Manual of Laparoscopic Urology

Alberto Rosenblatt
Renaud Bollens
Baldo Espinoza Cohen

Manual of
Laparoscopic
Urology
Foreword by Claude Schulman

With 334 Figures

123
 ISBN  978-3-540-74726-0
e-ISBN  978-3-540-74727-7

Library of Congress Control Number:

2007935176

© 2008 Springer-Verlag Berlin Heidelberg

Alberto Rosenblatt This work is subject to copyright. All rights are reserved, whether the
Albert Einstein Jewish Hospital (HIAE) whole or part of the material is concerned, specifically the rights of
Av. Albert Einstein, 627/701 translation, reprinting, reuse of illustrations, recitation, broad-cast-
São Paulo 05651-901 ing, reproduction on microfilm or any other way, and storage in data
banks. Duplication of this publication or parts thereof is permitted
Brazil
only under the provisions of the German Copyright Law of Septem-
albrose1@gmail.com
ber 9, 1965, in its current version, and permission for use must al-
ways be obtained from Springer. Violations are liable to prosecution
Renaud Bollens under the German Copyright Law.
Erasme Hospital
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1070 Brussels cific statement, that such names are exempt from the relevant pro-
Belgium tective laws and regulations and therefore free for general use.
renaud.bollens@ulb.ac.be
Product liability: the publishers cannot guarantee the accuracy of
any information about dosage and application contained in this
Baldo Espinoza Cohen
book. In every individual case the user must check such information
Hospital Clinico Regional de Antofagasta
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Effort only fully releases its reward
after a person refuses to quit.

Napoleon Hill

Foreword
Fellows from all over the world come to the Depart-
ment of Urology at the University Clinics of Brussels at
Erasme Hospital to learn or improve their skills in lapa-
roscopy, a very rapidly expanding new surgical approach
for most urological procedures traditionally performed
by open surgery.
The urologists, whether experienced or in training,
come to familiarise themselves with the different lapa-
roscopic procedures, but it can take quite a long time to
see all of the various procedures, and it can be especially
difficult to learn the numerous tips and tricks that are
used by expert laparoscopists.
The idea of writing a manual of laparoscopic urology
grew progressively during the fellowship of Dr. Alberto
Rosenblatt and Dr. Baldo Espinoza in our department
in 2006. Their main objective was to compile valuable
and difficult to find information and offer this instruc-
tive and well-illustrated material to the urologic com-
munity.
This manual was conceived in a very practical way
and highlights the step-by-step approach used in each
procedure. The text also calls attention to the “little de-
tails” that make all the difference when it comes to put-
ting the steps into practice.
Of course, every expert in laparoscopy or open sur-
gery has his own technique and his particular variety
of practical advice. The techniques that are illustrated
in this book are the standard ones used by Dr. Renaud
Bollens at Erasme Hospital and by the different mem-
bers of the department’s team under his expertise.
Essentially, this comprehensive Manual of Laparo-
scopic Urology is an expansion of personal notes that
should be extremely helpful to all of those interested in
learning this challenging surgical technique.
December 2007 Professor Claude Schulman
Brussels, Belgium

Preface
The excitement of moving into the field of laparoscopic
surgery can be quickly overshadowed by the realization
of how long it takes to acquire the skills needed to mas-
ter the technique. Indeed, laparoscopic surgery requires
a very good knowledge of anatomy as well as fairly good
manual dexterity. Skills can be developed by practicing
basic laparoscopic sutures in the “black box” or by train-
ing in a virtual environment, but it is only by performing
real laparoscopic operations that a surgeon can become
truly competent.
However, learning time can be reduced by gaining
an understanding of the small details and “tricks of the
trade” that laparoscopic experts utilize and that increas-
ingly facilitate the laparoscopic procedure.
The aim of this manual of urologic laparoscopy is
to provide urologists and surgeons who are willing to
master the techniques with a time-tested and reliable
source of practical information on laparoscopic surgery.
Although the focus of this manual is on urological pro-
cedures, plenty of valuable technical information that
can be applied to any laparoscopic specialty has been
included.
Like a mentor, this manual will guide the laparo-
scopic surgeon through every aspect of the laparo-
scopic procedure, from the equipment’s settings to the
correct positioning of the needle on the needle holder.
Every urologic procedure is described in a step-by-step
sequence of events, and the text is supplemented with
innumerous tips, colored illustrations, and high-defini-
tion pictures depicting the main steps.
By following this well-illustrated sequence of surgical
steps, readers can be confident in their ability to master
the laparoscopic technique.
August 2007 Alberto Rosenblatt, M.D.
São Paulo, Brazil
  

Contents

Section I Postoperative Considerations  . . . . . . . . . . . . . . . . .   48

S uggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   48
General Laparoscopic Information
Chapter 4
Chapter 1 Laparoscopic Assisted Transperitoneal
Fundamentals of Laparoscopic Surgery Nephroureterectomy
Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   3 Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   49
General Considerations  . . . . . . . . . . . . . . . . . . . . . . .   3 Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . .   49
Special Considerations  . . . . . . . . . . . . . . . . . . . . . . . .   6 Patient Positioning and Initial Preparation   .. . . .   50
Technical Considerations  .. . . . . . . . . . . . . . . . . . . . .   7 Trocars and Laparoscopic Instruments   . . . . . . . .   52
Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . . .   17 Access and Port Placement  .. . . . . . . . . . . . . . . . . . .   52
Access for the Lower Ureteral Dissection   . . . . . .   56
Surgical Technique   . . . . . . . . . . . . . . . . . . . . . . . . . .   56
Section II Postoperative Considerations  . . . . . . . . . . . . . . . . .   62
Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   62
Laparoscopic Surgery for Malignant
Urological Disorders Chapter 5
Extraperitoneal Laparoscopic Radical
Chapter 2 Prostatectomy
Transperitoneal Laparoscopic Radical Introduction   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   63
Nephrectomy Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . .   63
Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   21 Patient Positioning and Initial Preparation  . . . . .   64
Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . . .   21 Trocars and Laparoscopic Instruments   . . . . . . . .   65
Patient Positioning and Initial Preparation   .. . . . .   22 Access and Port Placement   .. . . . . . . . . . . . . . . . . .   65
Trocars and Laparoscopic Instruments   . . . . . . . . .   24 Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . .   73
Access and Port Placement  .. . . . . . . . . . . . . . . . . . . .   24 Postoperative Considerations  . . . . . . . . . . . . . . . . .   88
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . .   27 Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   89
Postoperative Considerations  . . . . . . . . . . . . . . . . . .   34
Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . . .   34 Chapter 6
Transperitoneal Laparoscopic Radical
Chapter 3 Prostatectomy
Transperitoneal Laparoscopic Partial Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   91
Nephrectomy Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . .   91
Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   35 Patient Positioning and Initial Preparation  . . . . .   92
Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . . .   35 Trocars and Laparoscopic Instruments   . . . . . . . .   93
Patient Positioning and Initial Preparation  . . . . . .   36 Access and Port Placement  .. . . . . . . . . . . . . . . . . . .   93
Trocars and Laparoscopic Instruments   . . . . . . . . .   37 Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . .   95
Access and Port Placement  .. . . . . . . . . . . . . . . . . . . .   37 Postoperative Considerations  . . . . . . . . . . . . . . . . .   113
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . .   41 Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   113
XII Contents  

Chapter 7 Patient Positioning and Initial Preparation   .. . . .   166

Laparoscopic Transperitoneal Radical  rocars and Laparoscopic Instruments  .. . . . . . . .
T   167
Cystectomy Access and Port Placement  .. . . . . . . . . . . . . . . . . . .   167
Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   115 Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . .   172
Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . .   115 Postoperative Considerations  . . . . . . . . . . . . . . . . .   178
Patient Positioning and Initial Preparation  . . . . .   116 Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   178
Trocars and Laparoscopic Instruments   . . . . . . . .   116
Access and Port Placement  .. . . . . . . . . . . . . . . . . . .   116 Chapter 11
Radical Cystectomy in the Male  . . . . . . . . . . . . . . .   119 Hand-Assisted Bilateral Laparoscopic
Radical Cystectomy in the Female  .. . . . . . . . . . . .   134 Intraperitoneal Nephrectomy
Postoperative Considerations  . . . . . . . . . . . . . . . . .   137 Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   179
Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   137 Indications  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   179
Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . .   179
Chapter 8 Patient Positioning and Initial Preparation  . . . . .   180
Laparoscopic Pelvic Lymph Node Dissection Trocars and Laparoscopic Instruments   . . . . . . . .   181
Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   139 Access and Port Placement  .. . . . . . . . . . . . . . . . . . .   181
Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . .   140 Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . .   184
Patient Positioning and Initial Preparation  . . . . .   140 Postoperative Considerations  . . . . . . . . . . . . . . . . .   186
Trocars and Laparoscopic Instruments   . . . . . . . .   140 Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   186
Access and Port Placement  .. . . . . . . . . . . . . . . . . . .   140
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . .   142 Chapter 12
Postoperative Considerations  . . . . . . . . . . . . . . . . .   148 Laparoscopic Promontory Fixation
Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   148 Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   187
Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . .   187
Patient Positioning and Initial Preparation  . . . . .   188
Section III Trocars and Laparoscopic Instruments   . . . . . . . .   188
Access and Port Placement  .. . . . . . . . . . . . . . . . . . .   189
Laparoscopic Surgery for Benign Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . .   191
Urological Disorders Postoperative Considerations  . . . . . . . . . . . . . . . . .   200
Schematic mesh position . . . . . . . . . . . . . . . . . . . . . .   201
Chapter 9 Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   201
Transperitoneal Laparoscopic Pyeloplasty
Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   153 Chapter 13
Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . .   153 Extraperitoneal Laparoscopic Prostatic
Patient Positioning and Initial Preparation   .. . . .   154 Adenomectomy
Trocars and Laparoscopic Instruments   . . . . . . . .   154 Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   203
Access and Port Placement  .. . . . . . . . . . . . . . . . . . .   155 Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . .   203
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . .   158 Patient Positioning and Initial Preparation  . . . . .   204
Postoperative Considerations  . . . . . . . . . . . . . . . . .   164 Trocars and Laparoscopic Instruments   . . . . . . . .   205
Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   164 Access and Port Placement  .. . . . . . . . . . . . . . . . . . .   206
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . .   206
Chapter 10 Postoperative Considerations  . . . . . . . . . . . . . . . . .   213
Transperitoneal Laparoscopic Donor Suggested Readings  . . . . . . . . . . . . . . . . . . . . . . . . . .   213
Nephrectomy
Introduction  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   165 Subject Index  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   215
Preoperative Preparation  . . . . . . . . . . . . . . . . . . . . .   165
Section I

General Laparoscopic
Information
 Chapter 1
Fundamentals
of Laparoscopic Surgery
Contents
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     3
 eneral Considerations  .. . . . . . . . . . . . . . . . . . . . . . . .     3
G since the laparoscope merged with the video camera
Physiologic Effects of Pneumoperitoneum   .. .     3
Pneumoperitoneum
and Potential Clinical Outcomes  .. . . . . . . . . . . . .     4
General Advantages of Laparoscopy  . . . . . . . . .     4
Laparoscopic Contraindications  .. . . . . . . . . . . . .     5
Special Considerations  . . . . . . . . . . . . . . . . . . . . . . . . .     6
Anesthesia Problems in Laparoscopic Surgery    6
Technical Considerations  . . . . . . . . . . . . . . . . . . . . . . .     7
Preinsufflation Checklist  . . . . . . . . . . . . . . . . . . . . .     7
I nsufflator Checklist   . . . . . . . . . . . . . . . . . . . . . . . . .     8
I nsufflator Tips  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .     8
Electrosurgical Unit Settings   .. . . . . . . . . . . . . . . .     9
I nstruments for Laparoscopic Surgery  .. . . . . . .    9
Veress Needle Introduction (Closed Access)    11
Technique of Laparoscopic Trocar
Introduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   13
Laparoscopic Suturing Techniques  . . . . . . . . . . .   15
Introduction
The use of laparoscopic surgery has rapidly expanded
in the mid-1980s. Since then, significant developments
of laparoscopic equipment and instruments have been
made. Along with the technology, surgical skills have
also improved with the incorporation of advanced lapa-
roscopic techniques, allowing surgeons to safely per-
form a multitude of laparoscopic interventions. Apart
from the state-of-the-art equipment and surgical ex-
pertise, laparoscopic procedures are usually technically
demanding, requiring well-trained operative teams and
good coordination with an anesthesiologist well versed
in laparoscopy. Putting everything to work in perfect
combination can make the difference between a safe,
efficient operation and a long, difficult procedure that
will increase the risk of perioperative and postoperative
complications.
General Considerations
Physiologic Effects of Pneumoperitoneum
Carbon dioxide (CO2) is the gas commonly used for in-
flating the abdomen. Once inside the abdominal space,
it is rapidly absorbed across the peritoneal membrane
into the circulatory system. In the blood, carbonic acid
is produced leading to respiratory acidosis, but this con-
dition is attenuated due to the absorption of the CO2 by
body buffers. However, during long laparoscopic pro-
cedures, body buffers become saturated and hypercap-
nia or respiratory acidosis develops. At this point, the
lungs become responsible for the absorption and release
of CO2 from the body buffers. Although this condition
 Section I
can be corrected by the anesthesiologist, the associated
effects of pneumoperitoneum pressure on the different
organ systems can potentiate significant clinical distur-
bances (see Pneumoperitoneum and Potential Clinical
Outcomes).
The pressure effects of pneumoperitoneum:
• Increases intra-abdominal pressure
• Decreases cardiac output and stroke volume
• Decreases femoral venous blood flow and venous re-
turn
• Reduces renal perfusion and intraoperative urine
output
• Decreases respiratory compliance and increases air-
way pressure
• Increases intracranial pressure
 neumoperitoneum
P • D
and Potential Clinical Outcomes
Pulmonary System
• H igh peak airway pressures leading to an increased
risk of barotrauma and/or pneumothorax
• Superior displacement of the diaphragm leading to
an increase in Pco2 and/or a decrease in Po2 levels
• Decreased pulmonary compliance and vital capacity
leading to an increase in Pco2 and/or a decrease in
Po2 levels
Circulatory System
• I ncreased central venous pressure, systemic vascular
resistance, capillary wedge pressure, and mean arte-
rial pressure leading to an increase in cardiac work
• Indirect effects on the sympathetic system, renin–an-
giotensin system, and vasopressin leading to an in-
crease in blood pressure and cardiac output
• Indirect effects of hypercapnia, such as arteriolar
dilation and myocardial depression leading to a de-
crease in blood pressure
• Vasovagal response caused by a rapid stretch of the
peritoneum leading to bradycardia and occasionally
a decrease in blood pressure
General Laparoscopic Information
• C
 oagulation disturbances, such as lower extrem-
ity venous stasis leading to deep venous thrombosis
(DVT) and pulmonary embolism (PE)
Renal System
• R educed renal blood flow and glomerular filtration
rate leading to a diminished urine output (direct
pressure on kidney and renal vein)
• Increased release of renin with sodium retention
• Release of antidiuretic hormone (ADH), increasing
water reabsorption in the distal tubules
Gastrointestinal System
 ecreased sympathetic response leading to less ileus
paralyticus
Central Nervous System
• I ncreased intracranial pressure leading to reduced
central perfusion pressure
Immunologic System
• L ess pronounced immune suppression
• Fast return of cytokine levels to normal values
General Advantages of Laparoscopy
• S mall incision
• Minimal pain
• Attenuated stress response
• Earlier return to ambulation
• Reduced hospital stay
• Fast recovery
 Chapter 1 Fundamentals of Laparoscopic Surgery 

Laparoscopic Contraindications General Complications 

of Laparoscopy
Intraperitoneal Access
Injury to Adjacent Organs
Absolute Contraindications
• Bowel puncture (see Veress Needle Introduction)
•  cute peritonitis
A •  owel wall thermal injury
B
• Severe chronic pulmonary obstructive disease • Bleeding from solid organs (liver and spleen)
• Congestive heart failure • Bladder perforation
• Abdominal wall infections • Uterus puncture
• Bleeding diatheses
• Intestinal obstruction
• Malignant ascites Vascular Injuries
• Acute glaucoma
• Increased cranial pressure • Abdominal wall vessels
• Ventriculoperitoneal and peritoneojugular shunts (in­
creased CO2 absorption and acidosis) TIP

An injury to the abdominal wall vessels is usu-

Relative Contraindications
• S evere chronic pulmonary obstructive disease
• Extensive prior abdominal surgery
• Aneurysms of the aorta or iliac arteries
• Intestinal obstruction
• Pelvic fibrosis (previous radiation therapy and previ-
ous hip replacement surgery due to sealant leakage)
• Organomegaly
• Severe diaphragmatic hernia (risk of CO2 leakage
into the mediastinum)
• Pregnancy
• Intra-abdominal large and small vessels
ally visible as blood dripping from one of the tro-
cars and/or blood seen on the surface of abdomi-
nal structures. The usual cause of the bleeding is
an iatrogenic injury to the inferior epigastric ar-
tery or one of its branches. The bleeding can be
controlled with the application of direct pressure
using the involved trocar, coagulation of the ves-
sel with the bipolar grasper, or a laparoscopic-
guided or open suture ligation tied over a gauze
bolster to tamponade the bleeding site.

Extraperitoneal Access TIP

Relative Contraindications The right common iliac artery lies directly below
the umbilicus. (see Veress Needle Introduction)
• P rior lower abdominal surgery
• Prior pelvic surgery
• Prior inguinal hernia surgical repair

Access Complications

• P ort site hernia

• Wound infection
 Section I
• Port site seeding of tumor cells
Pneumoperitoneum Complications
•  neumothorax
P
• Pneumomediastinum
• Subcutaneous emphysema
• Gas embolus
Special Considerations
Anesthesia Problems 
in Laparoscopic Surgery
Trendelenburg Position
• I ncreases intracranial and intraocular pressures,
which may lead to cerebral edema, retinal detach-
ment, and even blindness (especially the long-lasting
extreme head-down position for pelvic and lower ab-
dominal procedures)
• Increases intrathoracic pressure, central venous pres-
sure, capillary wedge pressure, and mean arterial
pressure leading to an increase in cardiac work
• Increases venous return, which in combination with
pneumoperitoneum may lead to congestive heart
failure and even acute myocardial infarction
Hypercapnia
When hypercapnia occurs:
• Reduce the intra-abdominal pressure or stop the pro-
cedure until Pco2 decreases
• Decrease the angle of the Trendelenburg position
• Increase the minute volume of ventilation
General Laparoscopic Information
TIP
To avoid the risk of subcutaneous emphysema
and hypercapnia, never suture the skin around
the trocar when fixing it.
CO2 Embolism
Usually occurs due to misplacement of the Veress nee-
dle:
• Into a vessel
• Into a parenchymal organ (mainly the liver)
• Hypovolemia is a risk factor
Signs of CO2 Embolism
•  rofound hypotension
P
• Cyanosis
• Arrhythmias
• Asystole
• Immediate increase of end-tidal CO2 accompanied
by a sudden decline in oxygen saturation and then a
marked decrease in end-tidal CO2 due to cardiovas-
cular collapse
When a CO2 embolism is suspected, the following meas­
ures must be taken immediately:
• Stop insufflation and deflate the pneumoperitoneum
• Place the patient in a left lateral head-down position
(this will enable the gas embolus to move into the
right ventricular apex, preventing its entry into the
pulmonary artery)
• Increase minute ventilation and 100% in-tidal O2 ad-
ministration
• Introduce a central venous catheter to enable aspira-
tion of the gas
• Administer cardiopulmonary resuscitation in case of
asystole
• Administer hyperbaric oxygen therapy, if available
 Chapter 1
TIP
Most cases of suspected gas embolism will resolve
with the first two measures above.
Recovery Period
Extended postoperative mechanical ventilation may
sometimes be needed until all extra CO2 has been elimi-
nated:
• Following prolonged laparoscopic procedures
• When high intra-abdominal insufflation pressure is
applied
• When extensive subcutaneous emphysema is present
Urine output must be carefully controlled:
• Following prolonged laparoscopic procedures
• When high intra-abdominal insufflation pressure is
applied
Postoperative Nausea and Vomiting
Etiology
• M echanical pressure to gut and stomach
• Stretching of vagal nerve endings in the peritoneum
• Vasodilatation of the cerebral vessels by CO2, conse-
quently raising the intracranial pressure
Prophylaxis
• A ntiemetics
• Ondansetron, 4 mg administered intravenously just
before the end of surgery
• Dexamethasone in combination with Ondansetron
to extend the duration of antiemesis
Pain Management
• Evacuation of residual gas before trocar removal
• Opioid analgesia
• Local anesthetic infiltration of port sites
Fundamentals of Laparoscopic Surgery 
• Preemptive analgesia
Technical Considerations
Preinsufflation Checklist
• C O2 tank is full or an extra tank is available
• Gas valve on the cylinder is open
• Laparoscopic tower is switched on and equipment is
operational
• Insufflator is operational and settings are correct (see
Insufflator Checklist)
• In-line filter is connected between insufflator and in-
sufflation tubing
• Electrosurgical unit is operational and settings are
correct
• Instruments are compatible with electrocautery and
adequately insulated
• Bipolar and monopolar scissor pedals are connected
and operational
• Laparoscope image is white balanced
• Suction device is operational (suction and irrigation
tubing are connected and working)
• Veress needle tip retracts properly
F ig . 1
Insufflator settings
 Section I General Laparoscopic Information

• An extra pair of scissors is available

Insufflator Checklist

• M aximum pressure on the insufflator is set to

12 mmHg
• Pressure is set according to the following:
– Initiate with high pressure when performing an
extraperitoneal laparoscopic radical prostatec-
tomy or when using the open access technique
– Initiate with low pressure when using the Veress
needle (closed access) technique
• CO2 flow rate is set to 35 L/min (Fig. 1)
F ig . 2
• Safety valve pressure is set to 35 mmHg
Electrosurgical unit

Insufflator Tips

• I ntra-abdominal pressure for safe trocar introduction

should be equal to or higher than 10 mmHg.

