Posterior Approach to Robotic-Assisted Laparoscopic Radical Prostatectomy

Introduction

The introduction of the prostate-specific antigen (PSA) test led to an unprecedented increase in the number of men diagnosed with prostate cancer. With that rise in rate of diagnosis came a rise in men found to have localized disease. As the concurrent adoption of minimally invasive surgical approaches progressed, laparoscopic techniques began to be applied to radical prostatectomy performed for prostate cancer with initial marginal results and cause for question. Pioneered in Montsouris, France by Dr Guillonneau and Dr Vallancien in an attempt to have shorter catheter durations and to get men out of the hospital quicker, the Montsouris technique for laparoscopic prostatectomy described a technique that was quicker and easier, allowing dissemination and acceptance of minimally invasive radical prostatectomy (MIRP) as a viable surgical strategy. The Montsouris technique utilized a dissection that began posteriorly with the midline identification and liberation of the vas deferens (VD) followed by the seminal vesicles (SVs) bilaterally. This allowed direct visualization of the tips of the SVs and thereby avoidance of damage to the erectile nerves that course in the area. Furthermore, it removed the need for blind dissection of those structures after the bladder was dropped and the bladder neck was incised (thereby sparing the ureters and rectum from potential blind damage). This approach, dissecting in the pouch of Douglas behind the bladder and anterior to the rectum, was not an area that most urologists had experience in, let alone were comfortable with, and it is a testament to the visionary approach by Dr Guillonneau and Dr Vallancien, as well as Dr Schuessler, Dr Clayman, and Dr Kavoussi before them.

After the introduction of the Zeus and DaVinci robotic surgical systems, urologists rapidly applied this new technology to prostatectomy. Laparoscopic prostatectomy had already been proven to have advantages in visualization of pelvic anatomy, decreased blood loss, and a more rapid convalescence. However, laparoscopic surgery in the pelvis had significant limitations. There was a very difficult learning curve due to the challenge of manipulating distant tissues with very long, nonarticulating instruments using two-dimensional images. The introduction of articulating robotic arms along with binocular vision allowed the surgeon to keep the improved outcomes from laparoscopic MIRP as well as vastly improved on these limitations and significantly shortened the learning curve. Shortly thereafter, a proliferation of surgical approaches to prostatectomy occurred with changes in many areas of dissection. Early adopters published included the Frankfurt Technique, which applied the Montsouris approach of a posterior dissection as done with laparoscopic prostatectomy, however, with the aid of the DaVinci robotic platform. As well as the Vattikuti Urology Institute where among other changes, the approach was to initially develop the space of Retzius and separate the bladder from the anterior abdominal wall rather than by dissection of the VDs and the SVs. As the DaVinci robot proliferated in Western medicine, the majority of MIRP transitioned from laparoscopic to robotic approaches. Today, there are two main approaches to robotic-assisted laparoscopic radical prostatectomy, and they essentially consist of beginning the dissection anteriorly or posteriorly. Here we will be describing the Montsouris-based posterior approach.