethral sphincter muscle
5. Posterior part of Denonvilliers’ fascia
6. Denonvilliers’ fascia
3. Indications
Indications
Laparoscopic radical prostatectomy is used in the management of localized prostate cancer.

Contraindications
Contraindications to laparoscopic surgery for localized prostate tumors are mainly anesthesia-related as the patient has to undergo general anesthesia. It is also important to ensure that coagulation is normal.


Non-contraindications:
Previous transurethral resection of the prostate is not a contraindication for laparoscopic surgery.

Previous hormonal treatment: this modifies the tissue around the prostate gland and makes dissection more difficult.
4. Preop management
The preoperative workup for localized tumors is simple and depends on the surgeon’s preferences:
- bone scintigraphy;
- abdomino-pelvic CT scan or MRI to check for lymph node invasion;
- ilio-obturator lymph node dissection (dissection occurs intraoperatively) depending on the PSA (prostate-specific antigen) level.
No skin or bowel preparation is required.
Prophylactic antibiotic therapy with second generation cephalosporin is administered. A bolus injection is given just before inducing anesthesia, and antibiotics are continued intravenously on postoperative day 1 (POD1), and then orally until the urinary catheter is removed (POD5).
Prevention of deep venous thrombosis is essential, as for all laparoscopic procedures. Antithrombotic drug treatment is begun on the evening of the operation with an injection of half-dose low molecular weight heparin. A full dose injection is administered the next day, and the treatment is continued for 3 weeks following surgery.
5. Operating room
• Patient
- general anesthesia;
- supine, arms against the body;
- both legs on classical leg supports and spread 50° to permit the videoscopic unit at the patient’s feet to be moved forward;
- 30° Trendelenburg position at the beginning of the procedure;
- no shoulder rest: correct body position is maintained by interposing a no-slip drape between the patient and the table mattress;
- upper body ventilated patient warming system.
• Team
1. The surgeon is on the patient’s left.
2. The assistant is on the patient’s right.
3. A second assistant next to the first can help pass the instruments and also handle one of the trocars. He/she stands next to the first assistant.
• Equipment
1. The laparoscopic unit and the monitor are placed at the patient’s feet, between the legs.
2. The operating table must permit a 30° Trendelenburg position.
6. Instruments
The basic instrumentation is common to all laparoscopic procedures:
1. 0° laparoscope
2. Fine dissecting scissors
3. Ultrasonic dissectors (optional)
4. Fine grasping forceps
5. 2 fenestrated grasping forceps
6. Bipolar cauterizing grasper
7. Needle holder
8. Suction-irrigation device
9. 5 mm clip applier
10. Retrieval bag
- urinary catheter
- 2.0 braided suture, 26 mm needle
- 3.0 absorbable monofilament suture, 26 mm needle
7. Trocar placement
• Landmarks
Five trocars are usually required. They are placed following the enlarged triangulation principle. The landmarks are as follows:
1. Umbilicus
2. Right iliac crest
3. Left iliac crest
4. Pubic symphysis
• Trocar position
The size and position of trocars are the following:
Trocar A: 10 mm, in the umbilical position. It is placed either via a minilaparotomy or percutaneously after insufflation of the peritoneal cavity with a Veress needle. Certain surgical teams do not use insufflation and introduce this trocar percutaneously.
Trocar B: 5 mm, in right lateral position, 2 cm medial to the anterior superior iliac spine. Its position in relation to the umbilicus may vary depending on the surgeon’s practice and patient’s anatomy.
Trocar C: 5 mm, halfway between the umbilicus and trocar B. Its position may vary and be either identical to or 3-4 cm lower than trocar B. Trocars B and C must be positioned with as much space as possible from one another.
Trocar D: 5 mm, on the midline, halfway between the umbilicus and the pubic symphysis.
Trocar E: 5 mm, in left iliac position, more or less symmetrical to trocar B.
• Variation
Certain teams are used to placing trocars in a W-shaped fashion or in a herringbone pattern. Trocar D may be placed symmetrically to trocar C.