TIP

Pressure is the most important parameter.

• I ntra-abdominal volume for safe trocar introduction

should be equal to or higher than 2.5 L.

F ig . 3
Instruments for laparoscopic surgery

F ig . 4 F ig . 5
Bipolar grasper Ethicon™ clip applier (10 mm) and clips
 Chapter 1 Fundamentals of Laparoscopic Surgery 

F ig . 6
a LigaSure™ 5 mm (Tyco Healthcare). b LigaSure at bladder pedicle

TIP

Misconnecting the insufflation line to the Ver-

ess needle can cause the gas to leak, resulting in
false readings.

Electrosurgical Unit Settings

•  onopolar Coagulation set to 50 Watts (Fig. 2)

M
• Cutting set to 0
• Bipolar Coagulation set to 50 Watts
• Auto stop set to Off

Instruments for Laparoscopic Surgery

Basic Instruments (see Fig. 3)

• N eedle holder F ig . 7
• Bipolar grasper (Fig. 4) a Multifire Endo GIA™ 30 12-mm stapler. b Endo GIA sta-
• Monopolar scissors pling renal vein
10 Section I General Laparoscopic Information

F ig . 8
a Endo Catch II 15 mm (Autosuture). b Renal vein (A); V. cava (B); Right renal artery (C); Kidney inside Endobag (D)

• Graspers

Other Instruments for Vessel and Tissue Ligation

• C
 lip applier forceps (non-disposable) (Fig. 5)
• Laparoscopic sealer/divider instrument

TIP

™
The LigaSure 5 mm (Tyco Healthcare) has a
small tip suitable for tissue dissection, and the
sealing and dividing function is hand-controlled.
(Fig. 6a,b)

• E
 ndo GIA ™ 30 12-mm stapler (Autosuture) (Fig.
7a,b)

Specimen Retrieval Device

• Endobag (Fig. 8a,b)

F ig . 9
a Laparoscopic instruments/trocars for radical prostatec-
tomy. b Laparoscopic instruments/trocars for promontory
fixation
 Chapter 1
F ig . 1 0
Disposable Veress needle
Laparoscopic Instruments Table (see Fig. 9a,b)
 eress Needle Introduction 
V sound can often be heard, meaning the blunt tip
(Closed Access)
The Veress needle can be disposable or reusable
(Fig. 10).
The blunt tip of the needle retracts when it is pressed
against a tough structure, exposing its sharp edge. Af-
ter the needle passes through the abdominal wall lay-
ers, the blunt tip is deployed, preventing damage to the
abdominal structures. The CO2 gas for the abdominal
insufflation passes through the hollow cannula of the
Veress needle.
TIP
The maximum flow through the needle is 0.2 L/
min due to its internal diameter.
While introducing the needle, it is important to feel it
passing through the layers of the abdominal wall. The
initial thrust is at the level of the external oblique/rectus
fascia, followed by the transversalis fascia and perito-
neum.
Fundamentals of Laparoscopic Surgery 11
F ig . 1 1
Veress needle introduction
TIP
As the needle enters the peritoneal cavity, a click
has sprung forward.
It is preferable to avoid introduction of the Veress needle
in the vicinity of a previous abdominal scar.
TIP
When bowel adhesions are suspected, the Ver-
ess needle is not used, and the fascia is opened
under direct vision (i.e., open access); the perito-
neum should be digitally entered and the adhe-
sions carefully released with gentle digital move-
ments.
Introduction Technique 
for Pelvic Laparoscopic Procedures
A subumbilical incision is made 50% larger than the di-
ameter of the trocar that will be inserted. The abdominal
12 Section I
wall is elevated by manually grasping the skin and sub-
cutaneous tissue (Fig. 11).
The Veress needle is grasped by the shaft like a dart and
then passed into the incision perpendicularly to the ab-
dominal wall. Following introduction, two tests are per-
formed in sequence to confirm that the needle is inside
the peritoneal cavity (Fig. 12).
F ig . 1 2
Syringe is connected to Veress needle
F ig . 1 3
a Subcostal incision. b Needle introduction through the incision
General Laparoscopic Information
1. Initially, a 20-mL syringe is connected to the needle,
and the plunger is drawn out to test for the presence
of air or blood. If blood is aspirated, a vessel was
punctured and conversion to open surgery should
be done without removal of the Veress needle. In the
case that gas and/or a yellow or cloudy fluid are as-
pirated, the needle is placed inside the lumen of the
bowel. The needle is then removed and replaced in
the correct position. The optic is reintroduced, and
the puncture of the bowel must be found and lapa-
roscopically repaired. In this particular situation,
a prosthesis should not be placed due to the risk of
bacterial contamination.
2. Then, the syringe is filled with 20 mL of air. It is re-
connected to the Veress needle, the air is injected, and
the plunger is drawn out to test for the presence of air.
No air should return to the syringe (if air returns, the
needle is placed in a closed location and most prob-
ably in the preperitoneal space). The insufflation tub-
ing is connected to the Veress needle, the stopcock
is opened, and the abdomen is insufflated. Initiating
with a low flow is recommended to avoid damage to
a vital structure in case the needle is mispositioned.
Switch to high flow if the intra-abdominal pressure
is low and the insufflation pressure is increasing at a
steady and normal level along with a tympanic per-
cussion of the liver area. Then, the needle is removed
and the primary trocar is introduced perpendicularly
to the abdominal wall.
 Chapter 1
F ig . 1 4
Disposable blunt tip and reusable trocars
Introduction Technique 
for Upper Tract Laparoscopic Procedures
A cutaneous incision is made 50% larger than the diam­
eter of the trocar that will be inserted. This is done two
fingerbreadths below the costal margin arch, at the level
of the lateral border of the rectus muscle. The abdomi-
nal wall is elevated by manually grasping the skin and
subcutaneous tissue, and the Veress needle is introduced
through the incision (Fig. 13a,b).
The Veress needle must be introduced perpendicu-
larly to the plane of the patient
TIP
For the right side, the needle can be introduced
at an angle of 30° caudally to the abdominal
wall to avoid liver puncture.
After introduction, the procedures to confirm the cor-
rect placement of the needle are the same as for the pel-
vic laparoscopic surgery.
Fundamentals of Laparoscopic Surgery 13
Technique 
of Laparoscopic Trocar Introduction
Types of Trocars
Trocars can be disposable or reusable and are available
in different sizes (2 mm, 5 mm, 10 mm, 12 mm, and
15 mm). The obturator tip may be bladed or blunt, and
the blunt tip may be associated with a lower incidence
of injury to intraperitoneal structures and vessels of the
abdominal wall (Fig. 14).
TIP
Always check for a sharp tip on reusable trocars;
unsharpened tips will result in a forceful thrust,
increasing the risk of vessel or organ injury dur-
ing laparoscopic access.
At the end of the laparoscopic procedure, the aponeu-
rosis of trocar sites 10 mm or larger should be closed to
avoid the occurrence of incisional hernias. The risk of
hernias may be reduced by the utilization of the blunt
tip trocar.
Trocar Positioning
The primary camera port preferably should be in line
with the structure of interest (for example, the renal hi-
lum during a laparoscopic nephrectomy), and at a 45°
angle to the area of interest. The working ports (right
and left hand) should be on either side of the camera
port and at an adequate distance from each other and
from the camera, preventing the crossing of the instru-
ments. The smaller diameter trocar is usually positioned
at the surgeon’s dominant hand side, and the larger
trocar is for the nondominant one. This is to prevent
instrument shaking while performing sensitive tasks,
which are usually exerted by the dominant hand. The
secondary trocar placement site is marked by pressing
a finger on the abdominal wall, and the indentation is
internally viewed with the optic, allowing the insertion
of all secondary trocars under direct laparoscopic visu-
alization.
14 Section I General Laparoscopic Information

F ig . 1 5
a Trocar introduction (see middle finger position). b Trocar introduction

F ig . 1 6 F ig . 1 7
The thread is straightened out Half loop open with both needle holders in close proximity
 Chapter 1 Fundamentals of Laparoscopic Surgery 15

F ig . 1 8
a Left needle holder advances. b Right needle holder moves out of the loop

Trocar Introduction
Pneumoperitoneum should be adequate. The skin inci-
sion is made 50% larger than the diameter of the trocar.
The trocar is firmly grasped against the palm of the hand
to arm the device; the middle finger is extended for fur-
ther insertion control, and the trocar is introduced with
a firm and constant screwing motion (Fig. 15a,b).
The trocar should be inserted perpendicularly to the
abdominal wall, and the insertion angle can be changed
as soon as the tip pierces the peritoneum.
Following trocar placement and obturator removal,
the trocar valve is briefly opened to check for egress of
gas, confirming it is correctly placed inside the abdomen.
The insufflator line is then connected to the trocar.
• Th
 e axis of the thread is kept perpendicular to the
left needle holder to facilitate loop construction
(Fig. 16).
• A half loop is made.
• The left needle holder stays in close proximity to the
right one to keep the loop opened (Fig. 17).
• The left needle holder advances forward, and the
right needle holder moves out of the half loop (Fig.
18a,b).

Laparoscopic Suturing Techniques

Basic Suturing

• Th
 e left needle holder grasps the thread.
• The thread is straightened out by pulling with the
right needle holder.
F ig . 1 9
Left needle holder grabs the open loop
16 Section I General Laparoscopic Information

F ig . 2 0 F ig . 2 1
The knot is closed Left needle holder swiftly grabs proximal thread

• Th
 e knot is completed by advancing the right needle
holder forward, and the left needle holder pulls in to-
ward the trocar.

TIP

To avoid intra-abdominal injures, never pull the

thread by the needle.

Advanced Suturing

• W hen the first knot loosens, the left needle holder

F ig . 2 2
grabs the open loop, and the right needle holder
Threads are pulled out, and the knot is tied
grabs the distal thread (Fig. 19).
• The left needle holder gently pulls the loop to close
the knot (Fig. 20).
TIP • The left needle holder swiftly grabs the proximal
thread while the right needle holder keeps the distal
Do not pull with the right needle holder before thread tensioned (Fig. 21).
the second knot is tied to avoid loosening the • Both thread ends are pulled out to tie the knot (Fig.
knot. 22).
 Chapter 1
Suggested Readings
1. Sriprasad S, Yu DF: Positional anatomy of vessels that may
be damaged at laparoscopy: new access criteria based on
CT and ultrasonography to avoid vascular injury. J Endou-
rol 2006 Jul; 20(7):498–503.
2. Hamade AM, Butt I: Closed blunt-trocar 5 mm-port for
primary cannulation in laparoscopic surgery: a safe tech-
nique. Surg Laparosc Endosc Percutan Tech 2006 Jun;
16(3):156–160.
3. Jean JMCH de la Rosette, Inderbir SG: Laparoscopic Uro-
logic Surgery in Malignancies. Springer, 2005.
4. Saber AA, Meslemani AM: Safety zones for anterior ab-
dominal wall entry during laparoscopy: a CT scan mapping
of epigastric vessels. Ann Surg 2004 Feb; 239(2):182–185.
5. Shalhav AL, Barret E: Transperitoneal laparoscopic renal
surgery using blunt 12-mm trocar without fascial closure.
J Endourol 2002 Feb; 16(1):43–46.
6. Rist M, Hemmerling TM: Influence of pneumoperitoneum
and patient positioning on preload and splanchnic blood
Fundamentals of Laparoscopic Surgery 17
volume in laparoscopic surgery of the lower abdomen.
J Clin Anesth 2001; 13:244–249.
7. Philips PA, Amaral JF: Abdominal access complications in
laparoscopic surgery. J Am Coll Surg 2001; 19:525–536.
8. Odeberg-Wernerman S: Laparoscopic surgery – effects on
circulatory and respiratory physiology: an overview. Eur J
Surg Suppl 2000; 585:4–11.
9. Kashtan J, Green JF: Hemodynamic effects of increased ab-
dominal pressure. J Surg Res 1981; 30:249–255.
10. Chapron CM, Pierre F: Major vascular injuries during gy-
necologic laparoscopy. J Am Coll Surg 1997; 185:461–465.
11. Riza ED, Deshmukh AS: An improved method of securing
abdominal wall bleeders during laparoscopy. J Laparoen-
dosc Surg 1995; 5:37–40.
12. Vasquez JM: Vascular complications of laparoscopic sur-
gery. J Am Assoc Gynecol Laparosc 1994; 1:163–167.
13. Loris J: Anesthetic Management of Laparoscopy, 4th ed..
New York, Churchill Livingstone, 1994.
Section II

Laparoscopic Surgery
for Malignant Urological
Disorders
 Chapter 2
Transperitoneal
Laparoscopic Radical
Nephrectomy
Contents
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   21
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . . .  
P 21
Patient Positioning and Initial Preparation   . . . .   22
Trocars and Laparoscopic Instruments   .. . . . . . . .   24
Access and Port Placement  . . . . . . . . . . . . . . . . . . . . .   24
Veress Needle  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   25
First Port (11 mm, optic 0°)  . . . . . . . . . . . . . . . . . . .   25
S econd Port (5 mm, monopolar round-tipped
scissors)  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   26
Third Port (11 mm, bipolar grasper)  . . . . . . . . . .   27
Fourth Port (5 mm, suction device)  .. . . . . . . . . .   27
Fifth Port (5 mm, liver retractor grasper)  .. . . . .   27
Final Position of the Ports (see Figs. 8 and 9)    27
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .   27
Colon Mobilization  .. . . . . . . . . . . . . . . . . . . . . . . . . .   27
Ureter and Gonadal Vessels Identification  . . . .   28
Exposure and Dissection of the Renal Hilum    30
Renal Hilum Ligature and Transection  .. . . . . . .   32
M obilization of the Kidney and Adrenal Gland    32
Transection of the Ureter   . . . . . . . . . . . . . . . . . . . .   33
K idney Extraction   .. . . . . . . . . . . . . . . . . . . . . . . . . . .   33
Closure of the Abdominal Wall  . . . . . . . . . . . . . . .   33
Postoperative Considerations  . . . . . . . . . . . . . . . . . .   34
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . . .   34
Introduction
Laparoscopic radical nephrectomy (LRN) is the sur-
gical treatment of choice for patients presenting with
early stage (T1) renal cell carcinoma. The laparoscopic
approach has many advantages compared with open
radical nephrectomy, including decreased blood loss,
less pain, faster postoperative recovery, and improved
cosmetics. Furthermore, this minimally invasive ap-
proach parallels the open technique in oncologic effi-
cacy. The laparoscopic procedure has been increasingly
used for higher stage tumors even though the use of the
technique on large tumors has not yet been proved safe.
Urologic surgeons with advanced laparoscopic skills are
now able to manage highly selected patients with locally
advanced disease and tumors with renal vein or vena
cava thrombi. For selected kidney tumors less than 4 cm,
current trends in organ preservation favor laparoscopic
partial nephrectomy (see Chap. 3).
Preoperative Preparation
Before a patient consents to a laparoscopic nephrectomy,
it is important to discuss the specific risks of the surgery,
including the potential need to convert to the traditional
open operation if difficulties arise.
The patient is admitted to the hospital the day before
the surgery for bowel preparation, which includes 2 L
®
of Colopeg (1 envelope/L) p.o. and a Fleet enema. ®
Fasting starts at midnight before surgery. Thrombo-
prophylaxis protocol is implemented with good hydra-
tion, placement of compressive elastic stockings on the
lower extremities, and low-molecular-weight heparin.
® ®
Enoxaparin (Clexane , Lovenox ) 40 mg sc 1 × day or
® ®
nadroparin (Flaxiparine , Fraxiparin ) 0.6 mL sc 1 ×
22 Section II
day is initiated on day 1 after the surgery and continued
daily until the patient is discharged from the hospital.
In selected cases, the treatment is continued for 30 days
after the procedure. Patients also receive antibiotic pro-
phylaxis with a single preoperative dose of intravenous
second-generation cephalosporin, unless they are aller-
gic to penicillin. Blood type and crossmatch are deter-
mined.
Patient Positioning and Initial Preparation
The patient is initially positioned supine for intravenous
access, induction of general anesthesia, and endotra-
cheal intubation. An orogastric tube is placed and the
stomach decompressed to avoid puncture during trocar
placement and to allow additional space during abdom-
inal insufflation. An 18Fr Foley catheter with 10 mL in
the balloon is introduced for decompression of the blad-
der. During skin preparation, the entire flank and abdo-
men are included in case conversion to an open proce-
dure is required. The umbilicus is placed over the break
in the operating table, and the patient is positioned in a
modified lateral decubitus position.
Fig. 1
a Patient position. b Padding
Laparoscopic Surgery for Malignant Urological Disorders
TIP
For a left-side nephrectomy, the patient is placed
in a strict lateral decubitus position.
The table can be flexed as needed, or an inflatable bal-
loon is positioned under the patient at the level of the
umbilicus. Padding is used to support the buttocks and
dorsum, and all potential pressure points are cushioned.
An axillary roll is placed to prevent brachial plexus in-
jury, and the arms should be positioned as far away from
the trunk as possible so as not to disturb the movement
of the operative team. The patient is held in position
with strips of cloth tape (Fig. 1a,b).
The surgeon operates from the abdominal side of the
patient, and the first assistant is placed caudally to the
surgeon. The laparoscopic cart is positioned at the back
of the patient’s chest with the operative team facing the
video monitor. The instruments table is positioned be-
hind the operative team, and the assistant is positioned
higher than the surgeon to prevent the laparoscopic in-
struments from conflicting (Fig. 2a–d).
 Chapter 2 Transperitoneal Laparoscopic Radical Nephrectomy 23

Fig. 2
a Patient and laparoscopic cart. b Steps below assistant.
c Instruments table behind operative team. d Operative
team’s position
24 Section II Laparoscopic Surgery for Malignant Urological Disorders

Trocars and Laparoscopic Instruments Access and Port Placement

Right-side nephrectomy:
• 2 × 11 mm (optic 0° and bipolar grasper)
• 3 × 5 mm (monopolar scissors, suction device, and
liver retractor grasper)
Left-side nephrectomy:
• 2 × 11 mm (optic 0°, bipolar grasper, and 10-mm clip
applier)
• 2 × 5 mm (scissors and suction device)
• Monopolar round-tipped scissors, bipolar grasper,
liver retractor grasper, 5-mm suction device, 10-mm
clip applier (non-disposable), needle drivers (2), and
10-mm laparoscopic optic 0°
Four ports are generally enough to perform the proce-
dure, although a fifth trocar may be necessary for liver
retraction during a right-side nephrectomy (Fig. 3). Be-
fore trocars are placed, the abdomen is insufflated using
a Veress needle.
TIP
In case of previous surgery, the Veress needle is
not inserted, and the open access technique is
used to place the first trocar.

