Feasibility, Technique, and Principles of Tension- and Energy-Free Laparoscopic Radical Prostatectomy with Lateral Intrafascial Dissection of the Neurovascular Bundles with the Use of a High-Definition Optical Device

Abstract

RADICAL RETROPUBIC PROSTATECTOMY (RRP) with nervesparing technique is based on the finding that cavernosal nerves, which are responsible for ejaculation, continence, and erectile function, pass around the bladder neck, the proximal part of the prostate, and the seminal vesicles directly to the apex caudally. The main objectives of RRP for clinically localized prostate cancer are oncologic clearance coupled with good functional outcomes for urinary continence and erectile function.1 Open RRP is still considered the gold standard.2,3 Furthermore, as more prostate cancers are detected at a younger age, patients expect a high level of functional outcome after surgical therapy.2 All RRPs are performed with either an anterograde, retrograde, or a combined approach. In our opinion, the Huland and Studer technique is one of the best technical improvements during the last decade for RRP to preserve the neurovascular bundles (NVBs). Graefen and associates2 developed a combined anterograde-retrograde technique with a lateral approach to the NVB using a “peanut” sponge stick to push the bundle laterally and downward. With this technique, we acquired anatomic knowledge during laparoscopic and robot-assisted radical prostatectomy that we have applied in our daily practice to develop a tension-free and energy-free laparoscopic radical prostatectomy (LRP) with pure lateral intrafascial dissection of the NVB. At our institution, we have performed LRP since 1997. After completing more than 3000 procedures, we have achieved results comparable to those of RRP with the conventional technique.4 In January 2005, we introduced the robot-assisted laparoscopic prostatectomy (RALP). After an initial experience of almost 400 cases, in which we reproduced our laparoscopic technique, we developed a new technique for the dissection of the NVBs. In consideration of the technique described by Graefen and colleagues,2 combined with the anatomic knowledge that we have acquired during our laparoscopic and robotic daily practice, we developed a tension-free and energy-free RALP with pure lateral intrafascial dissection of NVBs.5 In June 2007, when we introduced in our department the new high-definition (HD) optical device from Karl Storz (Tuttlingen, Germany), we realized that we were able to identify some anatomic structures learned during our robot experience. With this experience and with the encouraging short-term functional results of the lateral tension-free and energy-free RALP,5 we wondered whether the same approach was possible using conventional laparoscopy with the HD optical device assistance. We used the HD camera, HD 16:9 monitor, and 10-mm, 0degree lens from Storz. The launch of Image 1® HD marks an important improvement over standard definition (SD) and even over first-generation HD technologies. It provides, in our opinion, excellent vision that allows an expert surgeon to better recognize the anatomy learned during the robot experience. In this way, it makes him or her able to perform a more precise dissection with conventional laparoscopic instrumentation.