Northwestern MedicinePelvic Fascia-sparing Robotic-assisted Radical Prostatectomy

Anterior Pelvic Fascial Sparing Approach in Robotic-Assisted Laparoscopic Radical Prostatectomy: Refining Surgical Technique for Improved Outcomes

Dr. Edward Schaefer, Chair of the Department of Urology at Fineberg School of Medicine and Northwestern Medicine, presents a refined surgical technique for robotic-assisted laparoscopic radical prostatectomy. This approach, called anterior pelvic fascial sparing, aims to effectively remove the prostate while preserving vital supportive structures around the prostate, bladder, and rectum. The technique represents an evolution in surgical practice, focusing on minimizing impact on adjacent structures and potentially enhancing post-operative outcomes.

Key Points:

• The procedure is performed on a 67-year-old patient with newly diagnosed localized prostate cancer.
• The anterior pelvic fascial sparing approach is a refinement of the standard robotic-assisted laparoscopic radical prostatectomy.
• The procedure begins with a posterior approach to separate the prostate from the rectum.
• A 30° up lens is used for better visualization of the surgical space.
• The bladder neck is precisely dissected from the prostate tissue to minimize impact on adjacent structures.
• Lateral pelvic fascia is separated from the prostate structure using sharp and blunt dissection.
• Neurovascular bundles are identified and preserved to optimize recovery of sexual function.
• Vascular pedicles are controlled using clips to minimize electrocautery exposure to the neurovascular bundle.
• The anterior prostatic fascia, which is thicker than the lateral fascia, is carefully released.
• Pubo-prostatic ligaments are preserved, contrary to traditional approaches where they are disassembled.
• The dorsal venous complex is carefully managed to maintain hemostasis.
• The vesicourethral anastomosis is performed using a 3-0 V-Lok suture in a standard fashion.
• Hemostatic material is applied around the neurovascular bundles in cases of aggressive nerve preservation.
• The anterior fascia is reapproximated to its native position after the anastomosis is complete.
• The procedure concludes with an evaluation of the resection bed from an inferior approach to ensure complete hemostasis.

In a 2021 study, researchers concluded that patients undergoing robotic prostatectomy had better continence than those undergoing laparoscopic surgery when assessed at 3 months following surgery. Age and the nerve-sparing technique further affected continence restoration.

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