Fig. 3
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)
 Chapter 2 Transperitoneal Laparoscopic Radical Nephrectomy 25

Fig. 4
a Cutaneous incision below costal margin. b Insertion of Veress needle

Veress Needle TIP

A cutaneous incision is made two fingerbreadths below Pneumoperitoneum is established with an intra-
the costal margin arch, at the level of the lateral border abdominal pressure higher than 10 mmHg.
of the rectus muscle (Fig. 4a,b).

TIP

The skin incision should be 50% larger than the

diameter of the 11-mm trocar.

The Veress needle is introduced through the incision

(see Chap. 1, Veress Needle Introduction).

First Port (11 mm, optic 0°)

Once pneumoperitoneum is established, the Veress

needle is removed, and the 11-mm trocar is introduced
Fig. 5
through the same incision, perpendicularly to the ab-
Perpendicular introduction of the trocar
dominal wall (Fig. 5).
26 Section II Laparoscopic Surgery for Malignant Urological Disorders

The optic is introduced through the trocar, and the TIP

abdomen is then inspected for any injury due to inser-
tion of the Veress needle or the trocar, and to identify To prevent lens fogging, insert the distal end of
adhesions in areas where the secondary ports will be the optic into warm sterile water or saline before
placed. intra-abdominal optic introduction.

TIP

After trocar placement and obturator removal,

the trocar valve is briefly opened to check for
egress of gas, confirming it is correctly placed
inside the abdomen. The insufflator line is then
connected to the trocar.

Second Port (5 mm, 

monopolar round-tipped scissors)

The triangulation rule must be followed for the place-

ment of the trocars as the body habitus is different for
each patient: four fingerbreadths between the optic trocar
Fig. 6
and the working trocars (Fig. 6), and five fingerbreadths
Triangulation rule, four fingers
between the working trocars (Fig. 7a,b).

Fig. 7
a Triangulation rule, five fingers. b Ports in place
 Chapter 2 Transperitoneal Laparoscopic Radical Nephrectomy 27

T ip

The 5-mm port is usually reserved for the most

skilled hand, as the movements of the working
instruments must be more precise inside the
smaller ports.

Third Port (11 mm, bipolar grasper)

The triangulation rule must be followed as above.

Fig. 8
Fourth Port (5 mm, suction device)
Right-side ports

For the introduction of the 5-mm trocar, a cutaneous

incision is made approximately midline between the
umbilicus trocar and the anterior superior iliac spine on
the side of the procedure.

Fifth Port (5 mm, liver retractor grasper)

If liver retraction is necessary during a right-side ne-

phrectomy, a cutaneous incision is made approximately
two fingerbreadths below the level of the second port,
and a 5-mm port is introduced (Fig. 8).

Final Position of the Ports (see Figs. 8 and 9)

Fig. 9
Left-side ports
Surgical Technique

Colon Mobilization TIP

For a left-side nephrectomy, the plane between the The lateral attachments of Gerota’s fascia to the
descending colon and the underlying Gerota’s fascia abdominal wall should not be freed at this time
is developed to allow the colon to fall medially (Fig. to avoid the kidney falling medially into the op-
10a–c). erating field.
28 Section II
This plane of dissection is carried out cranially. The
splenorenal and lienocolic ligaments are incised, allow-
ing the spleen and the tail of the pancreas to be sepa-
rated from the upper pole of the kidney. The en bloc
dissection of the colon, spleen, and pancreas must be
completed for adequate exposure of the renal vein (Fig.
11a,b).
For a right-side nephrectomy, the liver is cranially re-
tracted using a grasper that is fixed to the abdominal
wall (Fig. 12). The ascending colon is mobilized and dis-
sected from the underlying Gerota’s fascia. Mobilization
of the colon continues caudally to the common iliac ves-
sels.
Laparoscopic Surgery for Malignant Urological Disorders
Fig. 10
a Colon attachments to abdominal wall. b Release of colon
attachments to abdominal wall. c Colon is dissected from
Gerota’s fascia (Gerota is not freed from abdominal wall)
Ureter and Gonadal Vessels Identification
Following the medial mobilization of the colon and me-
socolon, the gonadal vessels are visualized. After the co-
lon is medially retracted, the Gerota’s fatty tissue at the
level of the lower pole of the kidney is incised and lifted
to locate the psoas muscle (Fig. 13).
TIP
The correct maneuver to expose the psoas muscle
is the continuous upper movement of the laparo-
scopic instruments to lift the fatty tissue.
 Chapter 2 Transperitoneal Laparoscopic Radical Nephrectomy 29

Fig. 11
a Spleen is released from kidney. b En bloc spleen dissection

Fig. 12 Fig. 13
Grasper retracting liver Lifting of fatty tissue to expose psoas muscle

The psoas is followed to expose the ureter just lateral sels are not divided at this time. Both structures are
and deep to the gonadal vessels. lifted and, by visualization of the psoas muscle (Fig.
Caudally, the ureter is dissected and freed until the 14a,b), followed cranially to the lower pole and hilum of
crossing of the iliac vessels. The ureter and gonadal ves- the kidney (Fig. 15a,b).
30 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 14
a Dissection of ureter and gonadal vessels. b Psoas muscle

Fig. 15
a Psoas is followed cranially to hilum. b Ureter and gonadal vessels approaching renal hilum

The dissection of the right gonadal vein is not nec-
essary, as it enters the vena cava on this side. Attach-
ments between the psoas muscle and Gerota’s fascia are
released by sharp and blunt dissection, and small vessels
to the ureter and branches of the gonadal vein are co-
agulated with the bipolar grasper.
Exposure and Dissection of the Renal Hilum
On the left, tracking the course of the left gonadal vein
into the renal vein and firm elevation of the lower pole
of the kidney on both sides assists in the identification
and blunt dissection of the renal hilum.
 Chapter 2 Transperitoneal Laparoscopic Radical Nephrectomy 31

Fig. 16
a Renal hilum exposed. b Dissection of renal vessels

Fig. 17
a Left adrenal vein (Adr); Gonadal vein (Gon). b Renal vein (V); Renal artery (A)

The renal vessels should be individually dissected (Fig. TIP

16a,b).
The renal vein is dissected, taking care with the lum-
bar veins that drain posterior to the vessel (Fig. 17a,b).
The left adrenal vein is preserved if the ipsilateral adre-
nal gland is not removed.
Dissection of the right renal vein is usually less
demanding as lumbar veins are normally absent
at this side.
32 Section II
Fig. 18
a Renal artery posterior to renal vein. b Dissection of the renal artery
The renal artery is exposed posterior to the renal vein
and dissected (Fig. 18a,b).
Renal Hilum Ligature and Transection
®
Hem-o-lok polymer clips (Weck, Teleflex Medical) are
applied to the artery.
TIP
One extra-large (XL) clip secures the renal ar-
tery before the renal vein is clipped.
Three clips (XL Hem-o-lok) are used on the renal vein,
which is then carefully transected.
TIP
The renal vein should be flat after the renal ar-
tery clip is placed; if the vein is still filling, an-
other renal artery should be located.
Laparoscopic Surgery for Malignant Urological Disorders
Following division of the renal vein, clipping of the renal
artery is completed (3 XL Hem-o-lok clips), and the ves-
sel is then transected.
Mobilization of the Kidney and Adrenal Gland
Once all the hilar vessels have been divided, the dissec-
tion continues posteriorly and superiorly to the upper
pole. The attachments of the kidney to the posterior
and lateral abdominal wall are released by blunt and
sharp dissection, taking care to coagulate the bleeding
vessels. The adrenal gland can be preserved in a simple
nephrectomy and particular cases of mid- and lower-
pole tumors, but otherwise are removed intact with
the specimen. This is accomplished by incising Gerota’s
fascia anteriorly just above the hilum (Fig. 19). Gerota’s
fascia is then gently peeled off circumferentially above
the upper pole of the kidney. At this point during the
dissection, care must be taken with the short adrenal
vein on the right side that drains posterolateral into the
vena cava. On the right, superior retraction of the liver
facilitates the dissection of the plane between the liver
and the upper pole of the kidney (Fig. 20).
 Chapter 2
Fig. 19
Left adrenal vein (A); Left renal vein (B); Gonadal vein (C)
Transection of the Ureter
Inferiorly, the ureter is double-clipped with (L) Hem-o-
®
lok clips and transected to allow the kidney to be fully
mobilized. This facilitates the dissection and incision of
the lateroposterior and uppermost attachments under
direct vision.
TIP
Both ureteral ends are clipped to avoid urine
spillage in case a transitional cell carcinoma is
present.
Kidney Extraction
A lower ilioinguinal muscle-splitting incision (Gib-
son type) is performed, but the muscle attached to the
peritoneum is not incised. A large laparoscopic bag
®
(Endo Catch II 15 mm, Tyco Autosuture) is introduced
through the small opening of the ilioinguinal incision.
Transperitoneal Laparoscopic Radical Nephrectomy 33
Fig. 20
Plane between kidney and liver
The kidney is placed intact inside the bag and the speci-
men is removed.
TIP
The string of the bag is pulled out to close it, and
the arm of the device is retracted to liberate the
metal ring.
Closure of the Abdominal Wall
The abdominal wall is closed using running Vicryl
2-0 SH 1 Plus (needle ½ 21.8 mm) for the peritoneum,
Vicryl 0 suture in “X” for the muscle, and running Vic-
ryl 1 CT Plus (needle ½ 39.9 mm) for the aponeurosis.
Once the abdominal wall is closed, pneumoperitoneum
is re-established and the optic introduced for revision of
the hemostasis. A silicone Penrose drain is inserted. Af-
ter evacuation of the pneumoperitoneum and removal
of the trocars, the aponeurosis of the 11-mm ports is
™
closed with a Dexon II HGU-46 suture. The skin in-
34 Section II
®
cisions are closed with subcuticular Monocryl 3-0 C
423.
Postoperative Considerations
The nasogastric tube is removed at the end of the proce-
dure, and the intravenous perfusion is stopped on day 1.
Pain is controlled with scheduled intramuscular nonste-
roidal anti-inflammatory drugs (NSAIDs) and oral an-
algesics. Intramuscular NSAIDs are often discontinued
after 24 hours. A light diet can generally be resumed one
day after surgery. The Foley catheter is usually removed
on day 1 and the Penrose drain on day 2 after surgery.
The patient leaves the hospital on the third or fourth
postoperative day. Patients can resume normal light ac-
tivities after hospital discharge, but vigorous activities
and heavy lifting are limited for at least one month after
surgery.
Laparoscopic Surgery for Malignant Urological Disorders
Suggested Readings
1. Hemal AK, Kumar A: Laparoscopic versus open radical ne-
phrectomy for large renal tumors: a long-term prospective
comparison. J Urol 2007 Mar; 177(3):862–866.
2. Mattar K, Finelli A: Expanding the indications for lapa-
roscopic radical nephrectomy. Curr Opin Urol 2007 Mar;
17(2):88–92.
3. Kouba E, Smith AM: Efficacy and safety of en bloc ligation
of renal hilum during laparoscopic nephrectomy. Urology
2007 Feb; 69(2):226–229.
4. Permpongkosol S, Link RE: Complications of 2,775 uro-
logical laparoscopic procedures: 1993 to 2005. J Urol 2007
Feb; 177(2):580–585.
5. Gong EM, Lyon MB: Laparoscopic radical nephrectomy:
comparison of clinical Stage T1 and T2 renal tumors. Urol-
ogy 2006 Dec; 68(6):1183–1187.
6. Romero FR, Muntener M: Pure laparoscopic radical ne-
phrectomy with level II vena caval thrombectomy. Urology
2006 Nov; 68(5):1112–1114.
7. Ono Y, Hattori R: Laparoscopic radical nephrectomy for re-
nal cell carcinoma: the standard of care already? Curr Opin
Urol. 2005 Mar; 15(2):75–78.
 Chapter 3
Transperitoneal
Laparoscopic Partial
Nephrectomy
Contents
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   35
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . . .  
P 35
Patient Positioning and Initial Preparation  .. . . .   36
Trocars and Laparoscopic Instruments   .. . . . . . . .   37
Access and Port Placement  . . . . . . . . . . . . . . . . . . . . .   37
Veress Needle  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   38
First Port (11 mm, optic 0°)  . . . . . . . . . . . . . . . . . . .   38
S econd Port
(5 mm, monopolar round-tipped scissors)  .. . .   39
Third Port (11 mm, bipolar grasper)  . . . . . . . . . .   40
Fourth Port (5 mm, suction device)  .. . . . . . . . . .   40
Fifth Port (5 mm, liver retractor grasper)  .. . . . .   40
Sixth Port (11 mm, Satinsky vascular clamp)    41
Final Position of the Ports  . . . . . . . . . . . . . . . . . . . .   41
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .   41
Colon Mobilization  .. . . . . . . . . . . . . . . . . . . . . . . . . .   41
Ureter and Gonadal Vessels Identification  . . . .   43
Exposure and Dissection of the Renal Hilum    43
Localization of the Kidney Tumor  .. . . . . . . . . . . .   44
Tumor Resection  . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   44
Closure of the Abdominal Wall  . . . . . . . . . . . . . . .   47
Postoperative Considerations  . . . . . . . . . . . . . . . . . .   48
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . . .   48
Introduction
Since the introduction of cross-sectional imaging for the
diagnosis of intra-abdominal pathologies, an increased
number of small renal masses are being incidentally
discovered. These lesions are often peripherally located,
with a benign histology in less than half of the cases.
Following removal, no significant differences in sur-
vival rates exist between patients who have undergone
partial or radical nephrectomy. In addition, the local
recurrence rate after nephron-sparing surgery (NSS) is
less than 3%. For all of these reasons, and motivated by
the benefits of decreased patient morbidity and fast re-
covery, laparoscopic partial nephrectomy is successfully
becoming the standard of care for the surgical manage-
ment of exophytic renal tumors 4 cm in diameter or
smaller. However, despite the potential advantages of
nephron-sparing surgery and the laparoscopic approach
over open surgery, laparoscopic partial nephrectomy is
still not widely performed because of technical difficul-
ties inherent to the procedure. There is ongoing debate
regarding the need for complete hilar clamping, warm
ischemia time, and the use of haemostatic techniques af-
ter tumor removal. Even in skilled hands, this complex
procedure is still evolving. The technique described uses
a transperitoneal route and an extracorporeal clamp ap-
proach of delayed occlusion and early release of the re-
nal pedicle to minimize warm ischemia time.
Preoperative Preparation
Before a patient consents to a laparoscopic partial ne-
phrectomy, it is important to discuss the specific risks of
the surgery, including the potential need to convert to
the traditional open operation if difficulties arise.
36 Section II
The patient is admitted to the hospital the night be-
fore the surgery for bowel preparation, which includes 2
® ®
L of Colopeg (1 envelope/L) p.o. and a Fleet enema.
Fasting starts at midnight before surgery. Thrombopro-
phylaxis protocol is implemented with good hydration,
placement of compressive elastic stockings on the lower
extremities, and low-molecular-weight heparin. Enoxa-
® ®
parin (Clexane , Lovenox ) 40 mg sc 1 × day or nad-
® ®
roparin (Flaxiparine , Fraxiparin ) 0.6 mL sc 1 × day
is initiated on day 1 after the surgery and continued
daily until the patient is discharged from the hospital.
In selected cases, the treatment is continued for 30 days
after the procedure. Patients also receive antibiotic pro-
phylaxis with a single preoperative dose of intravenous
second-generation cephalosporin, unless they are aller-
gic to penicillin. Blood type and crossmatch are deter-
mined.
Patient Positioning and Initial Preparation
The patient is initially positioned supine for IV access,
the induction of general anesthesia, and endotracheal
intubation. An orogastric tube is placed and the stomach
decompressed to avoid puncture during trocar place-
Fig. 1
a Patient position. b Padding
Laparoscopic Surgery for Malignant Urological Disorders
ment and to allow additional space during abdominal
insufflation. An 18Fr Foley catheter with 10 mL in the
balloon is introduced for decompression of the bladder.
During skin preparation, the entire flank and abdomen
are included in case conversion to an open procedure is
required. The umbilicus is placed over the break in the
operating table, and the patient is positioned in a modi-
fied lateral decubitus position.
TIP
For a left-side nephrectomy, the patient is placed
in a strict lateral decubitus position.
The table can be flexed as needed, or an inflatable bal-
loon is positioned under the patient at the level of the
umbilicus. Padding is used to support the buttocks and
dorsum, and all potential pressure points are cushioned.
An axillary roll is placed to prevent brachial plexus in-
jury, and the arms should be positioned as far away from
the trunk as possible so as not to disturb the movement
of the operative team. The patient is held in position
with strips of cloth tape (Fig. 1a,b).
The surgeon operates from the abdominal side of the
 Chapter 3
patient, and the first assistant is placed caudally to the
surgeon. The laparoscopic cart is positioned at the back
of the patient’s chest with the operative team facing the
video monitor. The instruments table is positioned be-
hind the operative team, and the assistant is positioned
higher than the surgeon to prevent laparoscopic instru-
ments from conflicting (Fig. 2a–c).
Trocars and Laparoscopic Instruments
• 3 × 11 mm (optic 0°, Satinsky vascular clamp, and
bipolar grasper)
• 3 × 5 mm for right-side partial nephrectomy (scis-
sors, suction device, and liver retractor grasper)
Transperitoneal Laparoscopic Partial Nephrectomy 37
Fig. 2
a Patient and laparoscopic cart. b Steps below assistant.
c Instruments table behind operative team
• 2 × 5 mm for left-side partial nephrectomy (scissors
and suction device)
• Monopolar round-tipped scissors, bipolar grasper,
Satinsky vascular clamp, liver retractor grasper,
5-mm suction device, needle drivers (2), and 10-mm
laparoscopic optic 0°
Access and Port Placement
Five ports are generally enough to perform the pro-
cedure, although a sixth trocar may be necessary for
liver retraction during a right-side partial nephrectomy
(Fig. 3). Before trocars are placed, the abdomen is insuf-
flated using a Veress needle.
38 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 3
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)

TIP TIP

In case of previous surgery, the Veress needle is The skin incision should be 50% larger than the
not inserted, and the open access technique is diameter of the 11-mm trocar.
used to place the first trocar.

The Veress needle is introduced through the incision

(see Chap. 1, Veress Needle Introduction).

Veress Needle
A cutaneous incision is made two fingerbreadths below
the costal margin arch in the midaxillary line, lateral to
the ipsilateral rectus muscle (Fig. 4a,b).
First Port (11 mm, optic 0°)
Once pneumoperitoneum is established, the Veress
needle is removed, and the 11-mm trocar is introduced
through the same incision, perpendicularly to the ab-
dominal wall (Fig. 5).
 Chapter 3 Transperitoneal Laparoscopic Partial Nephrectomy 39

Fig. 4
a Cutaneous incision below costal margin. b Insertion of Veress needle

TIP The optic is introduced through the trocar, and the

abdomen is then inspected for any injury due to inser-
Pneumoperitoneum is established with an intra- tion of the Veress needle or the trocar, and to identify
abdominal pressure higher than 10 mmHg. adhesions in areas where the secondary ports will be
placed.

TIP

After trocar placement and obturator removal,

the trocar valve is briefly opened to check for
egress of gas, confirming it is correctly placed
inside the abdomen. The insufflator line is then
connected to the trocar.

 econd Port
S
(5 mm, monopolar round-tipped scissors)

The triangulation rule must be followed for the place-

ment of the trocars as the body habitus is different for
each patient: four fingerbreadths between the optic trocar
Fig. 5
and the working trocars (Fig. 6), and five fingerbreadths
Perpendicular introduction of the trocar
between the working trocars (Fig. 7a,b).
40 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 6
Triangulation rule, four fingers

Fig. 7
a Triangulation rule, five fingers. b Ports in place

TIP Fourth Port (5 mm, suction device)

The skin incision should be 50% larger than the For the introduction of the 5-mm trocar, a cutaneous
diameter of the trocar. incision is made approximately midline between the
umbilicus trocar and the anterior superior iliac spine on
the side of the procedure.