• Instruments/trocars
The position of the instruments in the trocars is the following:
Trocar A: laparoscope
Trocar B: grasper, suction cannula
Trocar C: grasper, suction cannula, scissors for cutting sutures
Trocar D: monopolar or ultrasonic scissors, needle holder
Trocar E: dissection forceps, bipolar grasper
8. Standard technique
Most of the time, approach to the bladder neck marks the beginning of the standard procedure.
Key steps:
Anterior steps:
- bladder detachment;
- anterior and lateral approach to prostate gland.
Superior step:
- dissection of bladder and prostate.
Posterior steps:
- dissection of seminal vesicles;
- incision of Denonvilliers’ fascia;
- dissection of prostate and rectum.
Lateral step:
- dissection of neurovascular bundles.
Inferior steps:
- hemostasis and division of preprostatic venous plexus;
- urethral division.
Bagging of operative specimen
Vesicourethral anastomosis
9. Operative protocol
• Anterior step
• Bladder detachment
Once the trocars are in place the peritoneum is incised superiorly on the abdominal wall in order to decrease the risk of bladder injury. The incision is extended from one umbilical artery to the other. The urachus is divided on the midline. The incision assists in opening the prevesical area of loose connective tissue (Retzius’ space).
Hemostasis is performed with bipolar forceps. Division is performed either with monopolar scissors or ultrasonic scissors.
• Freeing
During the freeing of the bladder and prostate, the bladder is either totally empty or at least partially empty.
The anterior surface of the bladder is completely mobilized. This mobilization is extended laterally and cephalad to the passage of the vas deferens on each side of the bladder.
Prostate dissection, anterior approach:
The anterior surface of the prostate is freed of its lateral margins to the plane covered by the pelvic fascia on both sides. The apical and medial parts of the prostate are then freed. All of the retropubic fat is removed to facilitate access to the preprostatic (Santorini’s) venous plexus. The superficial dorsal vein is coagulated with bipolar forceps.
• Apical dissection
Anterior and lateral approach:
The endopelvic fascia is opened with dissecting scissors along the lateral border of the prostate gland. The incision may be performed in different ways. In some cases, it may start near the apex of the prostate and is extended posteriorly. In other cases, incision may start from the base and is extended towards the apex.
The muscular fibers of the levator ani muscle are simply reflected with the tip of the scissors from their lateral prostatic attachments. Once the lateral surfaces of the prostate are completely freed, the dissection is continued to the apex and the origin of the urethra.
The puboprostatic ligaments are carefully divided with dissecting scissors. The apex of the prostate can then be lowered and the preprostatic venous plexus is revealed. At the end of this operative step, the preprostatic venous plexus is isolated. It appears to be less spread out than in open surgery, due to the CO2 pressure and the complete dissection of the fibrous structures that surround it. In a radical prostatectomy with preservation of the neurovascular bundles, monopolar cautery must be avoided during this dissection.
The venous plexus may be controlled by ligature at this time of procedure. Some experts postpone it to the end of the procedure just before urethral division.
• Superior step
• Bladder neck
The objective of the vesicoprostatic dissection is to completely separate the bladder neck from the base of the prostate and to identify the first part of the urethra. Dividing the urethra at this level ensures preservation of the bladder neck.
During this dissection posterior to the bladder neck, it is mandatory to be in the correct dissection plane as errors of dissection may occur. If the dissection is too oblique anteriorly, there is a danger of extending into the plane between the prostatic tumor and capsule; if it is too oblique posteriorly, then there is a danger of extending into the vesical wall and injuring the trigone of the bladder.
• Urethral division/Dissection plane
The dissection plane between the two organs must be identified laterally, on both sides of the bladder neck, by following the curved contours of the base of the prostate. The fatty tissue covering this plane is highly vascularized. Hemostasis with bipolar cautery is essential at this level. After dividing this fatty plane, the dissection is carried out laterally, in contact with the prostatic margin, progressively freeing the vesical fiber attachments. The space between the base of the prostate and the neck of the bladder becomes more and more evident. The dissection is continued on both sides towards the midline and reveals the subcervical urethra, which is completely freed to the level of its posterior wall. The posterior dissection of the urethra gives access to the anterior leaflet of the rectoprostatic fascia.
The urethra is clearly exposed. It is divided on its anterior margin with dissecting scissors, just below the limit of the bladder neck. The urinary catheter is removed. The posterior surface of the urethra is identified and is divided as far as possible from the trigone of the bladder and the urethral openings, freeing the bladder neck.
