Robot-Assisted Laparoscopic Radical Prostatectomy with Intrafascial Dissection of the Neurovascular Bundles and Preservation of the Pubovesical Complex: A Step-By-Step Description of the Technique

Abstract

The preservation of sexual potency after radical prostatectomy has always been the topic of much anxiety and debate. While cancer control and urinary continence are of supreme importance, the preservation of sexual function completes the trifecta that both patient and surgeon strive to achieve. The introduction of robotic assistance to modern laparoscopic surgery has provided many advantages, the two greatest being improved three-dimensional magnified vision and wristed instrumentation. These technical enhancements provide the surgeon with improved surgical tools that have the potential to facilitate a more precise surgical approach. One of the potential advantages during robot-assisted laparoscopic prostatectomy (RALP) is improving visualization, control, and dissection of the neurovascular bundle (NVB). With this article, we provide the description of our current technique of intrafascial, tension and energy-free dissection of the NVB during RALP, aiming to maximize the preservation of the periprostatic neuronal network and improve erectile function outcomes. A step-by-step description of the preservation of the pubovesical complex is also provided.

Comparison of intrafascial and non-intrafascial radical prostatectomy for low risk localized prostate cancer

“…This might due to that the surgical trauma was less during the IFRP compared with NIFRP. The intrafascial procedure eliminated the incision of endopelvic fascia, mobilized the levator ani muscles, and even preserved the pubovesical complex in some medical centers 30 , 31 . The other reason for the low complication rates is that IFRP has a longer learning curve than NIFRP.…”

Retzius‐sparing robot‐assisted laparoscopic radical prostatectomy: Critical appraisal of the anatomic landmarks for a complete intrafascial approach

“…Like the Retzius-sparing approach, the recentlydescribed pubovesical-complex sparing technique does not interrupt the PVC to expose the prostatourethral junction (Asimakopoulos et al, 2010(Asimakopoulos et al, , 2012a. Instead, as in the perineal approach, the prostate gland is shelled out from under the overlying DA and DVC, entirely avoiding the pubovesical ligaments.…”

“…The indications, the pre-operative work-up and preparation, the robotic and laparoscopic instruments, and the sutures have been described previously (Asimakopoulos et al, 2012a). Institutional review board approval was obtained for the Retzius-sparing RALP.…”

“…These include the pubovesical-complex sparing technique (Asimakopoulos et al, 2010(Asimakopoulos et al, , 2012a, the identification of landmark arteries or vein layers beyond the prostatic capsule that serve to guide the grading of the nerve-sparing dissection (Patel et al, 2012;Pisipati et al, 2014), the minimization of stretch neuropathy and neurapraxia (Alemozaffar et al, 2012), and the enhanced nervesparing using the Veil of Aphrodite technique (Savera et al, 2006). The inherent advantages of the robotic approach, such as 3D imaging magnification and instruments with seven degrees of freedom, allow the surgeon to follow anatomical planes that were hard to find through the classic open-retropubic or laparoscopic approach, and has led to the development of innovative approaches to RP.…”

“…Some recently-described technical refinements have improved the outcomes of robot-assisted laparoscopic prostatectomy (RALP). These include the pubovesical-complex sparing technique (Asimakopoulos et al, 2010(Asimakopoulos et al, , 2012a, the identification of landmark arteries or vein layers beyond the prostatic capsule that serve to guide the grading of the nerve-sparing dissection (Patel et al, 2012;Pisipati et al, 2014), the minimization of stretch neuropathy and neurapraxia (Alemozaffar et al, 2012), and the enhanced nervesparing using the Veil of Aphrodite technique (Savera et al, 2006). Galfano et al (2010) first described the approach through the recto-vesical pouch (trans-Douglas) to perform a RALP with no dissection of the anterior compartment, i.e., the retropubic (Retzius) space.…”