Transperitoneal versus extraperitoneal robotic-assisted radical prostatectomy: which one?

摘要

As robotic surgery has proliferated, both in its availability as well as in its popularity, there are certainly several unresolved matters in the burgeoning field of robotic radical prostatectomy. Matters that are commonly discussed at forums relating to robotic prostatectomy include training, proctoring, overcoming the learning curve, positive surgical margins, quality of life issues, etc. Among the approaches available for robotic radical prostatectomy are the trans-peritoneal (TP) and the extraperitoneal (EP) approaches. Although use of the TP approach vastly outnumbers the EP approach by a wide margin, one must not discount the need for learning the EP approach, especially in patients who could greatly benefit from this approach. The obese, those who have had intraperitoneal procedures in the past, those with ostomies (colostomy, ileostomy) should be considered candidates for the EP approach. For the beginner, it is recommended that familiarizing oneself with the TP approach may be the quickest way to get proficient with use of the robot and for getting over the learning curve, which varies from surgeon to surgeon. Once comfortable with the TP approach, one should consider the application of the EP access, when indicated. One distinct disadvantage of the EP approach is the limited space available for robotic movements. This is why one would prefer getting experience in the TP before forging into the EP approach. Certainly, adequate balloon dissection of the retroperitoneal space above the bladder is critical, as well as additional dissection with the camera in place. Another criticism of the EP approach is the fact that one may not have enough space or ability to perform a complete pelvic lymph node dissection. However, in experienced hands, one is able to do a very comparable job. Though the TP approach would continue to be the premium approach for robotic and laparoscopic radical prostatectomy, one should familiarize oneself with the EP approach since this can clearly be applied to the patient with the correct indication.