Third Port (11 mm, bipolar grasper) Fifth Port (5 mm, liver retractor grasper)

The triangulation rule must be followed as above. If liver retraction is necessary during a right-side par-
tial nephrectomy, a cutaneous incision is made approxi-
 Chapter 3
Fig. 8
Right-side ports
mately two fingerbreadths below the level of the second
port, and a 5-mm port is introduced (Fig. 8).
Sixth Port (11 mm, Satinsky vascular clamp)
A cutaneous incision is made approximately in line
with the most caudal trocar but placed slightly infe-
rior to the umbilicus (Fig. 9).
TIP
The 11-mm trocar for the Satinsky vascular
clamp is inserted only after the exposure and
dissection of the renal hilum.
Final Position of the Ports
®
The ports are tied to the skin with Vicryl 2-0 to prevent
accidental removal.
Transperitoneal Laparoscopic Partial Nephrectomy 41
Fig. 9
11-mm port for introduction of Satinsky vascular clamp (A)
Surgical Technique
Colon Mobilization
For a left-side partial nephrectomy, the plane between
the descending colon and the underlying Gerota’s fas-
cia is developed to allow the colon to fall medially (Fig.
10a–c).
TIP
The lateral attachments of the kidney to the ab-
dominal wall should not be freed at this time to
avoid the kidney falling medially into the oper-
ating field.
This plane of dissection is carried out cranially.
The splenorenal and lienocolic ligaments are incised,
allowing the spleen and the tail of the pancreas to
be separated from the upper pole of the kidney (Fig.
11a,b).
42 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 10
a Colon attachments to abdominal wall. b Release of colon
attachments to abdominal wall. c Colon is dissected from
Gerota’s fascia (Gerota is not freed from abdominal wall)

Fig. 11
a Spleen is released from kidney. b En bloc spleen dissection
 Chapter 3 Transperitoneal Laparoscopic Partial Nephrectomy 43

TIP

In this maneuver, the weight of the spleen dis-

sected en bloc opens the space spontaneously.

For a right-side partial nephrectomy, the liver is crani-

ally retracted using a grasper that is fixed to the abdomi-
nal wall (Fig. 12).
The ascending colon is mobilized and dissected from
the underlying Gerota’s fascia. Colon mobilization con-
tinues caudally to the common iliac vessels to expose
the lower pole of the kidney, the ureter, and the gonadal
vessels.

Fig. 12
 reter and Gonadal Vessels 
U
Grasper retracting liver
Identification

After the colon is medially retracted, the Gerota’s fatty

tissue at the level of the lower pole of the kidney is in-
cised and lifted to locate the psoas muscle (Fig. 13).

TIP

The correct maneuver to expose the psoas muscle

is the continuous upper movement of the laparo-
scopic instruments to lift the fatty tissue.

The psoas is followed to expose the gonadal vessels and

the ureter just lateral and deep to these vessels. Both
structures are elevated and, by visualization of the psoas
muscle (Fig. 14a,b), followed cranially to the lower pole
and hilum of the kidney.
Attachments between the psoas muscle and Gerota’s
fascia are released with sharp and blunt dissection, and
small vessels to the ureter and branches of the gonadal
vein are coagulated with the bipolar grasper.
Exposure and Dissection of the Renal Hilum
On the left, tracking the course of the left gonadal vein
into the renal vein and firm elevation of the lower pole
of the kidney on both sides assists in the identification
and blunt dissection of the renal hilum (Fig. 15).
Fig. 13
Lifting of fatty tissue to expose psoas muscle
The renal vein is dissected, taking care with the lum-
bar veins that drain posterior to the vessel. The renal
artery is routinely not dissected. The Satinsky vascular
clamp is introduced and positioned around the pedicle,
but it is not clamped at this time (Figs. 9 and 16a,b).
The renal vessels should be clamped en bloc, but a
single vein is left unclamped to permit venous drainage
in case an accessory renal artery was missed and not
properly secured (Fig. 17a,b).
44 Section II Laparoscopic Surgery for Malignant Urological Disorders

TIP

The en bloc clamping of the pedicle using a large

Satinsky clamp is technically faster as less dis-
section is required, but there is always a risk of
parenchymal flow overpressure due to a missed
polar artery, which can jeopardize bleeding con-
trol. For this reason, it is safer to completely dis-
sect the kidney to exclude an accessory artery
when performing the en bloc hilar control.

Localization of the Kidney Tumor

The Gerota’s fascia overlying the area where the tumor

is likely to be found is incised with monopolar scissors
(Fig. 18). Palpation with the tip of the instrument also
aids in this objective.

Tumor Resection

The fatty tissue overlying the tumor is removed and sent

to pathology. The surface of the renal cortex bordering
Fig. 14
the lesion is stripped of fatty tissue to permit good visu-
a Dissection of ureter and gonadal vessels. b Psoas muscle
alization of the lateral margins of the tumor (Fig. 19).

Fig. 15
a Psoas is followed cranially to hilum. b Ureter and gonadal vessels approaching renal hilum
 Chapter 3 Transperitoneal Laparoscopic Partial Nephrectomy 45

Fig. 16
a Satinsky vascular clamp (S). b Satinsky around the pedicle

Fig. 17
a Satinsky vascular clamp around the hilum. b Renal vein left unclamped

Fig. 18
Gerota’s fascia incised over tumor
46 Section II Laparoscopic Surgery for Malignant Urological Disorders

The Gerota’s fascia is mobilized beyond the margins

of the wedge resection to facilitate posterior kidney
reconstruction. After delimitating a tumor-free mar-
gin of at least 0.5 cm, the cortex and renal parenchyma
around the nodule are incised with monopolar scissors.
At this time, if necessary, the pedicle is clamped and
the ischemia time begins. The renal parenchyma bor-
dering the nodule is coagulated and cut with the same
instrument, and the tumor is completely excised (Fig.
20a–c).
If a renal calyx is opened during the resection, a run-
ning suture of Vicryl 2-0 is used to close the defect fol-
lowing tumor removal (Fig. 21a,b).
Interrupted U-shaped sutures of Vicryl 0 GS 24 are
placed through the Gerota and the renal parenchyma
Fig. 19
(Fig. 22).
Renal cortex surface around nodule stripped of fatty tissue

Fig. 20
a Demarcation of the incision. b Renal parenchyma is cut.
c Tumor excision
 Chapter 3
Fig. 21
a Open calyx. b Suture closing open calyx
Fig. 22
U-shaped sutures are placed through the Gerota and the
renal parenchyma
®
Two Surgicel bolsters 10 × 20 cm are placed under
the loose loops of the suture to fill in the defect and help
with the hemostasis (Fig. 23).
The knot is gently and carefully tied to avoid tearing
of the parenchyma. The vascular clamp is opened, and
any eventual bleeding is controlled with a further Vicryl
0 suture (Fig. 24).
Transperitoneal Laparoscopic Partial Nephrectomy 47
Fig. 23
Surgical bolsters
Closure of the Abdominal Wall
®
The specimen is placed in an Endo Catch bag (Tyco
Autosuture), and the incision is enlarged for specimen
removal. A 12-mm silicone Penrose drain is introduced.
The aponeurosis of the 11-mm ports is closed with a
™
Dexon II HGU-46 suture, and the skin incisions are
48 Section II
Fig. 24
Final result
®
closed with running intradermic Monocryl 3-0. The
®
Penrose is sutured to the skin with Flexidene 2-0, and
®
the skin incision is closed with an Opsite dressing.
Postoperative Considerations
The nasogastric tube is removed at the end of the pro-
cedure, and the intravenous perfusion is stopped on day
1. Pain is controlled with scheduled intramuscular non-
steroidal anti-inflammatory drugs (NSAIDs) and oral
analgesics. Intramuscular NSAIDs are often discontin-
ued after 24 h. A light diet can generally be resumed
Laparoscopic Surgery for Malignant Urological Disorders
on day 1 after surgery. The Foley catheter is usually re-
moved on the first post-operative day, and the Penrose
drain is removed before discharge or when drainage is
less than 50 mL. Patients can resume normal light ac-
tivities after hospital discharge, but vigorous activities
and heavy lifting are limited for at least one month after
surgery.
Suggested Readings
1. Orvieto MA, Zorn KC: Recovery of renal function af-
ter complete renal hilar versus artery alone clamping
during open and laparoscopic surgery. J Urol 2007 Jun;
177(6):2371–2374.
2. Verhoest G, Manunta A: Laparoscopic partial nephrectomy
with clamping of the renal parenchyma: initial experience.
Eur Urol 2007 Nov; 52(5):1340–6.
3. Bollens R, Rosenblatt A: Laparoscopic partial nephrectomy
with “on-demand” clamping reduces warm ischemia time.
Eur Urol 2007 Apr; 52(3): 804–810.
4. Van Dijk JH, Pes PL: Haemostasis in laparoscopic partial
nephrectomy: current status. Minim Invasive Ther Allied
Technol 2007; 16(1):31–44.
5. Häcker A, Albadour A: Nephron-sparing surgery for renal
tumours: acceleration and facilitation of the laparoscopic
technique. Eur Urol 2007 Feb; 51(2):358–365.
6. Breda A, Stepanian SV: Use of haemostatic agents and glues
during laparoscopic partial nephrectomy: a multi-institu-
tional survey from the United States and Europe of 1347
cases. Eur Urol 2007 Feb; 52(3):798–803.
 Chapter 4

Laparoscopic Assisted
Transperitoneal
Nephroureterectomy

Contents
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   49
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . . .  
P 49
Patient Positioning and Initial Preparation   . . . .   50
Trocars and Laparoscopic Instruments   .. . . . . . . .   52
Access and Port Placement  . . . . . . . . . . . . . . . . . . . . .   52
Veress Needle  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   53
First Port (11 mm, optic 0°)  . . . . . . . . . . . . . . . . . . .   53
S econd Port  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   54
Third Port   .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   55
Fourth Port (5 mm, suction device)  .. . . . . . . . . .   55
Fifth Port (5 mm, liver retractor grasper)  .. . . . .   55
Access for the Lower Ureteral Dissection   .. . . . . .   56
Surgical Technique   . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   56
Colon Mobilization  .. . . . . . . . . . . . . . . . . . . . . . . . . .   56
Ureter and Gonadal Vessels Identification  . . . .   58
Exposure and Dissection of the Renal Hilum    60
Renal Hilum Ligature and Transection  .. . . . . . .   60
M obilization of the Kidney and Adrenal Gland    61
K idney Extraction and Distal Ureteral
Dissection  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   61
Closure of the Abdominal Wall  . . . . . . . . . . . . . . .   62
Postoperative Considerations  . . . . . . . . . . . . . . . . . .   62
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . . .   62
Introduction
In recent years, laparoscopic nephroureterectomy has
been developed and applied to patients with transitional
cell carcinoma (TCC) of the renal pelvis and ureter. The
laparoscopic approach results in less blood loss, fewer
postoperative pain and analgesic requirements, and
faster recovery to normal activity compared with open
nephroureterectomy. The main issue of this procedure
is the oncologic control, particularly the management of
the distal ureter. The en bloc ureteral resection to avoid
tumor spillage is the preferred method, and many inno-
vative techniques have been used to address the subject.
With the technique here described, the kidney and
proximal ureter are dissected laparoscopically by way of
a transperitoneal approach, and an ilioinguinal incision
(Gibson-type) is performed for continued dissection of
the distal ureter with a cuff of bladder. The abdominal
incision permits safe specimen removal, reducing the
technical complexity of the procedure and operative
times.
Preoperative Preparation
Before a patient consents to a laparoscopic nephroure-
terectomy, it is important to discuss the specific risks of
the surgery, including the potential need to convert to
the traditional open operation if difficulties arise.
The patient is admitted to the hospital the day before
the surgery for bowel preparation, which includes 2 L
® ®
of Colopeg (1 envelope/L) p.o. and a Fleet enema.
Fasting starts at midnight before surgery. Thrombo-
prophylaxis protocol is implemented with good hydra-
tion, placement of compressive elastic stockings on the
lower extremities, and low-molecular-weight heparin.
® ®
Enoxaparin (Clexane , Lovenox ) 40 mg sc 1 × day or
50 Section II
® ®
nadroparin (Flaxiparine , Fraxiparin ) 0.6 mL sc 1 ×
day is initiated on day 1 after the surgery and continued
daily until the patient is discharged from the hospital.
In selected cases, the treatment is continued for 30 days
after the procedure. Patients also receive antibiotic pro-
phylaxis with a single preoperative dose of intravenous
second-generation cephalosporin, unless they are aller-
gic to penicillin. Blood type and crossmatch are deter-
mined.
Patient Positioning and Initial Preparation
The patient is initially positioned supine for intravenous
access, the induction of general anesthesia, and endotra-
cheal intubation. An orogastric tube is placed and the
stomach decompressed to avoid puncture during trocar
placement and to allow additional space during abdom-
inal insufflation. An 18Fr Foley catheter with 10 mL in
the balloon is introduced for bladder decompression.
During skin preparation, the entire flank and abdomen
are included in case conversion to an open procedure is
required. The umbilicus is placed over the break in the
Fig. 1
a Patient’s position. b Padding
Laparoscopic Surgery for Malignant Urological Disorders
operating table, and the patient is positioned in a modi-
fied lateral decubitus position.
TIP
For a left-side nephroureterectomy, the patient is
placed in a strict lateral decubitus position.
The table can be flexed as needed, or an inflatable bal-
loon is positioned under the patient at the level of the
umbilicus. Padding is used to support the buttocks and
dorsum, and all potential pressure points are cushioned.
An axillary roll is placed to prevent brachial plexus in-
jury, and the arms should be positioned as far away from
the trunk as possible so as not to disturb the movement
of the operative team. The patient is held in position
with strips of cloth tape (Fig. 1a,b).
The surgeon operates from the abdominal side of
the patient, and the first assistant is placed caudally to
the surgeon. The laparoscopic cart is positioned at the
back of the patient’s chest with the operative team facing
the video monitor. The instruments table is positioned
 Chapter 4 Laparoscopic Assisted Nephroureterectomy 51

Fig. 2
a Patient and laparoscopic cart. b Steps below assistant.
c Instruments table behind operative team. d Operative
team’s position
52 Section II Laparoscopic Surgery for Malignant Urological Disorders

behind the operative team, and the assistant stands on • M

steps (Fig. 2a–d).
Trocars and Laparoscopic Instruments
Right-side nephroureterectomy:
• 2 × 11 mm (optic 0°, bipolar grasper, 10 mm-clip ap-
plier)
• 3 × 5 mm (monopolar scissors, suction device, and
liver retractor grasper)
Left-side nephroureterectomy:
• 2 × 11 mm (optic 0° and bipolar grasper)
• 2 × 5 mm (scissors and suction device)
 onopolar round-tipped scissors, bipolar grasper,
liver retractor grasper, 5-mm suction device, Ethi-
con 10-mm clip applier (non-disposable), needle
drivers (2), and 10-mm laparoscopic optic 0°
Access and Port Placement
Four ports are generally sufficient to complete the pro-
cedure, although a fifth trocar may be necessary for
liver retraction during a right-side nephroureterectomy
(Fig. 3).

Fig. 3
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)
 Chapter 4 Laparoscopic Assisted Nephroureterectomy 53

Fig. 4
a Cutaneous incision below costal margin. b Insertion of Veress needle

Veress Needle TIP

A cutaneous incision is made two fingerbreadths below Pneumoperitoneum is established with an intra-
the costal margin arch, at the level of the lateral border abdominal pressure higher than 10 mmHg.
of the rectus muscle (Fig. 4a,b).

TIP

The skin incision should be 50% larger than the

diameter of the 11-mm trocar.

The Veress needle is introduced through the incision

(see Chap. 1, Veress Needle Introduction).

First Port (11 mm, optic 0°)

Once pneumoperitoneum is established, the needle is

removed, and the 11-mm trocar is introduced through
the same incision, perpendicularly to the abdominal
wall (Fig. 5).
Fig. 5
Perpendicular introduction of the trocar
54 Section II Laparoscopic Surgery for Malignant Urological Disorders

The optic is introduced through the trocar, and the ab-
domen is then inspected for any injury due to insertion
of the Veress needle or the trocar, and to identify adhe-
sions in areas where the secondary ports will be placed.
TIP
After trocar placement and obturator removal,
the trocar valve is briefly opened to check for
egress of gas, confirming it is correctly placed
inside the abdomen. The insufflator line is then
connected to the trocar.

Second Port

• F or a right-side nephroureterectomy: 5 mm (mono-

polar round-tipped scissors)
• For a left-side nephroureterectomy: 11 mm – po-
sitioned around the umbilicus (monopolar round-
tipped scissors, optic, 10-mm clip applier)

Fig. 6
Triangulation rule for right-side nephroureterectomy

Fig. 7
a Triangulation rule. b Ports in place
 Chapter 4
TIP
The position of the working trocars for a left-
side nephroureterectomy are switched over when
compared to the transperitoneal laparoscopic
nephrectomy; therefore, the 5-mm port is placed
at the xiphoid process, and the 11-mm port is
placed close to the umbilicus (see Chap. 2, Access
and Port Placement).
The triangulation rule must be followed for the place-
ment of the trocars as the body habitus is different for
each patient: four fingerbreadths between the optic
trocar and the working trocars (Fig. 6), and five finger-
breadths between the working trocars (Fig. 7a,b).
Third Port
• F or a left-side nephroureterectomy: 5 mm positioned
at the xiphoid process (bipolar grasper)
• For a right-side nephroureterectomy: 11 mm (bipo-
lar grasper, optic)
The triangulation rule must be followed as above.
Laparoscopic Assisted Nephroureterectomy 55
Fig. 8
Fourth port (caudal port) in line with
the periumbilical port
Fourth Port (5 mm, suction device)
For the introduction of the 5-mm trocar, a cutaneous
incision is made approximately three fingers caudally to
the umbilicus and in line with the periumbilical trocar
(Fig. 8).
TIP
This trocar is positioned lower than for the
transperitoneal laparoscopic nephrectomy; the
trocar will be used for the placement of a bipolar
grasper during the ureteral part of the procedure
(Fig. 9).
Fifth Port (5 mm, liver retractor grasper)
If liver retraction is necessary during a right-side
nephroureterectomy, a cutaneous incision is made ap-
proximately two fingerbreadths below the level of the
second port, and a 5-mm trocar is introduced.
®
The ports are finally tied to the skin with Vicryl 2-0
to prevent accidental removal.
56 Section II
Fig. 9
Reposition of the instruments (see Access for the lower ureteral dissection)
Access for the Lower Ureteral Dissection
During the ureteral part of the procedure, the posi-
tion of the instruments is changed for the ureteral
dissection. The optic is repositioned at the periumbili-
cal port, the bipolar grasper at the caudal port, the mo-
nopolar scissors at the initial optic port, and the suc-
tion device at the xiphoid process port (Fig. 9).
TIP
The assistant moves to the right side of the sur-
geon.
Laparoscopic Surgery for Malignant Urological Disorders
Surgical Technique
Colon Mobilization
For a left-side nephroureterectomy, the plane between
the descending colon and the underlying Gerota’s fas-
cia is developed to allow the colon to fall medially (Fig.
10a–c).
TIP
The lateral attachments of Gerota’s fascia to the
abdominal wall should not be freed at this time
to avoid the kidney falling medially into the op-
erating field.
 Chapter 4 Laparoscopic Assisted Nephroureterectomy 57

Fig. 10
a Colon attachments to abdominal wall. b Release of the
colon attachments to abdominal wall. c Colon is dissected
from Gerota’s fascia (Gerota is not freed from abdominal
wall)

Fig. 11
a Spleen is released from kidney. b Spleen dissected en bloc
58 Section II
Fig. 12
Lifting of fatty tissue to expose psoas muscle
This plane of dissection is carried out cranially. The spl-
enorenal and lienocolic ligaments are incised, allowing
the spleen and the tail of the pancreas to be separated
from the upper pole of the kidney. The en bloc dissection
of the colon, spleen, and pancreas must be completed
for adequate exposure of the renal vein (Fig. 11a,b).
For a right-side nephroureterectomy, the liver is crani-
ally retracted using a grasper that is fixed to the abdomi-
Fig. 13
a Dissection of ureter and gonadal vessels. b Psoas muscle
Laparoscopic Surgery for Malignant Urological Disorders
nal wall. The ascending colon is mobilized and dissected
from the underlying Gerota’s fascia. Colon mobilization
continues caudally to the common iliac vessels.
Ureter and Gonadal Vessels Identification
Following the medial mobilization of the colon and me-
socolon, the gonadal vessels are visualized. After the co-
lon is medially retracted, the Gerota’s fatty tissue at the
level of the lower pole of the kidney is incised and lifted
to locate the psoas muscle (Fig. 12).
TIP
The correct maneuver to expose the psoas muscle
is the continuous upper movement of the laparo-
scopic instruments to lift the fatty tissue.
The psoas is followed to expose the ureter just lateral
and deep to the gonadal vessels.
By tracking the cranial course of the ureter, the plane
is followed up to the renal pedicle.
The ureter and gonadal vessels are not divided at this
time. Both structures are lifted and, by visualization of
the psoas muscle (Fig. 13a,b) together with the gonadal
 Chapter 4 Laparoscopic Assisted Nephroureterectomy 59

Fig. 14
a Psoas is followed cranially to hilum. b Ureter and gonadal vessels approaching renal hilum

Fig. 15
a Renal hilum exposed. b Individual vessel dissection

vessels on the left side, followed cranially to the lower between the psoas muscle and Gerota’s fascia are re-
pole and hilum of the kidney (Fig. 14a,b). leased with sharp and blunt dissection, and small ves-
The dissection of the right gonadal vein is not neces- sels to the ureter and branches of the gonadal vein are
sary, as it enters the vena cava on this side. Attachments coagulated with the bipolar grasper.
60 Section II Laparoscopic Surgery for Malignant Urological Disorders

The renal vein is dissected, taking care with the lum-

bar veins that drain posteriorly to the vessel. The left ad-
renal vein is preserved if the ipsilateral adrenal gland is
not removed (Fig. 16).

