Extraperitoneal Robot-Assisted Laparoscopic Radical Prostatectomy

Abstract

Although open radical retropubic prostatectomy (RRP) is generally performed extraperitoneally, the majority of laparoscopic or robot-assisted laparoscopic radical prostatectomies (RALPs) are instead performed transperitoneally. The extraperitoneal approach is preferred by many surgeons in the quest of duplicating the gold standard open RRP. The main argument in favor of this approach has been the exclusion of intraperitoneal complications. The extraperitoneal approach decreases the risk of ileus, and keeps potential urine leak or bleeding confined to the retroperitoneum. It also facilitates conversion to an open approach should that become necessary, as may occur in the early stage of the learning curve. In 2006, we published our experience reporting the largest series of extraperitoneal RALPs. Prior to acquiring the da Vinci® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA), we had performed a number of cases with this approach using a pure laparoscopic technique. Through multiple reiterations, we have standardized our robotic technique and have made it first-line therapy for over 1,500 suitable patients with organ-confined prostate cancer. With experience, we have been able to develop the extraperitoneal space expeditiously, resulting in rapid time from skin incision to docking of the robot. In this chapter, we describe our technique of extraperitoneal RALP, emphasizing all necessary key steps to complete this procedure successfully.