• Incision of the leaflet
CLICK ON THE FRAME AT THE TOP LEFT FOR A SCHEMATIC ANATOMICAL VIEW AND SWITCH BACK
To expose the leaflet, the base of the prostate is reflected anteriorly (with the assistant’s grasper) and the posterior edge of the bladder neck is reflected posteriorly. The anterior leaflet of the rectoprostatic fascia appears taut and should be incised perpendicularly. Continuing the posterior dissection between the two organs gives access to the start of the dissection plane of the vesiculodeferential complex.
• Posterior step
• Dissection of vesicles
Each vas deferens is dissected to the summit of the seminal vesicle and divided 4 cm from the summit after electrocauterization of the deferential artery.
The summit of the seminal vesicles is freed by cauterizing their arterial supply (a branch of the inferior vesical artery). The vesicles are mobilized and dissected laterally. Hemostasis of several perforating arterial branches is done. The peritoneum that is against the posterior surface of the seminal vesicles is dissected and the vesiculodeferential complex is completely freed until contact with the base of the prostate is made.
• Preservation of nerves
In the case of nerve-sparing prostatectomy, hemostasis of the vessels supplying the seminal vesicles and vasa deferentia should be done prohibiting the use of monopolar cautery in order to avoid injuring the nerve bundles with the heating effect of the cauterization. The first contact with the neurovascular bundles takes place during dissection of the summit and the lateral surfaces of the seminal vesicles.
• Rectoprostatic fascia
CLICK ON THE FRAME AT THE TOP LEFT FOR A SCHEMATIC ANATOMICAL VIEW AND SWITCH BACK
When the vesiculodeferential complex is lifted cephalad, the posterior leaflet of the rectoprostatic fascia (Denonvilliers’ fascia) is clearly revealed. It is incised horizontally, 1 cm below the root of the seminal vesicles. Sharp incision is made with the dissecting scissors, revealing the prerectal fat. It is continued laterally along the entire width of the prostatic base.
• Dissection
The dissection between the prostate and the rectum is performed along the anterior surface of the rectum, in contact with the fat, freeing the entire posterior surface of the prostate on the two lateral lobes, down to the level of the apex. It is continued on each side, to free the rectum laterally, and ends inferiorly at the level of the apex. This step exposes the posterior surface of the prostatic neurovascular bundles. Because of the angulation of the axis of the instruments and of the anterior wall of the rectum, and the resulting risk of rectal injury, the dissection must not be pursued further.
• Lateral steps
• Division of pedicles
At the base of the prostate, the vascular pedicles are thick. It is sometimes difficult to distinguish between the thick part of the pillar attached to the base of the prostate and the neurovascular structures of the bundles that join the lateral surface of the prostate at this level.
Hemostasis of the pedicles must be progressive and meticulous. The vessels can be identified after dissecting the fatty tissue. The selective division of the pedicles enables the surgeon to come into contact with the lateral surface of the prostate and the angle of fixation of the seminal vesicle.
• Neurovascular bundles
The selective dissection of neurovascular bundles is critical to preserve postoperative erectile function. It is not always possible, as it depends on the characteristics of the prostate (extent of tumor invasion, previous history of infectious disease). To avoid injury to the nerve structure, hemostasis of the vessels supplying the prostate must be performed either with vascular clips, bipolar cautery, ultrasonic scissors or with a vessel sealing device. There is a consensus that the use of monopolar cautery is prohibited.
• Dissection of bundles
The lateral prostatic dissection is easier. The neurovascular bundle stands out clearly. It is progressively separated from the prostate. Hemostasis of the vascular branches entering the bundle is continued. The visceral leaflet of the endopelvic fascia (in contact with the prostate gland) is incised towards the apex, taking care to preserve the capsule. The freeing of the neurovascular bundles down to the prostatic apex can then be achieved on both sides.
• Variation
If the preservation of the neurovascular bundles is not called for, or if it seems impossible, the division of the prostatic pedicles is much easier and quicker.
• Inferior steps
• Hemostasis
The preprostatic venous plexus is ligated with a 2.0 braided suture using a 26 mm needle. A figure-of 8-stitch is used, followed by a second, more superficial stitch, where the puboprostatic ligaments are attached. The knot is then tied intracorporeally. The entire venous plexus should be taken but the urethral wall must be preserved.
