Demonstration of anatomical and technical details of robotic laparoscopic radical prostatectomy as described in the current literature

Background: Since robot-assisted laparoscopic prostatectomy (RALP) has nowadays become widely accepted world-wide, there needs to be an agreement on the most efficient surgical techniques. This should be based on the video-anatomy of the prostate and a summary of the actual literature. Material and methods: Using video material taken during RALP-procedures performed by the same surgeon (J.R.), the anatomical details of different surgical techniques and operative steps are shown based on the anatomy of the male pelvis applying the standard nomenclature. This was supplemented by a systematic literature search in PubMed focusing on preservation of continence and minimal rates of positive margins. 3,825 publications could be reduced to 604 articles according to the inclusion criteria (randomized controlled trials, meta-analyses, systematic reviews and clinical studies), When expanding the search to encompass individual operation techniques, we identified 27 relevant articles. Results: Crucial surgical details include preserving the levator fascia, the puboprostatic collar, a long urethral stump with protection of the urethral lissosphincter and posteriorly reconstruction of the rectourethralis with the prostatovesical muscle. Fascial preservation for the M. Levator ani results to one year-continence between 78,0 and 98,3%, preservation of the puboprostatic collar and detrusor apron between 95,6 and 100%, maximal functional urethral length between 90,5 and 97,5%. Posterior reconstruction leads to a 3-months continence between 92,3 and 96,9%. Preserving the Retzius` space and thus the total anterior sphincter apparatus results to a one-year continence of 95,8%, however associated with a higher rate of positive surgical margins (14-42 vs. 10-29%). Conclusions: The increase of knowledge of the video-anatomy of the prostate and surrounding structures allows translation into novel surgical techniques of RALP. Thereby continence rates could be significantly improved including approaches to spare anatomical structures of the sphincter apparatus, such as preservation of the levator fascia, the puboprostatic collar, the urethral lissosphincter, but also reconstructive techniques, such as posterior reconstruction of the vesico-prostatic and recto-urethralis muscle. Demanding techniques, such as the Retzius-sparing approach result to higher continence rates, but are also associated with a higher rate of surgical margins.