Robotic-assisted radical prostatectomy: A surgical guide to the extraperitoneal approach

Robotic surgery is ideally suited for work in tight anatomic spaces within which there is a relatively small and static target. The prostate, with its typical size and central location in the pelvis, is a target organ that fits these criteria. In addition, its extraperitoneal location allows for access to the cancerous prostate without entry into the abdominal cavity. Extraperitoneal robotic-assisted radical prostatectomy uses an approach to the prostate that is identical to that used in open retropubic radical prostatectomy, with comparable avoidance of abdominal structures and of steep Trendelenburg position, but with fine robotic instruments as the surgical tools. The advantages of extraperitoneal robotic surgery to access and remove the prostate are only counterbalanced somewhat by an increased level of difficulty in learning to safely and reliably access the extraperitoneal space of Retzius, avoid or manage inadvertent peritoneotomy, and handle the posterior structures (seminal vesicles, vasa deferentia) in antegrade fashion. None of these hurdles are insurmountable, and virtually all patients can benefit from this approach. In fact, it is perhaps ideally suited for men who pose additional challenges to radical prostatectomy, such as the obese, those who have had prior abdominal or inguinal surgery, and/or those with concomitant inguinal hernia(s).