It is not necessary to place a ligature on the vessels above the division on the anterior part of the prostate. Some experts prefer to use clamps/clips or coagulation to ensure venous control.
• Division/venous plexus
Using dissecting scissors, the preprostatic fascia is incised below the ligature of the preprostatic venous plexus. The division must be done in contact with the prostatic capsule, passing beneath the venous plexus, which progressively retracts towards the pubic symphysis.
• Urethral division
At the apex of the prostate, the urethra is clearly recognizable. Lateral dissection of the urethra on both sides is performed to separate the urethra from the pillars attached to the apex of the prostate (the passage of the bundles is even more lateral). The urethra is divided just below the apical limit. The apical pillars are then divided on each side. The lateral dissection separates any residual attachments between the bundles and the lateral surfaces of the prostate.
• End of apical division
The apex of the prostate is still attached to the rectal wall by the lower thick portion of the posterior leaflet of Denonvilliers’ fascia. Identification of this fascia is essential before division to avoid any rectal injury at this level. The fascia is divided close to its prostatic limit. The prostate is then completely freed.
If there is residual bleeding of the venous plexus, additional sutures may be required. If there is bleeding at the level of the neurovascular bundles monopolar cautery should be avoided to reduce the risk of injury.
10. Initial dissection/seminal vesicles
• Peritoneal incision
The posterior approach starts with the dissection of the vesiculodeferential complex.
Historically this variation was first proposed for laparoscopic radical prostatectomy.
The vasa deferentia are identified on each side. The horizontal peritoneal incision should be extended at the superior part of the anterior surface of the vesicorectal (Douglas) pouch between the two vasa deferentia. Each vas deferens is dissected to the summit of the seminal vesicle and divided 4 cm from the summit after electrocauterization of the deferential artery.
• Dissection of vesicles
The summit of the seminal vesicles is freed by cauterizing their arterial supply (a branch of the inferior vesical artery) using either clips or bipolar cautery. The vesicles are mobilized and dissected laterally. Hemostasis of several perforating arterial branches is done. The peritoneum that is against the posterior surface of the seminal vesicles is dissected and the vesiculodeferential complex is completely freed until contact with the base of the prostate is made.
• Preservation of nerves
In the case of nerve-sparing prostatectomy hemostasis of the vessels supplying the seminal vesicles and vasa deferentia should be done without the use of monopolar cautery in order to avoid injuring the nerves. The first contact with neurovascular bundles takes place during dissection of the summit and the lateral surfaces of the seminal vesicles.
• Rectoprostatic fascia
When the vesiculodeferential complex is lifted cephalad, the posterior leaflet of the rectoprostatic fascia (Denonvilliers’ fascia) is clearly revealed. It is incised horizontally, 1 cm below the root of the seminal vesicles. Sharp incision is made with the dissecting scissors, revealing the prerectal fat. It is continued laterally along the entire width of the prostatic base.
• Dissection
The dissection between the prostate and the rectum is performed along the anterior surface of the rectum, in contact with the fat, freeing the entire posterior surface of the prostate on the two lateral lobes, down to the level of the apex. It is continued on each side, to free the rectum laterally, and ends inferiorly at the level of the apex. This step exposes the posterior surface of the prostatic neurovascular bundles. Because of the angulation of the axis of the instruments and of the anterior wall of the rectum, and the resulting risk of rectal injury, the dissection must not be pursued further.
Other steps:
The other steps take place chronologically following the protocols described in the standard technique. The only difference occurs following division of the anterior leaflet of Denonvilliers’ fascia. Such division helps to free the previously dissected space, which surrounds seminal vesicles. The previously divided vasa deferentia appear again, just like the dissected seminal vesicle. Dissection of the neurovascular bundles may be undertaken.
11. Intrafascial dissection
• Dissection of bladder neck
In the case of subclinical prostate cancer in a young patient with a desire for preservation of erectile functions, an intrafascial dissection may be performed (inside the prostatic fascia). Such dissection makes it possible to achieve complete preservation of the neurovascular bundles but may entail a higher risk of injury to the prostate gland.

