The Technique of Robotic Nerve Sparing Prostatectomy: Extraperitoneal Approach

Extraperitoneal robotic-assisted radical prostatectomy approaches the prostate in a manner identical to open retropubic radical prostatectomy, with comparable avoidance of abdominal structures and of the steep Trendelenburg position, but with robotic instruments as the surgical tools. The advantages of extraperitoneal robotic surgery to access and remove the prostate are only somewhat counterbalanced by an increased level of difficulty in learning to safely and reliably access the extraperitoneal space of Retzius, avoid or manage inadvertent peritoneotomy, and approach the seminal vesicles and vasa deferentia anteriorly (see Chapter 36). Once mastered by the robotic surgeon, virtually all patients can benefit from this approach, which is associated with a decreased risk of ileus and other abdominal complications. In fact, the extraperitoneal approach to robotic radical prostatectomy is ideally suited for those who pose additional challenges to robotic radical prostatectomy, such as obese men, men with prior abdominal surgery, and/or men with concomitant inguinal hernia(s).