TIP

Dissection of the right renal vein is usually less

demanding as the gonadal and lumbar veins are
normally absent at this side.

The renal artery is exposed posterior to the renal vein

and dissected (Fig. 17a,b).

Fig. 16
Renal Hilum Ligature and Transection
Left adrenal vein (A); Left renal vein (B); Gonadal vein (C)

Hem-o-lok clips are applied to the artery.

Exposure and Dissection of the Renal Hilum TIP

On the left, tracking the course of the left gonadal vein One extra-large (XL) clip secures the renal ar-
into the renal vein and firm elevation of the lower pole tery before the renal vein is clipped.
of the kidney on both sides assists in the identification
and blunt dissection of the renal hilum. The renal vessels
should be dissected separately (Fig. 15a,b).

Fig. 17
a Renal artery posterior to renal vein. b Dissection of the renal artery
 Chapter 4
Fig. 18
Plane between kidney and liver
Three clips (XL Hem-o-lok) are used on the renal vein,
which is then carefully transected.
TIP
The renal vein should be flat after the renal ar-
tery clip is placed; if the vein is still filling, an-
other renal artery should be located.
Following division of the renal vein, clipping of the renal
artery is completed (3 XL Hem-o-lok clips), and the ves-
sel is then transected.
Mobilization of the Kidney 
and Adrenal Gland
Once all the hilar vessels have been divided, the dissec-
tion continues posteriorly and superiorly to the upper
pole. The attachments of the kidney to the posterior and
lateral abdominal wall are released by blunt and sharp
dissection, taking care to coagulate the bleeding vessels.
The adrenal gland can be preserved in most cases. On
the right, superior retraction of the liver facilitates the
Laparoscopic Assisted Nephroureterectomy 61
dissection of the plane between the liver and the upper
pole of the kidney (Fig. 18).
The ureteral dissection is continued distally as far as
is technically feasible, and if an invasive ureteral lesion is
suspected, the dissection should include a wide margin
of surrounding tissue.
TIP
The instruments are repositioned (Fig. 9)
The ureter is double-clipped as low as possible with Liga-
®
clip II ML, and the remainder of the procedure can be
completed through a lower ilioinguinal incision.
Kidney Extraction 
and Distal Ureteral Dissection
The position of the patient is maintained, and a Gib-
son-type incision is made. The kidney, along with the
proximal and midureter, is removed, and the renal bed
is inspected for bleeding. The peritoneum is incised at
the level of the iliac vessels, and the incision extends me-
dial to the medial umbilical ligament to the pelvis. The
vas deferens in male patients and the round ligament in
female patients is double-clipped (Ligaclip II ML) and
divided. The distal ureter, now lifted and placed on trac-
tion, is dissected free between the bladder and the me-
dian umbilical ligament down to its entrance into the
bladder.
TIP
The bladder cuff is dissected extravesically, free-
ing the ureter from the surrounding detrusor
muscle.
A bladder cuff 2–3 cm surrounding the intramural ure-
ter is delineated with the cautery, and the dissection of
the intramural ureter extends into the bladder. The blad-
der mucosa bordering the ureteral orifice is incised, and
the specimen is removed. The bladder is closed in two
planes using running Vicryl 2-0 for the inner mucosal
layer and interrupted Vicryl 0 for the muscular layer.
62 Section II
Closure of the Abdominal Wall
The abdominal wall is closed using running Vicryl 2-0
SH 1 Plus (needle ½ 21.8 mm) for the peritoneum, Vic-
ryl 0 suture in “X” for the muscle, and running Vicryl 1
CT Plus (needle ½ 39.9 mm) for the aponeurosis. Once
the abdominal wall is closed, pneumoperitoneum is re-
established, and the optic is introduced for revision of
the hemostasis. A silicone Penrose drain is inserted. Af-
ter evacuation of the pneumoperitoneum and removal
of the trocars, the aponeurosis of the 11-mm ports is
closed with a Dexon II HGU-46 suture. The skin inci-
sions are closed with subcuticular Monocryl 3-0 C 423.
Postoperative Considerations
The nasogastric tube is removed at the end of the proce-
dure, and the intravenous perfusion is stopped on day 1.
Pain is controlled with scheduled intramuscular nonste-
roidal anti-inflammatory drugs (NSAIDs) and oral an-
algesics. Intramuscular NSAIDs are often discontinued
after 24 h. A light diet can generally be resumed on day
1 after surgery. The Foley catheter is removed on day 3
after surgery and the Penrose drain on the second post-
Laparoscopic Surgery for Malignant Urological Disorders
operative day. Patients leave the hospital on the third or
fourth postoperative day and can resume normal light
activities, but vigorous activities and heavy lifting are
limited for at least one month after surgery.
Suggested Readings
1. Rouprêt M, Hupertan V: Oncologic control after open or
laparoscopic nephroureterectomy for upper urinary tract
transitional cell carcinoma: a single center experience.
Urology 2007 Apr; 69(4):656–661.
2. Busby JE, Matin SF: Laparoscopic radical nephroureterec-
tomy for transitional cell carcinoma: where are we in 2007?
Curr Opin Urol 2007 Mar; 17(2):83–87.
3. Rassweiler JJ, Schulze M: Laparoscopic nephroureterectomy
for upper urinary tract transitional cell carcinoma: is it bet-
ter than open surgery? Eur Urol 2004 Dec; 46(6):690–697.
4. Klingler HC, Lodde M: Modified laparoscopic nephroure-
terectomy for treatment of upper urinary tract transitional
cell cancer is not associated with an increased risk of tu-
mour recurrence. Eur Urol 2003 Oct; 44(4):442–447.
5. Gill IS, Sung GT: Laparoscopic radical nephroureterectomy
for upper tract transitional cell carcinoma: the Cleveland
Clinic experience. J Urol 2000 Nov; 164(5):1513–1522.
 Chapter 5
Extraperitoneal
Laparoscopic Radical
Prostatectomy
Contents
I ntroduction   .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . . .
P   63
Patient Positioning and Initial Preparation  .. . . .  
Trocars and Laparoscopic Instruments   .. . . . . . . .  
Access and Port Placement   .. . . . . . . . . . . . . . . . . . . .  
First Port (11 mm, optic 0°)  . . . . . . . . . . . . . . . . . . .  
S econd Port (5 mm, bladder retractor)  . . . . . . .  
Third Port (5 mm, suction device)  . . . . . . . . . . . .  
Fourth Port (11 mm, bipolar grasper)  .. . . . . . . .  
Fifth Port (5 mm, monopolar round-tipped
scissors)  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Peritoneum Displacement
and Exposure of the Bladder Neck  .. . . . . . . . . . .  
Bladder Neck Dissection and Division  . . . . . . . .  
Dissection of the Seminal Vesicles
and Exposure of Denonvilliers’ Fascia  .. . . . . . . .  
Endopelvic Fascia and Puboprostatic
Ligaments  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Dorsal Venous Complex of the Penis (DVC)  . . .  
Identification and Preservation
of the Neurovascular Bundle   .. . . . . . . . . . . . . . . .  
The Prostatic Pedicles   .. . . . . . . . . . . . . . . . . . . . . . .  
Division of the Dorsal Vein Complex
and Urethra  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Bladder Neck Reconstruction
and Anastomosis  .. . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Postoperative Considerations  . . . . . . . . . . . . . . . . . .  
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . . .  
Introduction
63 Initially described as “extraperitoneal endoscopic radi-
cal retropubic prostatectomy,” this novel approach for
64 the treatment of prostate cancer avoids the potential dis-
65 advantages of the transperitoneal route of dissection. As
65 the peritoneal cavity is never entered, complications like
65 small bowel injury, urine ascites, small bowel obstruc-
66 tion, and intraperitoneal bleeding without the possibil-
67 ity of tamponade are almost nonexistent. In addition,
70 the occurrence of postoperative ileum is diminished.
The extraperitoneal approach more closely reproduces
72 the open retropubic radical prostatectomy technique, as
73 the steps of the operation are almost identical. However,
the pelvic and prostate anatomy is magnified during
73 laparoscopy, making dissection of important structures
76 much more precise. Although still considered a complex
procedure, extraperitoneal laparoscopic radical prosta-
76 tectomy is an evolving technique and has gained popu-
larity in the last years. It is a safe procedure and, in ex-
78 perienced hands, yields oncologic and functional results
79 equivalent to the open approach.
80
82
Preoperative Preparation
85 Before a patient consents to a laparoscopic radical pros-
tatectomy, it is important to discuss the specific risks of
86 the surgery, including the potential need to convert to
88 the traditional open operation if difficulties arise.
89 The patient is admitted to the hospital one day be-
fore the surgery for bowel preparation, which includes
® ®
2 L of Colopeg (1 envelope/L) p.o. and a Fleet enema.
Fasting starts at midnight before surgery. Thrombo-
prophylaxis protocol is implemented with good hydra-
64 Section II
Fig. 1
Patient position
tion, placement of compressive elastic stockings on the
lower extremities, and low-molecular-weight heparin.
® ®
Enoxaparin (Clexane , Lovenox ) 40 mg sc 1 × day or
® ®
(Flaxiparine , Fraxiparin ) 0.6 mL sc 1 × day is initi-
ated on day 1 after the surgery and continued daily until
the patient is discharged from the hospital. In selected
cases, the treatment is continued for 30 days after the
procedure.
TIP
Thromboprophylaxis is important due to the
concurrent risk factors of laparoscopy, cancer,
and pelvic surgery.
Patients also receive antibiotic prophylaxis with a single
preoperative dose of intravenous second-generation
cephalosporin, unless they are allergic to penicillin.
Blood type and crossmatch are determined.
Patient Positioning and Initial Preparation
The surgery is performed under general anesthesia. The
base of the table must be positioned below the patient’s
Laparoscopic Surgery for Malignant Urological Disorders
Fig. 2
Position of the legs
hip to avoid elevation of the abdomen while in the Tren-
delenburg position (Fig. 1).
The patient is placed in the supine position with the
lower limbs in abduction, allowing the laparoscopic cart
to be moved closer to the surgeon and intraoperative ac-
cess to the perineum (Fig. 2).
The lower buttocks must be placed at the distal end
of the operating table. The upper limbs are positioned
alongside the body to avoid the risk of stretch injuries to
the brachial plexus and to allow for free movements of
the operative team. Shoulder support is placed over the
acromium clavicular joint (Fig. 3) for the Trendelenburg
position.
A nasogastric tube is placed by the anesthesiologist
and the stomach decompressed to avoid puncture dur-
ing trocar placement and to allow additional space dur-
ing extraperitoneal insufflation. The abdomen, pelvis,
and genitalia are skin prepared in case conversion to
an open procedure is required. An 18Fr Foley catheter
with 10 mL in the balloon is introduced after the place-
ment of the sterile drapes. The surgeon and the second
assistant operate from the patient’s left side, and the first
assistant is placed at the opposite side of the surgeon.
The laparoscopic cart is placed at the patient’s feet, while
the instruments table and the coagulation unit are posi-
tioned at the left side of the patient (Fig. 4).
 Chapter 5 Extraperitoneal Laparoscopic Radical Prostatectomy 65

Fig. 3 Fig. 5
Shoulder support Instruments table

Trocars and Laparoscopic Instruments

• 2 × 11 mm (optic 0° and bipolar grasper)
• 3 × 5 mm (scissors, suction device, and palpator)
• Monopolar round-tipped scissors, bipolar grasper,
dissector, 5-mm suction device, needle drivers (2),
and 10-mm laparoscopic optic 0° (Fig. 5)

Access and Port Placement

See Figures 6 and 7.

First Port (11 mm, optic 0°)

A cutaneous incision is made at the inferior and right

margin of the umbilicus (Fig. 8).

TIP

The trocar is placed in the midline to facilitate

access to the right epigastric vessels in case in-
jury to these vessels occurs during insertion of
Fig. 4 the fifth trocar.
Laparoscopic cart at patient’s feet
66 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 6
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)

In patients with an enlarged umbilicus, where the linea semicircular line of Douglas (Fig. 12) and in the direc-
alba is usually wider, the cutaneous incision should be tion of the prostate.
placed more laterally, facilitating access to the right rec-
tus abdominis muscle. TIP
The subcutaneous fatty tissue is dissected with blunt
scissors, resulting in visualization of the superficial fas- The purse-string suture is “falsely” tied around
cia (rectus sheath). The fascia is grasped by two Kocher the trocar by placing a Kocher clamp that blocks
clamps and incised (Fig. 9a,b). both threads at the level of the fascia.
The right rectus abdominis muscle is dissected later-
ally, and a purse-string suture of Polysorb 0 UL 877 (nee-
dle 5/8) is placed through the superficial fascia to avoid
air leakage during the procedure and to facilitate closure
of the aponeurosis after the removal of the trocar. Second Port (5 mm, bladder retractor)
The optic is placed inside the 11-mm trocar before
insertion into the abdomen (Fig. 10). The optic and the Following visual confirmation that the peritoneum is not
trocar are then introduced through the skin incision at opened, the insufflation line is connected, and the pres-
an angle of 30° (Fig. 11), following the plane above the sure of insufflation is switched to maximum flow. With
 Chapter 5 Extraperitoneal Laparoscopic Radical Prostatectomy 67

gentle up and down and lateral movements on the optic

associated with the injected CO₂ gas, the preperitoneal
space between the two epigastric vessels and the pubic
arch is developed. A skin incision is made in the lower
abdomen, two fingerbreadths above the pubis slightly to
the left of the midline.

TIP

The incision is made 50% larger than the diam-

eter of the 5-mm trocar; it is placed slightly to
the left to avoid conflict between the optic and
this port.

A 5-mm trocar is introduced (Fig. 13).

Third Port (5 mm, suction device)

The bipolar grasper is introduced through the 5-mm

second port, with the tip directed toward the right an-
terior superior iliac spine. The Bogros space is then dis-
sected. The dissection should start in the angle between
Fig. 7
the epigastric vessels and the peritoneal reflection at the
Trocars in place
level of the deep inguinal ring (Fig. 14a–c).

Fig. 8
Cutaneous incision to the right of midline
68 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 9
a Superficial aponeurosis. b Aponeurosis incision

Fig. 10 Fig. 11
Optic inside trocar Angle of trocar introduction
 Chapter 5 Extraperitoneal Laparoscopic Radical Prostatectomy 69

Fig. 12 Fig. 13
Trocar follows the plane above the semicircular line of Second trocar position
Douglas

Fig. 14
Fig. 14 a Epigastric vessels (A); Closed Bogros space (B).
b Developing the dissection plane. c Peritoneal reflection
(A); Open Bogros space (B)
70 Section II
TIP
The Bogros space is situated laterally and cra-
nially to the Retzius space, corresponding to the
retroinguinal preperitoneum. Anteriorly, it is
limited by the deep layer of transversalis fascia
enveloping the epigastric vessels. Medially, it is
limited by the adherent zone of umbilico vesi-
cal fascia, transversalis fascia, and peritoneum,
situated just behind the epigastrics. The lateral
limits are the pelvic wall and the iliacus muscle.
The psoas muscle corresponds to the inferior
limit. The key point to visualize the Bogros space
is the dissection of the epigastric vessels, which
are superficial to the deep layer of transversalis
fascia and in close relation to the peritoneum. If
one penetrates the plane superficial to the deep
layer of transversalis fascia, the bare epigastrics
will be exposed, and the risk of bleeding increases
by trauma to the small branching vessels—this is
the wrong plane of dissection. By gently brushing
the tissue away from the epigastric arcade, the
right plane of dissection is usually easily visual-
ized. The dissection follows a sagittal direction
(the same direction as the fascia and the epi-
gastrics), and the dissector gently separates the
avascular plane that separates the peritoneum
from the deep layer of transversalis fascia.
The epigastric vessels are elevated by the bipolar; ini-
tially the instrument is pushed in and then pushed cra-
nially toward the direction of the right anterior superior
iliac spine. The bipolar is replaced by the optic, and the
same maneuver of sagittal dissection is done to open the
space for the introduction of the trocar. The grasper is
then placed under the epigastric vessels. The tip is ad-
vanced laterally to the vessels, and the grasper is lifted.
Holding this position, a skin incision is made from the
tip of the bipolar toward the direction of the right an-
terior superior iliac spine, and a 5-mm trocar is placed
(Fig. 15a–f).
D F i g . 15
a Right anterior iliac crest. b Internal view: Epigastric vessels (A); Bogros space (B). c Angle of trocar introduction. d Trocar pro-
truding muscle. e Horizontal angle of trocar introduction. f Trocar through the muscle
Laparoscopic Surgery for Malignant Urological Disorders
TIP
The trocar must be introduced in the same di-
rection and inferior to the bipolar. Using this
upward maneuver on the grasper, the epigastric
vessels are protected from injury during trocar
insertion.
Fourth Port (11 mm, bipolar grasper)
The surgeon switches to the right side of the patient. The
bipolar grasper is introduced through the right anterior
superior iliac spine port, and the laparoscopic dissec-
tor is introduced through the lower abdomen port. The
Bogros plane on the left side of the patient is dissected.
Both instruments must be moved in the opposite up and
down direction for the development of the correct plane
of dissection. Then, the epigastric vessels are elevated by
the dissector, and the bipolar grasper executes the same
cephalad movement toward the direction of the left an-
terior superior iliac spine. The optic is introduced at this
site and moved cranially toward the anterior left iliac
spine to liberate the space for the introduction of the
trocar. The grasper is then placed under the epigastric
vessels. The tip is advanced laterally to the vessels, and
the grasper is lifted. Holding this position, a cutaneous
incision is made from the tip of the bipolar toward the
direction of the left anterior superior iliac spine, and an
11-mm trocar is introduced (Fig. 16a–d).
TIP
The epigastric vessels must be lifted by the bipo-
lar, and the trocar must be placed in the same
direction and inferior to the bipolar.
Chapter 5 Extraperitoneal Laparoscopic Radical Prostatectomy 71
72 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fifth Port (5 mm,  TIP

monopolar round-tipped scissors)
Pay attention to the epigastric vessels, which can
For the introduction of the last 5-mm trocar, a skin in- be visualized by pressing the right lateral side of
cision is made at a point situated at the junction of the the abdomen).
lateral 2/3 and medial 1/3 distance between the right
anterior superior iliac spine trocar and the umbilicus
trocar (Fig. 17a,b).

