title: Retzius-sparing robot-assisted laparoscopic radical prostatectomy: Critical appraisal of the anatomic landmarks for a complete intrafascial approach.
abstract: To provide an overview of the anatomical landmarks needed to guide a retropubic (Retzius)-sparing robot-assisted laparoscopic prostatectomy (RALP), and a step-by-step description of the surgical technique that maximizes preservation of the periprostatic neural network. The anatomy of the pelvic fossae is presented, including the recto-vesical pouch (pouch of Douglas) created by the reflections of the peritoneum. The actual technique of the trans-Douglas, intrafascial nerve-sparing robotic radical prostatectomy is described. The technique allows the prostate gland to be shelled out from under the overlying detrusor apron and dorsal vascular complex (DVC-Santorini plexus), entirely avoiding the pubovesical ligaments. There is no need to control the DVC, since the line of dissection passes beneath the plexus. Three key points to ensure enhanced nerve preservation should be respected: (1) the tips of the seminal vesicles, enclosed in a "cage" of neuronal tissue; a seminal vesicle-sparing technique is therefore advised when oncologically safe; (2) the external prostate-vesicular angle; (3) the lateral surface of the prostate gland and the apex. The principles of tension and energy-free dissection should guide all the maneuvers in order to minimize neuropathy. Using robotic technology, a complete intrafascial dissection of the prostate gland can be achieved through the Douglas space, reducing surgical trauma and providing excellent functional and oncological outcomes.
authors.affiliation: Department of Experimental Medicine and Surgery, UOC of Urology, University of Rome Tor Vergata, Policlinico Casilino, Rome, Italy.|Department of Urology, Clinique Saint-Augustin, Bordeaux, France.
authors.forename: Anastasios D
authors.initials: AD
authors.lastname: Asimakopoulos
authors.affiliation: Department of Experimental Medicine and Surgery, UOC of Urology, University of Rome Tor Vergata, Policlinico Tor Vergata, Rome, Italy.
authors.forename: Roberto
authors.initials: R
authors.lastname: Miano
authors.affiliation: Department of Urology, Ospedale Niguarda Ca' Granda, Milan, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Galfano
authors.affiliation: Department of Urology, Ospedale Niguarda Ca' Granda, Milan, Italy.
authors.forename: Aldo Massimo
authors.initials: AM
authors.lastname: Bocciardi
authors.affiliation: Department of Experimental Medicine and Surgery, UOC of Urology, University of Rome Tor Vergata, Policlinico Tor Vergata, Rome, Italy.
authors.forename: Giuseppe
authors.initials: G
authors.lastname: Vespasiani
authors.affiliation: Department of Experimental Medicine and Surgery, UOC of Urology, University of Rome Tor Vergata, Policlinico Casilino, Rome, Italy.
authors.forename: Enrico
authors.initials: E
authors.lastname: Spera
authors.affiliation: Department of Urology, Clinique Saint-Augustin, Bordeaux, France.
authors.forename: Richard
authors.initials: R
authors.lastname: Gaston
mesh_terms: D059925:Anatomic Landmarks / Q000033:anatomy & histology*; D000071938:Fasciotomy; D006801:Humans; D010535:Laparoscopy / Q000379:methods; D008297:Male; D011467:Prostate / Q000033:anatomy & histology* / Q000601:surgery; D011468:Prostatectomy / Q000379:methods*; D012371:Robotics / Q000379:methods*
keywords: Douglas pouch; cavity; laparoscopy; pelvis; peritoneal; peritoneum; prostate cancer; prostatectomy; robotics