Laparoscopic radical prostatectomy: Technique and early experience

Purpose: In 1999, Guillonuneau & Vallancien presented a refined approach of the descending laparoscopic radical prostatectomy based mainly on an improved suturing and knotting technique. Based on our own experience with open retropubic radical prostatectomy we have modified their technique. Method: A transperitoneal approach is used with a W-shaped arrangement of the trocars (13 mm umbilical port, 2 x 10 mm medial, 2 x 5 mm lateral ports). After exposure of Retzius' space we start with the incision of the endopelvic fascia and control of the dorsal vein complex. Following the pelvic lymphadenectomy, the dorsal vein complex is divided. After incision of the urethra at the apex, the dorsal pedicles of the prostate (+/- neurovascular bundle) are transsected. We now pull the apex ventrally and start with the incision at the bladder neck including exposure and division of both vasa deferens, seminal vesicles and the cranial pedicles. The gland is entrapped in the Extraction Bag(R) (Karl Storz). The vesico-urethral anastomosis is performed by endoscopic suturing. After placement of the forth suture, the Foley catheter is inserted into the bladder and the bladder neck closed by interrupted sutures. Now the prostate is extracted via the umbilical incision. Results: From March 1999 to March 2000, we treated 60 cases (26 pT2, 30 pT3 und 4 pT4 tumors). 1carcinoma was grade 1, 39 grade 2 and 20 grade 3. We had 4 (6.6 %) conversions (rectal injury, adhesion, 2 x bleeding at the dorsal vein complex). The mean operating time was 334 (235-500) min., the transfusion rate 48%. 52 (86%) of the patients did not require any analgesia on the second postoperative day. Positive margins were found in 11 (18%) of the patients, of which eight had a PSA-nadir to the value of less than 0.1 ng/ml within 3 weeks after surgery, On discharge, 27% were continent, after six months 77%, after nine months 95%, while only one patient still suffers from grade I stress incontinence. Conclusions: Laparoscopic radical prostatectomy is a technically demanding procedure, Its advantages with respect to postoperative morbidity are evident, its complication rate and functional results are similar to open surgery.