Fig. 16
a Right anterior superior iliac spine. b Muscle exposition. c Angle of trocar introduction. d Trocar through the muscle
 Chapter 5 Extraperitoneal Laparoscopic Radical Prostatectomy 73

FIG. 17
a Fifth port. b Ports in place

TIP TIP

If the peritoneum is opened during trocar intro- Steps are used to reduce conflict between the
duction, it should be left open to permit the free arms of the surgeon and first assistant.
flow of CO₂ gas between the extraperitoneal and
intraperitoneal space. The only time when the
peritoneum can be closed is while inserting the
first trocar, at the level of the umbilicus, when
gas is not yet inflated.
Surgical Technique

The operating table is moved down and backward,  eritoneum Displacement

and the patient is placed in a slight Trendelenburg
position. Steps are placed for the surgeon, and the bi-
polar and monopolar pedals are placed over the step
(Fig. 18a,b).
P
and Exposure of the Bladder Neck
The peritoneum is cranially mobilized to increase the
extraperitoneal space. The fibroareolar and fatty tissue
74 Section II
Fig. 18
a Steps under the surgeon. b Position of the operative team
layers between the superolateral aspect of the blad-
der and the medial aspect of the external iliac vein are
bilaterally released. This maneuver, along with reduc-
tion of any visible pelvic wall hernia, allows for further
peritoneum displacement.
TIP
Every effort should be made to thoroughly coag-
ulate the bleeding vessels during this dissection
to avoid image decay throughout the procedure.
The fatty tissue around the prostate is freed, starting lat-
erally from the reflection of the endopelvic wall toward
the midline on both sides (Fig. 19).
Laparoscopic Surgery for Malignant Urological Disorders
TIP
A little traction on the tissue opens the right
plane, and it is easier to start the dissection at
the endopelvic fascia.
The fibroareolar and fatty tissue attached at the level
of the Santorini plexus and over the anterior surface of
the prostate are pulled down toward the bladder neck
with gentle but firm traction with the bipolar grasper.
The superficial branch of the deep dorsal vein com-
plex is coagulated with the bipolar grasper and cut
with the cold scissors (Fig. 20).
 Chapter 5 Extraperitoneal Laparoscopic Radical Prostatectomy 75

Fig. 19 Fig. 20
Fatty tissue covering the prostate Superficial veins of the Santorini plexus (A)

The fatty tissue downward traction maneuver continues

until resistance is encountered, signaling the approach
of the bladder neck. The dissected fatty tissue is then
lifted and divided in the midline to facilitate the co-
agulation and transection of the vessels that overlie the
bladder neck. The removal of this fatty tissue facilitates
visualization and dissection of the bladder neck, which
is usually located under the crossing of the fibers of the
puboprostatic ligaments (Fig. 21).
Fig. 21
TIP
Anterior prostatic surface free of fatty tissue
The superficial branch of the deep dorsal vein
travels between the puboprostatic ligaments and
is the centrally located vein overlying the blad-
TIP
der neck and prostate. It has communicating
The superficial branch is transected at a safe branches over the bladder itself and into the en-
distance from the pubic bone to prevent retrac- dopelvic fascia, so it is important to coagulate
tion of the vein and to permit easy vessel control the vessels over the bladder neck when removing
in case of bleeding. the fatty tissue at this level.
76 Section II
Fig. 22
Bladder neck (A) at the crossing of the fibers of the pubo-
prostatic ligaments; Puboprostatic ligaments (B)
Bladder Neck Dissection and Division
The bladder neck is situated under the crossing of the
fibers of the puboprostatic ligaments (Fig. 22).
A transversal incision with the monopolar scissors
along with forceful counter pressure with the bipolar
grasper, which is placed over the bladder, opens the su-
perficial layer and exposes the correct plane of dissec-
tion (Fig. 23).
The incision progresses to assume an inverted
U-shape to avoid dissecting through the lateral sides of
the prostate. At the medial portion of the dissection, the
longitudinal muscle fibers of the anterior urethral wall
are exposed (Fig. 24). The urethra is dissected at its ante-
rior and lateral aspect and then transversally transected
close to the bladder neck to avoid perioperative urinary
retention.
The Foley catheter is removed, and a metal 45 Fr bou-
gie is introduced to facilitate elevation of the prostate.
The dissection of the posterior plane between the blad-
der neck and the prostate is initiated with a U-shaped
incision on the posterior urethral wall. To dissect the
right lateral side of the bladder neck, the bipolar grasper
with the jaws in the “closed” position is introduced into
the bladder. The monopolar scissors, placed at the ex-
Laparoscopic Surgery for Malignant Urological Disorders
Fig. 23
Bladder neck (A) dissection
ternal lateral side of the bladder, touch the tip of the
grasper to confirm the limits of the lateral dissection.
The lateral side of the bladder is dissected, and by apply-
ing downward tension on the grasper that now holds the
anterolateral bladder wall, the correct plane between the
posterior bladder neck and the prostate is developed.
TIP
Care must be taken not to perforate the bladder
at this level as the ureteral orifices are in close
proximity.
The dissection is carried out from the lateral side to the
center and continues to the other side to fully separate
the bladder neck from the base of the prostate (Fig. 25).
 issection of the Seminal Vesicles
D
and Exposure of Denonvilliers’ Fascia
The plane of longitudinal muscle fibers behind the blad-
der neck (Bell’s muscle layer) is transversally incised to
expose the vas deferens. A probe can be inserted via the
 Chapter 5 Extraperitoneal Laparoscopic Radical Prostatectomy 77

Fig. 24 Fig. 25
Anterior urethral wall (A) Opened bladder neck with Foley catheter

suprapubic port to aid in retraction of the bladder. The
vas is grasped and pulled up and laterally to expose its
medial side. With a sweeping movement with the mo-
nopolar scissors, the plane between the medial side of
the seminal vesicle and the Denonvilliers’ fascia is re-
leased (Fig. 26).
The vas is dissected inferiorly and cut with cold scis-
sors at its lower point.
fascia is bluntly incised, and with downward pressure of
the suction device placed at the incision, the posterior
surface of the prostate is released.
There are three planes of dissection at this level
(Fig. 27):
• A. A plane that extends into the prostate (the wrong
plane of dissection!)

TIP

With the bipolar, coagulate the vas deferens vas-

cular pedicle, which is situated behind the vas;
after cutting this pedicle, the seminal vesicle is
always exposed.

The seminal vesicle is grasped and pulled toward the op-

tic to facilitate exposure. The lateral pedicle of the semi-
nal vesicle is dissected and coagulated, and following the
inferior pedicle dissection and coagulation, the seminal
vesicle tip is then freed. The same dissection is made on
Fig. 26
the left vas and seminal vesicle. Both structures are then
Dissection of medial side of seminal vesicle (A); Denonvil-
grasped and lifted to facilitate dissection of the posterior liers’ fascia (B)
plane of the prostate from the Denonvilliers’ fascia. This
78 Section II
Fig. 27
Three posterior planes of prostate dissection (see text
above): (A), (B), and (C)
• B . A plane between the Denonvilliers’ fascia and the
prostate, which is the plane developed for neurovas-
cular bundle preservation
• C. A posterior plane between the rectum and the De-
nonvilliers’ fascia—developed in cases of wide exci-
sion of the prostate without neurovascular bundle
preservation
Endopelvic Fascia 
and Puboprostatic Ligaments
The two layers of the endopelvic fascia are separated
using gentle and forceful lateral traction and counter-
traction at the level of the bladder neck (Fig. 28). The fi-
bers should not be divided close to the prostate to avoid
lacerating the large veins that cross lateroposterior to
the prostate. As the two layers of endopelvic fascia be-
come more adherent moving toward the apex, they are
then incised with the monopolar scissors to open the
plane between the prostate and the endopelvic fascia
(Fig. 29a,b).
Laparoscopic Surgery for Malignant Urological Disorders
Fig. 28
Right endopelvic fascia
The dissection continues upward to liberate the peri-
urethral muscle from the prostatic apex.
TIP
The muscle is bluntly separated from the lateral
side of the apex with cold scissors and laterally
displaced to the pelvic wall to facilitate the dor-
sal venous complex ligature.
The puboprostatic ligament is cut close to the pubic
bone, and the vessels are carefully dissected to expose
the plane between the pubic bone and the dorsal venous
complex of the penis.
TIP
If bleeding occurs at this stage, the prostate is
lifted with the metal bougie and pressed against
the pubic bone.
 Chapter 5
Fig. 29
a Endopelvic fascia layers divided. b Incision with monopolar scissors
The same dissection is done at the other side, and
the dorsal venous complex is ready to be ligated
(Fig. 30).
Dorsal Venous Complex of the Penis (DVC)
The dorsal vein complex at the apex of the prostate is
ligated with Polysorb 0 CL 802 (needle ½ 40 mm) but
not immediately cut. The needle is passed from right to
left in the avascular plane between the urethra and the
dorsal vein complex.
TIP
The needle in the needle driver is positioned
with the tip facing down to the left and with an
angle of 90°.
The needle is loaded on the tissue and elevated. Then
it is advanced to the other side and finally turned to be
Extraperitoneal Laparoscopic Radical Prostatectomy 79
exited at the same entrance point level on the counterla-
teral side (Fig. 31a,b).
TIP
The common trunk of the Santorini deep venous
plexus and lateral venous plexuses are covered
and concealed by the prostatic and endopelvic
fascia. The lateral venous plexuses course pos-
terolaterally and communicate freely with the
pudendal, obturator, and vesical plexuses. Near
the puboprostatic ligaments, small branches
from the lateral plexus often penetrate the pelvic
sidewall musculature and communicate with the
internal pudendal vein. The lateral plexus inter-
connects with other venous systems to form the
inferior vesical vein, which empties into the in-
ternal iliac vein. With the complex of veins and
plexuses anastomosing freely, any laceration of
these rather friable structures can lead to con-
siderable blood loss.
80 Section II Laparoscopic Surgery for Malignant Urological Disorders

ers are incised with cold scissors, and the neurovascu-

lar bundle is gently separated from the prostate, taking
care not to disrupt the prostatic capsule. The dissection
is carried out in an “antegrade” or “descending” manner
bilaterally, and the use of coagulation is prohibited to
avoid damage to the neurovascular bundle (Fig. 32).

TIP

As the neurovascular bundle usually runs at a

minimal distance from the prostate at the level
of the apex, the dissection of the bundle is easier
at this level.

Fig. 30
The suction device should be positioned at a level inferior
Dorsal venous complex of the penis
to the dissection to aspirate the blood off the operat-
ing field.

I dentification and Preservation TIP

of the Neurovascular Bundle
The neurovascular bundles are dissected and preserved,
depending on anatomic and oncologic conditions. The
posterolateral surface of the prostate is exposed by roll-
ing it sideways, and sometimes the metal bougie must
be removed to facilitate this maneuver. The fascial lay-
The maneuver to dissect the neurovascular bun-
dle at the right side is medial displacement of the
posterolateral side of the prostate with the aid of
the grasper and dissection with the monopolar
scissors; for the left side, both instruments are
used alternately.

Fig. 31
a Dorsal vein complex ligation (A). b Angle of needle introduction (90°)
Chapter 5 Extraperitoneal Laparoscopic Radical Prostatectomy 81

Fig. 32
Left neurovascular bundle (A); Prostate (B)

Fig. 33
a Right prostatic pedicle suturing. b Left prostatic pedicle
suturing. c Prostatic pedicle – vessel ligation
82 Section II
The Prostatic Pedicles
There are several techniques to approach the prostatic
pedicles, and they should be individualized for each pa-
tient. The prostate is lifted with the metal bougie to put
the pedicles under tension. The pedicle is controlled at
a safe distance from the neurovascular bundle and high
on the base of the prostate. It is cut with cold mono-
polar scissors close to the prostate, and coagulation of
bleeding vessels should be avoided at all times if potency
preservation is being considered.
Laparoscopic Surgery for Malignant Urological Disorders
Fig. 34
a Dissector under right prostatic pedicle.
b Thread placed at the tip of the dissector.
c Thread encompasses right prostatic pedicle
Technique 1
Passing a Vicryl 0 at the base of the prostatic pedicle
(superficial to the neurovascular bundle), and tying the
knot but not cutting the needle. The pedicle is cut with
cold scissors and at the same time the pedicle vessels are
carefully dissected and tied with the suture already in
place. In this technique, the dissection of the neurovas-
cular bundle begins from the posterolateral side of the
prostate, and is done after the section of the vascular
pedicle. (Fig. 33a–c).
 Chapter 5
TIP
Two rounds of suture should be passed at every
stage, and too much space should not be left in
between the running suture to avoid tearing the
tissue while performing the final knot.
Extraperitoneal Laparoscopic Radical Prostatectomy 83
Fig. 35
a Neurovascular bundle (NVB); Prostatic pedicle vessel
(V). b Neurovascular bundle dissected with cold scissors.
c Neurovascular bundle displaced laterally
Technique 2
This technique involves passing a dissector underneath
the pedicle close to the prostate, at right angles to its
®
axis, and placing a simple suture of Vicryl 0 at the tip of
the clamp to be tied intracorporally. This suture should
not encompass the neurovascular bundle that runs par-
allel to the prostatic pedicle (Fig. 34a–c). To pass the dis-
sector through the left pedicle, the dissector is inserted
through the right iliac spine port, and the suction device
is placed through the paraumbilical port.
84 Section II
Technique 3
In the third technique, the pedicle is cut with cold scis-
sors and, at the same time, the vessels are dissected
and clipped with small size (5 mm) Hem-o-lok clips,
taking care not to compromise the prostatic margins.
In this technique, the dissection of the neurovascular
bundle begins from the posterolateral side of the pros-
tate and is done after the section of the vascular pedicle
(Fig. 35a–c).
Technique 4
The final technique involves placing bilateral atraumatic
vascular bulldog clamps (with long arms), which are in-
troduced with the aid of a laparoscopic bulldog clamp
applier. They are placed in a proximal position at the
prostatic pedicle, approximately 1 cm from the prostate.
After transecting the vascular pedicle, either a suture or
fibrin sealant can be used to control the bleeding follow-
ing removal of the vascular clamps (Fig. 36).
Fig. 36
Bulldog clamp at the pedicle
Laparoscopic Surgery for Malignant Urological Disorders
TIP
The Denonvilliers’ fascia must be longitudinally
incised on both sides of the rectum for the cor-
rect placement of the long arms’ bulldog clamp.
TIP
When bleeding occurs after the prostatic pedicle
®
is transected, a running suture of Vicryl 2-0 SH
Plus is superficially placed at the internal side
of the Denonvilliers’ fascia, endopelvic fascia,
and the vascular pedicle to control the bleeding
vessel. Beginning at the internal side of Denon-
villiers’ fascia, the needle is passed from a cra-
nial to a caudal direction; then at the endopelvic
fascia, the needle is passed from a caudal to a
cranial direction. The last suture is placed at the
proximal prostatic pedicle; the needle is intro-
duced from the lateral to the medial side, and
the knot is then tied.
Fig. 37
Dorsal vein complex division
 Chapter 5
After the pedicles are incised, the metal bougie is pulled
back from the urethra to facilitate elevation of the pros-
tate. The posterior attachments to the Denonvilliers’
fascia and the posterolateral attachments to the neuro-
vascular bundle are released up to the apex with blunt
and sharp dissection. The gland is now only connected
to the deep venous complex and the urethra.
 ivision of the Dorsal Vein Complex
D ®
and Urethra
By applying downward pressure on the metal bougie,
the anterior surface of the prostate is exposed. The dor-
sal vein complex is divided at the apex with cold scis-
sors, and the initial incisions are tangential to the pros-
tate to avoid inadvertent entry into the gland (Fig. 37).
By moving the metal bougie sideways, the urethra is
dissected at its lateral sides until the prostatourethral
junction is visualized. The metal bougie is retracted to
allow the transection of the urethra as close to the apex
as possible (Fig. 38).
Fig. 38
Prostatourethral junction divided
Extraperitoneal Laparoscopic Radical Prostatectomy 85
TIP
Following the transection of the anterior wall of
the urethra, the metal bougie is lifted to expose
the posterior wall.
The prostate is released, and the operative site is care-
fully inspected for bleeding (Fig. 39). A small endobag
(EndoCatch ) is introduced through the left 11-mm
port, and the prostate is inserted into it. The bag with
the specimen is left inside to be removed at the end of
the procedure (Fig. 40).
TIP
A retractor is introduced through the 11-mm
left iliac spine port, and the port is partially re-
moved over it. The string of the bag is exterior-
ized through the outer surface of the port, and
the port is replaced over the retractor. The bag is
then pulled out and partially exteriorized, fixing
the prostate away from the operative field.
Fig. 39
Prostate released
86 Section II
Fig. 40
Prostate inserted into endobag
 ladder Neck Reconstruction
B done with the left hand. For the anterior sutures,
and Anastomosis
When the bladder neck needs to be reconstructed, a
posterior running suture of Vicryl 2-0 is used to ap-
proximate full-thickness muscularis and mucosa, form-
ing a tennis racket closure. It is important to visualize
the position of the ureteral orifices before the closure
is initiated to avoid inadvertent passage of the suture
through the ureter. The bladder neck is narrowed to ap-
proximate the diameter of the urethra. The anastomosis
between the bladder neck and the urethra is performed
by interrupted sutures of Polysorb 2-0 GL 123 (needle
½ 26 mm). The lateral movements of the metal bougie
inserted at the urethra aid in the passage of the needle.
Beginning at the posterior bladder neck, a U-shaped
suture is placed from the inside–outside at the bladder
level; from the outside–inside of the lumen of the ure-
thra; from the inside–outside of the lumen of the ure-
thra; and finally from the outside–inside of the lumen of
the bladder. The double-looped knot, placed inside the
bladder neck, is spontaneously self-blocked due to the
tension applied to the threads, allowing the bladder and
urethra to be approached together (Fig. 41a–f).
Laparoscopic Surgery for Malignant Urological Disorders
TIP
If tension is encountered at this step, the insuf-
flator pressure and the Trendelenburg position
are reduced to facilitate the anastomosis.
The metal bougie is placed inside the bladder, guiding
the passage of the needle for the following sutures.
Two sets of lateral sutures alternating at the 5, 7,
2, and 10 o’clock positions (Figs. 42a,b and 43) and a
U-shaped suture at the 12 o’clock position with the knot
on the outside are introduced (Fig. 44a–d). This U-
shaped suture can also be used to close the bladder neck
anteriorly, if necessary. Traction should be avoided at all
times while passing the sutures to prevent tearing of the
urethral wall.
TIP
The right posterior sutures are done with the
right hand, and the left posterior sutures are
the instrument is crossed in the midline. The po-
sition of the needle on the needle holder is 2/3
posterior at a 45º angle for the posterior and an-
terior sutures and at a 90° angle for the lateral
sutures.
A silicone 18 Fr Foley catheter is introduced through a
guide after the anastomosis is completely performed to
avoid puncture of the catheter.
TIP
The guide with the catheter should be laterally
moved inside the bladder to confirm it is in the
correct intravesical position.
The balloon is filled with 10 mL of saline, and the in-
tegrity of the anastomosis is demonstrated by filling the
bladder with 200 mL of irrigation fluid.
The prostate is removed by enlarging the left iliac
spine port site.
 Chapter 5 Extraperitoneal Laparoscopic Radical Prostatectomy 87

Fig. 41
Posterior vesicourethral suture sequence: a Initial suture at bladder neck. b Suture at posterior right side of urethra. c Suture
exiting urethral lumen, right side. d Suture entering urethral lumen, left posterior side of urethra. e Final suture at bladder neck.
f Bladder neck approaching urethra
88 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 42
Right lateral vesicourethral suture sequence: a Suture entering lateral bladder side. b Suture entering lateral urethral lumen

TIP A Penrose drain is positioned close to the anastomosis

To enlarge the incision for the passage of the bag
containing the prostate, the skin is cut at its me-
dial end, and the fascia is cut at the lateral end
to avoid injuring the epigastric vessels.
and exited through the right iliac spine port site. The
aponeurosis of the 11-mm port is closed with Polysorb 0
sutures, and the skin is closed with running intradermic
Monocryl 3-0.

Postoperative Considerations
The nasogastric tube is removed at the end of the pro-
cedure. The patient is given appropriate analgesia as per
protocol, including intravenous paracetamol during the
first 24 h and major analgesics as necessary. The intra-
venous perfusion is stopped on day 1 after surgery, oral
fluids are started the morning after surgery, and a light
diet can generally be resumed on day 2. The suprapubic
drain is usually removed after 48–72 h or after secre-
tions are below 50 mL. The bladder catheter is removed
on day 5 after surgery if urine is clear, but in case of per-
sistent residual haematuria, a cystogram is performed.
Normal activity is resumed four weeks after surgery.

