Laparoscopic Radical Prostatectomy: Lessons Learned in Surgical Technique

Objective: Describe the rationale for and surgical modifications to the original Montsouris technique for laparoscopic radical prostatectomy (LRP). Methods: This is a retrospective review of laparoscopic prostatectomy and experience involving 1071 cases performed between January 1998 and March 2006 at two centres: the Departments of Urology of the Institut Mutualiste Montsouris, Paris, France (first 502 cases) and Memorial Sloan-Kettering Cancer Center, New York, NY (next 569 cases). Results: Since the first systematic description of the LRP technique, several modifications have been implemented. Most of the modifications have not yet been subjected to rigorous prospective evaluation, but, in our experience, they reduce complications or shorten operative time, and presumably lead to better oncologic results with improved preservation of quality of life. We describe those modifications to the LRP technique 8 yr after the program started, including urachal-sparing transperitoneal approach, extended lymph node dissection, systematic identification of the posterior longitudinal fascia of the detrusor muscle during dissection of the posterior bladder neck, intra/inter/extrafascial dissection of the neurovascular bundles, anatomic dissection of the apex with ligature of the dorsal vascular complex after its sectioning, anchoring of the anterior urethrovesical anastomotic stitches to the endopelvic fascia and pubovesical ligaments, extraction and evaluation of the specimen before completing the anastomosis, and use of postoperative care pathways. Conclusions: LRP technique has been refined, which allowed us to decrease the positive surgical margins rate and improve functional outcomes. It is hoped younger laparoscopic surgeons can take advantage of our experience to build on their expertise.