Technique description:
Initial approach to the bladder and prostate is similar to the protocol previously described.
Incision of the lateral margins of the endopelvic fascia is not necessary.
Dissection of the bladder and the prostate with preservation of the bladder neck is performed in the same fashion as previously described.
• Lateral dissection
The posterior lateral attachments of the neurovascular bundles to the prostate are dissected free. This is made possible by a superficial incision of the fascia covering the prostate, at the apical, posterior and basal portions of the prostate lobe. This fascia is progressively freed and detached from the gland parenchyma. The lateral leaflet of the fascia surrounding the prostate remains attached to the neurovascular bundle.
Incision of the endopelvic fascia is performed progressively during the prostate dissection and as close to the prostate as possible.
• Apical dissection
Apical dissection is slightly different: once the apex is reached, dissection is continued underneath the plane covering the endopelvic fascia. Control of the venous plexus is simpler and may be optional.
12. Specimen retrieval
The specimen retrieval bag is introduced through the 10 mm umbilical trocar following removal of the laparoscope. The specimen is then placed in the watertight bag, which is temporarily placed in the left parietocolic recess in the transperitoneal approach.
13. Vesicourethral anastomosis
• Technique
The surgeon must be highly skilled in laparoscopic suturing techniques for this step. The anastomosis can be done either with a series of interrupted sutures or with a running suture.
1. The surgeon inserts the needle holder through trocar D or C.
2. The dissecting forceps is inserted through trocar E.
3. The second assistant exposes the suture with dissecting forceps inserted through trocar B.
For a single running suture, a 3.0 absorbable monofilament, 26 mm needle, 20 cm suture length are used.
The running suture is passed through the bladder, laterally to medially, on the right lateral side. It is then passed through the urethra, medially to laterally, on the right lateral side (3 o’clock position).
It is continued along the entire posterior margin, and then upwards towards the left lateral side (9 o’clock position). When the posterior plane is completed, the urinary catheter is put in place (single-channel, 18 French). The running suture is completed with an anterior step and with an extra-urethral knot whose initial end is laid aside on the right lateral surface.
• Interrupted sutures
Interrupted sutures can also be used. Six to 7 stitches are placed circularly, starting from the right posterior lateral portion of the urethra to be continued anteriorly.
• Single-knot anastomosis
The single-knot technique described by Van Velthoven (Van Velthoven et al., 2003) can also be used. Two 15 cm long threads knotted centrally are used to achieve a running anastomosis of the posterior plane from the medial axis. Traction exerted on the two threads facilitates the bringing together of the posterior limit of the bladder neck with the urethral edge. The catheter is placed through the urethra at bladder level. The two half-running sutures help to complete an airtight anastomosis. The threads are knotted at 12 o’clock in contact with the bladder neck.
• Note
With a wider cervical opening, it is critical to identify and control the urethral orifices, to avoid catching them in the running suture. An interrupted suture or a running suture may be used. Ureteral orifices may be moved away from the anastomotic site by performing a posterior racket handle-type reconstruction with an interrupted or running suture. In some cases, it may be easier to perform an anterior racket-handle type reconstruction for closure of the bladder neck.
At the end, the anastomosis should be tested by irrigating the bladder.
14. End of procedure
Drainage is not done systematically; if needed, a simple 16 French drain is used. The retrieval bag containing the operative specimen is removed by enlarging the umbilical trocar wound. The wound is then closed in 2 layers (peritoneal and fascial planes). If there is a scar from previous surgery then this may be used to remove the specimen. The drain is removed on POD1 or POD2.
The urinary catheter is removed on POD5.
The patient is discharged from hospital after removal of the urinary catheter (generally on POD5).
Prophylaxis against deep venous thrombosis is given for 3 weeks following the operation.
15. Conclusions
Laparoscopic radical prostatectomy is now well established and the procedure has been standardized. It has been shown to reduce blood loss compared with open retropubic prostatectomy (Guillonneau et al., 2002).

Further studies are necessary to assess the potential benefits of the procedure with regard to postoperative continence and preservation of erectile function.

Oncological results and the rate of surgical positive margins seem to be more related to the technique of erectile nerve preservation and to the pathological stage than to a laparoscopic or conventional surgical technique.
16. Reference