Fig. 43
Left lateral vesicourethral suture
 Chapter 5 Extraperitoneal Laparoscopic Radical Prostatectomy 89

Fig. 44
Anterior vesicourethral suture sequence: a Initial suture at anterior bladder side. b Suture exiting at anterior urethral side. c Su-
ture entering urethral anterior side. d Final knot

4. Erdogru T, Teber D: Comparison of transperitoneal and

Suggested Readings
1. Levinson AW, Su LM: Laparoscopic radical prostatectomy:
current techniques. Curr Opin Urol 2007 Mar; 17(2):98–
103.
2. Stolzenburg JU, Rabenalt R: Endoscopic extraperitoneal
radical prostatectomy: oncological and functional results
after 700 procedures. J Urol 2005 Oct; 174(4 Pt 1):1271–
1275; discussion 1275.
3. Gill IS, Ukimura O: Lateral pedicle control during laparo-
scopic radical prostatectomy: refined technique. Urology
2005 Jan; 65(1):23–27.
extraperitoneal laparoscopic radical prostatectomy using
match-pair analysis. Eur Urol 2004 Sep; 46(3):312–319; dis-
cussion 320.
5. Ruiz L, Salomon L: Comparison of early oncologic results
of laparoscopic radical prostatectomy by extraperito-
neal versus transperitoneal approach. Eur Urol 2004 Jul;
46(1):50–54; discussion 54–56.
6. Bollens R, Vanden Bossche M: Extraperitoneal laparoscopic
radical prostatectomy. Results after 50 cases. Eur Urol 2001
Jul; 40(1):65–69.
7. Raboy A, Albert P: Early experience with extraperitoneal
endoscopic radical retropubic prostatectomy. Surg Endosc
1998 Oct; 12(10):1264–1267.
 Chapter 6

Transperitoneal
Laparoscopic Radical
Prostatectomy

Contents
Introduction
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   91 Laparoscopic radical prostatectomy has become an es-
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . .
P   91 tablished treatment for organ-confined prostate cancer
Patient Positioning and Initial Preparation  .. . .   92 and is increasingly performed at selected centers world-
Trocars and Laparoscopic Instruments   .. . . . . . .   93 wide. The potential advantages of the transperitoneal
Access and Port Placement  . . . . . . . . . . . . . . . . . . . .   93 laparoscopic radical prostatectomy compared to the
Veress Needle  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   93 extraperitoneal approach are a greater working space
First Port (11 mm, optic 0°)  . . . . . . . . . . . . . . . . . .   94 and reduced tension on the urethrovesical anastomosis.
S econd Port (11 mm, bipolar grasper)  .. . . . . .   94 Furthermore, when performing extended pelvic lymph-
Third Port (5 mm, suction device)  . . . . . . . . . . .   95 adenectomy for high-risk prostate cancer patients, the
Fourth Port (5 mm, monopolar round-tipped transperitoneal technique is technically less demanding
scissors)  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   95 than the extraperitoneal approach.
Fifth Port (5 mm, palpator)  . . . . . . . . . . . . . . . . . .   95
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . . .   95
Bowel Displacement   .. . . . . . . . . . . . . . . . . . . . . . .   95
Pelvic Lymphadenectomy  .. . . . . . . . . . . . . . . . . .   96
Preoperative Preparation
Douglas Pouch Incision and Dissection Before a patient consents to a laparoscopic radical pros-
of the Seminal Vesicles  .. . . . . . . . . . . . . . . . . . . . .   97 tatectomy, it is important to discuss the specific risks of
Anterior Dissection—Retzius Space  . . . . . . . . .   98 the surgery, including the potential need to convert to
Peritoneum Displacement and Exposure the traditional open operation if difficulties arise.
of the Bladder Neck  . . . . . . . . . . . . . . . . . . . . . . . . .   99 The patient is admitted to the hospital one day before
Bladder Neck Dissection and Division  . . . . . . .   100 the surgery for bowel preparation, which includes 2 L of
Dissection of the Seminal Vesicles ® ®
Colopeg (1 envelope/L) p.o. and a Fleet enema). Fast-
and Exposure of Denonvilliers’ Fascia  .. . . . . . .   101 ing starts at midnight before surgery. Thromboprophy-
Endopelvic Fascia and Puboprostatic laxis is implemented with good hydration, placement
Ligaments  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   102 of compressive elastic stockings on the lower extremi-
Dorsal Venous Complex of the Penis (DVC)    104 ties, and low-molecular-weight heparin. Enoxaparin
Identification and Preservation ® ®
(Clexane , Lovenox ) 40 mg sc 1 × day or nadroparin
of the Neurovascular Bundle   .. . . . . . . . . . . . . . .   104 ® ®
(Flaxiparine , Fraxiparin ) 0.6 mL sc 1 × day is initi-
The Prostatic Pedicles   .. . . . . . . . . . . . . . . . . . . . . .   105 ated on day 1 after the surgery and continued daily until
Division of the Dorsal Vein Complex the patient is discharged from the hospital. In selected
and Urethra  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   108
Bladder Neck Reconstruction
and Urethrovesical Anastomosis  . . . . . . . . . . . .   109
Postoperative Considerations  . . . . . . . . . . . . . . . . .   113
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . .   113
92 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 1 Fig. 2
Patient position Position of the legs

Patients also receive antibiotic prophylaxis with a single

preoperative dose of intravenous second-generation
cephalosporin, unless they are allergic to penicillin.
Blood type and crossmatch are determined.

Patient Positioning and Initial Preparation

The surgery is performed under general anesthesia. The
base of the table must be positioned below the patient’s
hip to avoid elevation of the abdomen while in the Tren-
delenburg position (Fig. 1).
The patient is placed in the supine position with the
lower limbs in abduction, allowing the laparoscopic cart
to be moved closer to the surgeon and intraoperative ac-
Fig. 3
cess to the perineum (Fig. 2).
Shoulder support
The lower buttocks must be placed at the distal end
of the operating table. The upper limbs are positioned
alongside the body to avoid the risk of stretch injuries to
cases, the treatment is continued for 30 days after the the brachial plexus and to allow for free movements of
procedure. the operative team. Shoulder support is placed over the
acromium clavicular joint (Fig. 3) for the Trendelenburg
TIP position.
A nasogastric tube is placed by the anesthesiologist
Thromboprophylaxis is justified due to the con- and the stomach decompressed to avoid puncture dur-
current risk factors of laparoscopy, cancer, and ing trocar placement. The abdomen, pelvis, and genita-
pelvic surgery. lia are skin prepared in case conversion to an open pro-
cedure is required. An 18Fr Foley catheter with 10 mL
 Chapter 6 Transperitoneal Laparoscopic Radical Prostatectomy 93

Fig. 4 Fig. 5
Laparoscopic cart at patient’s feet Instruments table

in the balloon is introduced after the placement of the

sterile drapes.
Access and Port Placement
The surgeon operates from the patient’s left side, and See Figure 6.
the first assistant is placed at the opposite side of the sur-
geon. The laparoscopic cart is placed at the patient’s feet, Veress Needle
while the instruments table and the coagulation unit are
positioned at the left side of the patient (Fig. 4). A cutaneous incision is made at the inferior and right
margin of the umbilicus.

Trocars and Laparoscopic Instruments
• 2 × 11 mm (optic 0°, bipolar grasper, and 10-mm clip
applier)
• 3 × 5 mm (scissors, suction device, and palpator)
• Monopolar round-tipped scissors, bipolar grasper,
dissector, 5-mm suction device, 10-mm clip applier
(non-disposable), needle drivers (2), and 10-mm lap-
aroscopic optic 0° (Fig. 5)
TIP
The incision should be 50% larger than the di-
ameter of the 11-mm trocar.
The trocar is placed in the midline to facilitate access to
the right epigastric vessels in case injury to these vessels
occurs during insertion of the fourth trocar. The Veress
94 Section II
needle is introduced through the incision, and pneumo-
peritoneum is started (see Chap. 1, Veress Needle Intro-
duction).
First Port (11 mm, optic 0°)
Once pneumoperitoneum is established, the needle is
removed, and the 11-mm port is introduced through the
same incision, perpendicularly to the abdominal wall.
TIP
Pneumoperitoneum is established with an intra-
abdominal pressure higher than 10 mmHg.
The optic is inserted through the port.
Fig. 6
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)
Laparoscopic Surgery for Malignant Urological Disorders
TIP
After trocar placement and obturator removal,
the trocar valve is briefly opened to check for
egress of CO , confirming it is correctly placed
2
inside the abdomen. The insufflator line is then
connected to the trocar.
Second Port (11 mm, bipolar grasper)
A cutaneous incision is made 2 cm medial and superior
to the left anterior superior iliac spine for insertion of
the 11-mm trocar.
 Chapter 6
Fig. 7
Ports in place
TIP
During trocar introduction, once the cutting tip
pierces the peritoneum, the position of the device
is secured, allowing further gliding of the trocar
to a desired site. This maneuver prevents block-
age of the movements of the working instruments
following an incorrect insertion.
Third Port (5 mm, suction device)
A cutaneous incision is made 2 cm medial and superior
to the right anterior superior iliac spine for introduction
of the 5-mm trocar.
Transperitoneal Laparoscopic Radical Prostatectomy 95
Fourth Port (5 mm, 
monopolar round-tipped scissors)
For insertion of the 5-mm trocar, a cutaneous incision is
made at a point situated at the junction of the lateral 2/3
and medial 1/3 distance between the right anterior iliac
spine trocar and the umbilicus trocar.
TIP
Pay attention to the epigastric vessels, which can
be visualized by pressing the right lateral part of
the abdomen.
Fifth Port (5 mm, palpator)
A 5-mm port is medially placed two fingers above the
pubis bone to complete placement of the ports (Fig. 7).
The operating table is moved down and backward,
and the patient is placed in an extended Trendelenburg
position. Steps are placed under the surgeon, and the
bipolar and monopolar pedals are placed over the step.
The surgeon, positioned higher than the assistant, can
then use the working instruments (bipolar grasper and
monopolar scissors) without being restrained by the as-
sistant holding the optic in the upper midline position
(Fig. 8a,b). This maneuver reduces the conflict between
the operative team’s arms.
Surgical Technique
Bowel Displacement
The intestine is positioned above the promontory by
gently pushing back the loops of the small bowel with
the aid of the Trendelenburg position. If necessary, the
cecum is dissected off the posterior peritoneum to in-
crease its mobility and assist in the cranial displacement
of the small bowel. To facilitate the left-side dissection,
the sigmoid and its mesocolon are laterally displaced
and fixed to the abdominal wall using a monofilament
2-0 straight needle suture.
96 Section II
TIP
The suture needle is passed through the skin at a
point lateral and cranial to the left port, placed
through the appendices epiploicae of the sigmoid
colon, and exited close to the entrance point. It is
held in place by a Kocher clamp.
The fixation has to be released for the left pelvic wall dis-
section.
Pelvic Lymphadenectomy
In selected cases, a standard pelvic lymphadenectomy is
bilaterally performed using a “split and roll” technique.
Fig. 8
a Steps under the surgeon. b Operative team’s position
Laparoscopic Surgery for Malignant Urological Disorders
The posterior peritoneum above and lateral to the ex-
ternal iliac artery is incised with monopolar scissors.
The genitofemoral nerve, which is the lateral limit of the
node dissection, should be identified and preserved as it
courses over the psoas muscle. The lymphatic tissue is
lifted off the surface of the muscle and swept medially
toward the iliac vessels. The tissue anterior to the iliac
artery is longitudinally divided using the monopolar
scissors, and the dissection extends to its lateral, medial,
and inferior sides. The same dissection is done on the
iliac vein.
At the caudal limit of the dissection, in the angle
between Cooper’s ligament and the inferior aspect
of the external iliac vein, the nodal package over the
external iliac artery and vein is clipped (XL Hem-o-lok
 Chapter 6 Transperitoneal Laparoscopic Radical Prostatectomy 97

clips) and transected to reduce the occurrence of a lym- TIP

phocele.
In thin patients, the outline of the vas deferens
can be followed to the seminal vesicles; other-
TIP
wise, the peritoneum is incised 1–2 cm above the
The node of Cloquet is dissected at the junction Douglas pouch level.
of the femoral canal.

The plane of loose areolar tissue that contains the semi-

The dissection is then carried down behind the iliac ves-
sels, where the lateral component of the lymphatic tissue
is swept under the vessels and brought to the obturator
fossa. The lymphatic package is then carefully mobilized
off the obturator neurovascular bundle.
TIP
nal vesicles is dissected to expose its posteroinferior side
(Figs. 10 and 11).
TIP
Be careful not to injure the ureters that course
just lateral to the seminal vesicles at this point.

Care must be taken not to injure the obturator

nerve. The vas deferens is bilaterally dissected, and its vascular
pedicles are coagulated.

The dissection at this level is bordered by the obliter- TIP

ated umbilical artery, which is the medial limit of the
dissection and should be preserved. Small lymphatic Coagulate the vascular pedicle situated posterior
vessels are ligated with Ligaclip II ML. The ureter is ex- to the vas with the bipolar forceps.
posed at the place where it crosses the iliac artery, and
it is then medially displaced together with the medial
leaf of the posterior peritoneum. The nodal dissection
progresses cranially to the bifurcation of the common
iliac artery, which is the cephalad limit of the dissection.
The hypogastric artery (posterior limit of the dissection)
is stripped of lymphatic tissue, with extreme care taken
not to injure the hypogastric vein. The dissected package
is then clipped (XL Hem-o-lok) and removed through
the left 11-mm port.

 ouglas Pouch Incision and Dissection

D
of the Seminal Vesicles

The posterior peritoneum at the level of the Douglas

pouch is transversally incised at the level of the seminal
vesicles bilaterally (Fig. 9).

Fig. 9
Douglas pouch incision
98 Section II
Fig. 10
Exposure of loose areolar tissue
Fig. 12
Obliterated umbilical artery
Both vasa are then transected. The dissection of the
seminal vesicles and its vascular pedicles, which must
be thoroughly coagulated, leaves them attached only
to the prostate. By lifting both vasa deferentia and the
seminal vesicles with a grasper, the Denonvilliers’ fascia
is exposed (see Dissection of the Seminal Vesicles and
Exposure of Denonvilliers’ Fascia, Fig. 21).
Laparoscopic Surgery for Malignant Urological Disorders
Fig. 11
Seminal vesicle (SV)
TIP
Denonvilliers’ Fascia can be dissected at a later
stage.
Anterior Dissection—Retzius Space
The anterior peritoneum is incised medial to the obliter-
ated umbilical artery (medial umbilical ligament) at the
femoral ring (Fig. 12), and a plane between the prevesi-
cal fat and the lateral pelvic wall is developed.
The incision of the peritoneum continues transver-
sally to the contralateral side, forming an arch cephalad
to the bladder and inferior to the umbilicus. The urachus
(median umbilical ligament) is identified and divided.
TIP
Be careful not to injure the dome of the bladder
at this level.
The plane between the prevesical fat and the anterior
abdominal wall is developed (Retzius space, Fig. 13),
 Chapter 6
Fig. 13
Retzius space (R); Bladder (B); Pubic bone (P)
exposing the endopelvic fascia bilaterally and the San-
torini plexus medially.
TIP
From this step onward, the progress of the dissec-
tion is similar to Laparoscopic Extraperitoneal
Radical Prostatectomy.
 eritoneum Displacement and Exposure
P tion of the vein and to permit easy vessel control
of the Bladder Neck
The fatty tissue around the prostate is freed, starting lat-
erally from the reflection of the endopelvic wall toward
the midline on both sides (Fig. 14).
TIP
A little traction on the tissue opens the right
plane, and it is easier to start the dissection at
the endopelvic fascia.
Transperitoneal Laparoscopic Radical Prostatectomy 99
Fig. 14
Fatty tissue covering the prostate
The fibroareolar and fatty tissue attached at the level of
the Santorini plexus and over the anterior surface of the
prostate are pulled down toward the bladder neck with
gentle but firm traction with the bipolar grasper. The su-
perficial branch of the deep dorsal vein complex is co-
agulated with the bipolar grasper and cut with the cold
scissors (Fig. 15).
TIP
The superficial branch is transected at a safe
distance from the pubic bone to prevent retrac-
in the case of bleeding.
The fatty tissue downward traction maneuver contin-
ues until resistance is encountered, signaling the ap-
proach of the bladder neck. The dissected fatty tissue is
then lifted and divided in the midline to facilitate the
coagulation and transection of the vessels that overlie
the bladder neck. The removal of this fatty tissue facili-
tates visualization and dissection of the bladder neck,
which is usually located under the crossing of the fibers
of the puboprostatic ligaments (Fig. 16).
100 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 15 Fig. 16
Superficial veins of the Santorini plexus (A) Anterior prostatic surface free of fatty tissue

TIP

The superficial veins of the Santorini plexus

travel between the puboprostatic ligaments and
are the centrally located veins overlying the blad-
der neck and prostate. There are communicating
branches over the bladder itself and into the en-
dopelvic fascia, so it is important to coagulate
the vessels over the bladder neck when removing
the fatty tissue at this level.

Bladder Neck Dissection and Division

Fig. 17
The bladder neck is situated under the crossing of the
Bladder neck (A); Puboprostatic ligaments (B)
fibers of the puboprostatic ligaments (Fig. 17).
A transversal incision with the monopolar scissors,
along with forceful counter pressure with the bipolar
grasper, which is placed over the bladder, opens the su-
perficial layer and exposes the correct plane of dissec-
tion (Fig. 18).
 Chapter 6
Fig. 18
Dissection of bladder neck (A)
The incision progresses to assume an inverted
U-shape to avoid entering through the lateral sides of
the prostate. At the medial portion of the dissection,
the longitudinal muscle fibers of the anterior wall of the
urethra are exposed (Fig. 19). The urethra is dissected
at its anterior and lateral aspect and then transversally
incised close to the bladder neck to avoid perioperative
urinary retention.
The Foley catheter is removed, and a metal 45 Fr
bougie is introduced to facilitate elevation of the pros-
tate. The dissection of the posterior plane between
the bladder neck and the prostate is initiated with
a U-shaped incision on the posterior urethral wall.
To dissect the right lateral side of the bladder neck, the
bipolar grasper with the jaws in the “closed” position is
introduced into the bladder. The monopolar scissors,
placed at the external lateral side of the bladder, touch
the tip of the grasper to confirm the limits of the lateral
dissection. The lateral side of the bladder is dissected,
and by applying downward tension on the grasper that
now holds the anterolateral bladder wall, the correct
plane between the posterior bladder neck and the pros-
tate is developed.
Transperitoneal Laparoscopic Radical Prostatectomy 101
Fig. 19
Anterior wall of the urethra (A)
TIP
Care must be taken not to perforate the bladder
at this level as the ureteral orifices are in close
proximity.
The dissection is carried out from the lateral side to the
center and extends to the other side to fully separate the
bladder neck from the base of the prostate (Fig. 20).
 issection of the Seminal Vesicles
D
and Exposure of Denonvilliers’ Fascia
The plane of longitudinal muscle fibers behind the blad-
der neck (Bell’s muscle layer) is horizontally incised to
expose the previously dissected retrovesical space. The
vasa deferentia and the seminal vesicles are then elevated
with the grasper to facilitate dissection of the posterior
plane of the prostate from the Denonvilliers’ fascia. If
not already dissected, this fascia is bluntly incised, and
with downward pressure of the suction device placed at
102 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 20 Fig. 21
Opened bladder neck with Foley catheter Three posterior planes of prostate dissection (see text): (A),
(B), and (C)

• A . A plane that extends into the prostate (the wrong

plane of dissection!)
• B. A plane between the Denonvilliers’ fascia and the
prostate, which is the plane developed for preserva-
tion of the neurovascular bundle
• C. A posterior plane between the rectum and the
Denonvilliers’ fascia, developed in cases of wide ex-
cision of the prostate without neurovascular bundle
preservation.

Endopelvic Fascia 
and Puboprostatic Ligaments

The two layers of the endopelvic fascia are separated

using gentle and forceful lateral traction and counter-
Fig. 22
traction at the level of the bladder neck (Fig. 22). The fi-
Right endopelvic fascia
bers should not be divided close to the prostate to avoid
lacerating the large veins that cross lateroposterior to
the prostate. As the two layers of endopelvic fascia be-
the incision, the posterior surface of the prostate is re- come more adherent moving toward the apex, they are
leased. then incised with the monopolar scissors to open the
There are three planes of dissection at this level plane between the prostate and the endopelvic fascia
(Fig. 21): (Fig. 23a,b).
 Chapter 6 Transperitoneal Laparoscopic Radical Prostatectomy 103

Fig. 23
a Endopelvic fascia layers divided. b Incision with monopolar scissors

The dissection continues upward to liberate the peri- The same dissection is done at the other side, and the
urethral muscle from the prostatic apex. dorsal venous complex is ready to be ligated (Fig. 24).

TIP

The muscle is bluntly separated from the lateral

side of the apex with cold scissors and laterally
displaced to the pelvic wall to facilitate the dor-
sal venous complex ligature.

The puboprostatic ligament is cut close to the pubic

bone, and the vessels are carefully dissected to expose
the plane between the pubic bone and the dorsal venous
complex of the penis.

TIP

If bleeding occurs at this stage, the prostate is

lifted with the metal bougie and pressed against
the pubic bone.

Fig. 24
Dorsal venous complex of the penis
104 Section II
Fig. 25
a Santorini deep venous plexus ligation (A). b Angle of needle introduction (90°)
Dorsal Venous Complex of the Penis (DVC)
The Santorini deep venous plexus at the apex of the pros-
tate is ligated with Polysorb 0 CL 802 (needle ½ 40 mm)
but not immediately cut. The needle is passed from right
to left in the avascular plane between the urethra and
the dorsal vein complex.
TIP
The position of the needle in the needle driver is
with the tip facing down to the left and with an
angle of 90°.
The needle is loaded on the tissue and elevated. Then
it is advanced to the other side and finally turned to be
exited at the same entrance point level on the counterla-
teral side (Fig 25a,b).
I dentification and Preservation
of the Neurovascular Bundle
The neurovascular bundles are dissected and preserved,
depending on anatomic and oncologic conditions. The
Laparoscopic Surgery for Malignant Urological Disorders
posterolateral surface of the prostate is exposed by roll-
ing it sideways, and sometimes the metal bougie must
be removed to facilitate this maneuver. The fascial lay-
ers are incised with cold scissors, and the neurovascu-
lar bundle is gently separated from the prostate, taking
particular care not to disrupt the prostatic capsule. The
dissection is carried out in an “antegrade” or “descend-
ing” manner bilaterally, and the use of coagulation is
prohibited to avoid damage to the neurovascular bundle
(Fig. 26).
TIP
As the neurovascular bundle usually runs at a
minimal distance from the prostate at the level
of the apex, the dissection of the bundle is easier
at this level.
The suction device should be positioned at a level infe-
rior to the dissection to aspirate the blood off the oper-
ating field.
 Chapter 6
Fig. 26
Left neurovascular bundle (A); Prostate (B)
TIP
The maneuver to dissect the neurovascular bun-
dle at the right side is medial displacement of the
posterolateral side of the prostate with the aid of
the grasper and dissection with the monopolar
scissors; for the left side, both instruments are
used alternately.
The Prostatic Pedicles
There are several techniques to approach the prostatic
pedicles, and they should be individualized for each pa-
tient. The prostate is lifted with the metal bougie to put
the pedicles under tension. The pedicle is controlled at
a safe distance from the neurovascular bundle and high
on the base of the prostate. It is cut with cold mono-
polar scissors close to the prostate, and coagulation of
bleeding vessels should be avoided at all times if potency
preservation is being considered.
Transperitoneal Laparoscopic Radical Prostatectomy 105
Technique 1
Passing a Vicryl 0 at the base of the prostatic pedicle
(superficial to the neurovascular bundle), and tying the
knot but not cutting the needle. The pedicle is cut with
cold scissors and at the same time the vessels are care-
fully dissected and tied with the suture already in place.
In this technique, the dissection of the neurovascular
bundle begins from the posterolateral side of the pros-
tate, and is done after the section of the vascular pedicle.
(Fig 27a–c)
T ip
Two rounds of suture should be passed at every
stage, and too much space should not be left in
between the running suture to avoid tearing the
tissue while performing the final knot.
Technique 2
This technique involves passing a dissector underneath
the pedicle close to the prostate, at right angles to its
axis, and placing a simple suture of Vicryl 0 at the tip of
the clamp to be tied intracorporally. This suture should
not encompass the neurovascular bundle that runs par-
allel to the prostatic pedicle (Fig. 28). To pass the dis-
sector through the left pedicle, the dissector is inserted
through the right iliac spine port, and the suction device
is placed through the paraumbilical port.
Technique 3
In the third technique, the pedicle is cut with cold scis-
sors and, at the same time, the vessels are dissected
and clipped with small size (5 mm) Hem-o-lok clips,
taking care not to compromise the prostatic margins.
In this technique, the dissection of the neurovascular
bundle begins from the posterolateral side of the pros-
tate and is done after the section of the vascular pedicle
(Fig. 29a–c).
106 Section II
Technique 4
The final technique involves placing bilateral atraumatic
vascular bulldog clamps (with long arms), which are in-
troduced with the aid of a laparoscopic bulldog clamp
applier. They are placed in a proximal position at the
prostatic pedicle, approximately 1 cm from the prostate.
After transecting the vascular pedicle, either a suture or
fibrin sealant can be used to control the bleeding follow-
ing removal of the vascular clamps (Fig. 30).
Laparoscopic Surgery for Malignant Urological Disorders
Fig. 27
a Right prostatic pedicle suturing. b Left prostatic pedicle
suturing. c Prostatic pedicle – vessel ligation
TIP
The Denonvilliers’ fascia must be longitudinally
incised on both sides of the rectum for the cor-
rect placement of the long arms’ bulldog clamp.
After the pedicles are incised, the metal bougie is pulled
back from the urethra to facilitate elevation of the pros-
tate. The posterior attachments to the Denonvilliers’
 Chapter 6 Transperitoneal Laparoscopic Radical Prostatectomy 107

Fig. 28 Fig. 29
a Dissector under right prostatic pedicle. b Thread placed a Neurovascular bundle (NVB); Prostatic pedicle vessel
at the tip of the dissector. c Thread encompasses right (V). b Neurovascular bundle dissected with cold scissors.
prostatic pedicle c Neurovascular bundle laterally displaced
108 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 30 Fig. 31
Bulldog clamp at the pedicle Dorsal vein complex division

Fig. 32 Fig. 33
Prostatourethral junction divided Prostate released

fascia and the posterolateral attachments to the neuro-

vascular bundle are released up to the apex with blunt
and sharp dissection. The gland is now only connected
to the deep venous complex and the urethra.
 Chapter 6
Fig. 34
Prostate inserted into endobag
 ivision of the Dorsal Vein Complex
D  ladder Neck Reconstruction
and Urethra
By applying downward pressure on the metal bougie, the
anterior surface of the prostate is exposed. The dorsal
vein complex is divided at the apex with cold scissors,
and the initial incisions are tangential to the prostate
to avoid inadvertent entry into the gland (Fig. 31). By
moving the metal bougie sideways, the urethra is dis-
sected at its lateral sides until the prostatourethral junc-
tion is visualized.
TIP
It is important at this stage to follow the ana-
tomic contours of the prostate.
The metal bougie is retracted to allow the transection of
the urethra as close to the apex as possible (Fig. 32).
T ip
After cutting the anterior wall of the urethra, the
metal bougie is lifted to expose the posterior ure-
thral wall.
Transperitoneal Laparoscopic Radical Prostatectomy 109
The prostate is released, and the operative site is care-
fully inspected for bleeding (Fig. 33). A small endobag
is introduced through the left 11-mm port, and the
prostate is inserted into it. The bag with the specimen
is left inside to be removed at the end of the procedure
(Fig. 34).
TIP
A retractor is introduced through the 11-mm
left iliac spine port, and the port is partially re-
moved over it. The string of the bag is exterior-
ized through the outer surface of the port, and
the port is replaced over the retractor. The bag is
then pulled out and partially exteriorized, fixing
the prostate away from the operative field.
B
and Urethrovesical Anastomosis
When the bladder neck needs to be reconstructed, a
posterior running suture of Vicryl 2-0 is used to ap-
proximate full-thickness muscularis and mucosa, form-
ing a tennis racket closure. It is important to visualize
the position of the ureteral orifices before the closure
is initiated to avoid inadvertent passage of the suture
through the ureter. The bladder neck is narrowed to ap-
proximate the diameter of the urethra. The anastomosis
between the bladder neck and the urethra is performed
by interrupted sutures of Polysorb 2-0 GL 123 (needle
½ 26 mm). The lateral movements of the metal bougie
inserted at the urethra aid in the passage of the needle.
Beginning at the posterior bladder neck, a U-shaped
suture is placed from the inside–outside at the bladder
level; from the outside–inside of the lumen of the ure-
thra; from the inside–outside of the lumen of the ure-
thra; and finally from the outside–inside of the lumen of
the bladder. The double-looped knot, placed inside the
bladder neck, is spontaneously self-blocked due to the
tension applied to the threads, allowing the bladder and
urethra to be approached together (Fig. 35a–f).
110 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 35
Posterior vesicourethral suture sequence: a Initial suture at bladder neck. b Suture at posterior right side of urethra. c Suture
exiting urethral lumen, right side. d Suture entering left posterior side of urethra. e Final suture at bladder neck. f Bladder neck
approaching urethra
 Chapter 6 Transperitoneal Laparoscopic Radical Prostatectomy 111

Fig. 36
Right lateral vesicourethral suture sequence: a Suture entering lateral bladder side. b Suture entering lateral side of urethra

Two sets of lateral sutures alternating at the 5, 7,

2, and 10 o’ clock positions (Figs. 36a,b and 37) and a
U- shaped suture at the 12 o’ clock position with the
knot on the outside are introduced (Fig. 38a–d). This U-
shaped suture can also be used to close the bladder neck
anteriorly, if necessary. Traction should be avoided at all
times while passing the sutures to prevent tearing of the
urethral wall.

TIP

The right posterior sutures are done with the

right hand, and the left posterior sutures are
done with the left hand. For the anterior sutures,
Fig. 37 the instrument is crossed in the midline. The po-
Left lateral vesicourethral suture sition of the needle on the needle holder is 2/3
posterior at a 45º angle for the posterior and an-
terior sutures and at a 90° angle for the lateral
sutures.
TIP

If tension is encountered at this step, the insuf-

flator pressure and the Trendelenburg position A silicone 18 Fr Foley catheter is introduced through a
are reduced to facilitate the anastomosis. guide after the anastomosis is completely performed to
avoid puncture of the catheter.

The metal bougie is placed inside the bladder, guiding

the passage of the needle for the following sutures.
112 Section II
Fig. 38
Anterior vesicourethral suture sequence: a Initial suture at right anterior bladder side. b Suture exiting at right anterior urethral
side. c Suture entering urethral left anterior side. d Final knot
TIP
The guide with the catheter should be laterally
moved inside the bladder to confirm it is in the
correct intravesical position.
The balloon is filled with 10 mL of saline, and the in-
tegrity of the anastomosis is demonstrated by filling the
bladder with 200 mL of irrigation fluid.
The prostate is removed by enlarging the left iliac
spine port site.
Laparoscopic Surgery for Malignant Urological Disorders
TIP
To enlarge the incision for the passage of the bag
containing the prostate, the skin is cut at its me-
dial end, and the fascia is cut at the lateral end
to avoid injuring the epigastric vessels.
A Penrose drain is positioned close to the anastomosis
and exited through the right iliac spine port site. The
aponeurosis of the 11-mm port is closed with Polysorb 0
sutures, and the skin is closed with running intradermic
Monocryl 3-0.
 Chapter 6
Postoperative Considerations
The nasogastric tube is removed at the end of the pro-
cedure. The patient is given appropriate analgesia as per
protocol, including intravenous paracetamol during the
first 24 h and major analgesics as necessary. The intra-
venous perfusion is stopped on day 1 after surgery, oral
fluids are started the morning after surgery, and a light
diet can generally be resumed on day 2. The suprapubic
drain is usually removed after 48–72 h or after secretions
are below 50 mL. The bladder catheter is removed on
day 5 after surgery if the urine is clear, but in case of per-
sistent residual haematuria, a cystogram is performed.
Normal activity is resumed four weeks after surgery.
Transperitoneal Laparoscopic Radical Prostatectomy 113
Suggested Readings
1. Levinson AW, Su LM: Laparoscopic radical prostatectomy:
current techniques. Curr Opin Urol 2007 Mar; 17(2):98–
103.
2. Stolzenburg JU, Schwalenberg T: Anatomical landmarks of
radical prostatectomy. Eur Urol 2007 Mar; 51(3):629–639.
3. Rassweiler I, Seemann 0: Laparoscopic versus open radical
prostatectomy: a comparative study at a single institution.
J Urol 2003 May; 169(5):1689–1693.
4. Guillonneau B, el-Fettouh H: Laparoscopic radical prosta-
tectomy: oncological evaluation after 1,000 cases at Mont-
souris Institute. J Urol 2003 Apr; 169(4):1261–1266.
5. Guillonneau B, Rozet F: Perioperative complications of
laparoscopic radical prostatectomy: the Montsouris 3-year
experience. J Urol 2002 Jan; 167(1):51–56.
6. Hull GW, Rabbani F: Cancer control with radical prostatec-
tomy alone in 1,000 consecutive patients. J Urol 2002 Feb;
167(2 Pt 1):528–534.
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nical aspects and experience with 125 cases. Eur Urol 2001
Jul; 40(1):46–52; discussion 53.
8. Schuessler WW, Schulam PG: Laparoscopic radical prosta-
tectomy: initial short-term experience. Urology 1997 Dec;
50(6):854–857.
 Chapter 7
Laparoscopic
Transperitoneal Radical
Cystectomy
Contents
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   115
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . .  
P 115
Patient Positioning and Initial Preparation  .. . .   116
Trocars and Laparoscopic Instruments   .. . . . . . .   116
Access and Port Placement  . . . . . . . . . . . . . . . . . . . .   116
Veress Needle  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   117
First Port (11 mm, optic 0°)  . . . . . . . . . . . . . . . . . .   117
S econd Port (11 mm, bipolar grasper)  .. . . . . .   118
Third Port (5 mm, suction device)  . . . . . . . . . . .   119
Fourth Port (5 mm, monopolar round-tipped
scissors, LigaSure)  .. . . . . . . . . . . . . . . . . . . . . . . . . .   119
R adical Cystectomy in the Male  .. . . . . . . . . . . . . . .   119
Bowel Displacement   .. . . . . . . . . . . . . . . . . . . . . . .   119
Retroperitoneal Incision and Exposure 
of Iliac Vessels  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   120
Ureteral Exposure and Division   . . . . . . . . . . . . .   120
Pelvic Lymphadenectomy  .. . . . . . . . . . . . . . . . . .   121
Recto-Vesical Dissection  . . . . . . . . . . . . . . . . . . . .   125
Division of the Anterior Branches
of the Hypogastric Vessels—LigaSure 5mm    128
Anterior Dissection of the Bladder—
LigaSure 5 mm  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   129
Apical Dissection   . . . . . . . . . . . . . . . . . . . . . . . . . . .   132
The Urinary Diversion  . . . . . . . . . . . . . . . . . . . . . . .   132
R adical Cystectomy in the Female  . . . . . . . . . . . . .   134
Ureteral Exposure and Division   . . . . . . . . . . . . .   134
I nfundibulopelvic Ligament
Division and Uterine Displacement  .. . . . . . . . .   134
Pelvic Lymphadenectomy  .. . . . . . . . . . . . . . . . . .   134
Recto-Vaginal Dissection  .. . . . . . . . . . . . . . . . . . .   135
Division of the Anterior Branches of the
Hypogastric Vessels—LigaSure 5mm  . . . . . . . .   136
Anterior Dissection—LigaSure 5mm  . . . . . . . .   136
The Urinary Diversion  . . . . . . . . . . . . . . . . . . . . . . .   137
 ostoperative Considerations  . . . . . . . . . . . . . . . . .   137
P
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . .   137
Introduction
Open radical cystectomy is the reference standard
treatment for muscle-invasive bladder cancer or recur-
rent high-grade superficial bladder cancer. It is usually
performed in elderly individuals with associated medi-
cal conditions, and the procedure can cause significant
stress for patients. Following the introduction of laparo-
scopic radical prostatectomy and the resulting decrease
in patient morbidity and recovery time, laparoscopic
radical cystectomy has rapidly evolved. The oncological
outcomes of the laparoscopic approach are comparable
to the open procedure, and the urinary diversion can be
performed completely laparoscopically or by open sur-
gery with a minimal incision. The use of LigaSure facili-
tates the dissection, reducing intraoperative blood loss,
operative time, and subsequent operative costs.
Preoperative Preparation
Before a patient consents to a laparoscopic radical cys-
tectomy, it is important to discuss the specific risks of
the surgery, including the potential need to convert to
the traditional open operation if difficulties arise.
The bowel preparation is initiated by a non-residue
diet for five days before surgery and oral self-adminis­
116 Section II Laparoscopic Surgery for Malignant Urological Disorders

tration of 2 L of an electrolyte solution such as Colopeg ®
(1 envelope/L) over two days before the procedure.
The patient is admitted two days before the operation
® ®
and placed on an Ensure or Navidish diet and bowel
®
prophylactic antibiotics (500 mg Flagyl + 1 g Neomi-
®
cine 3 × p.o.). Fasting starts at midnight before surgery.
Thromboprophylaxis is implemented with good hydra-
tion, placement of compressive elastic stockings on the
lower extremities, and low-molecular-weight heparin.
® ®
Enoxaparin (Clexane , Lovenox ) 40 mg sc 1 × day or
® ®
nadroparin (Flaxiparine , Fraxiparin ) 0.6 mL sc 1 ×
day is initiated on day 1 after the surgery and continued
daily until the patient is discharged. In selected cases,
the treatment is continued for 30 days after the proce-
dure.
TIP
Thromboprophylaxis is important due to the
concurrent risk factors of laparoscopy, cancer,
and pelvic surgery.
puncture during trocar placement. The abdomen, pelvis,
and genitalia are skin prepared in case conversion to an
open procedure is required. An 18Fr Foley catheter with
10 mL in the balloon is introduced after the placement
of the sterile drapes.
The surgeon operates from the patient’s left side, and
the first assistant is placed at the opposite side of the sur-
geon. The laparoscopic cart is placed at the patient’s feet,
while the instruments table and the coagulation unit are
positioned at the left side of the patient.
Trocars and Laparoscopic Instruments
• 2 × 11 mm (optic 0°, bipolar grasper)
• 2 × 5 mm (scissors, suction device, and LigaSure)
• Monopolar round-tipped scissors, bipolar grasper,
5-mm suction device, needle drivers (2), 10-mm
™
laparoscopic optic 0°, LigaSure Atlas 5 mm (Tyco
Healthcare)

Patients also receive antibiotic prophylaxis with intra-

Access and Port Placement
venous second-generation cephalosporin, unless they See Figure 2.
are allergic to penicillin. Blood type and crossmatch are
determined. Preoperative marking of the potential ileal
conduit stoma site by a stoma therapy nurse is routine.

Patient Positioning and Initial Preparation

The surgery is performed under general anesthesia. The
base of the table must be positioned below the patient’s
hip to avoid elevation of the abdomen while in the Tren-
delenburg position (Fig. 1). The patient is placed in the
supine position with the lower limbs in abduction, al-
lowing the laparoscopic cart to be moved closer to the
surgeon and intraoperative access to the perineum. The
lower buttocks must be placed at the distal end of the
operating table. The upper limbs are positioned along-
side the body to avoid the risk of stretch injuries to the
brachial plexus and to allow for free movements of the
Fig. 1
operative team. A nasogastric catheter is placed by the
Patient position
anesthesiologist and the stomach decompressed to avoid
 Chapter 7
Veress Needle
A midline cutaneous incision superior to the umbilicus
is made, and the Veress needle is introduced through
the incision (see Chap. 1, Veress Needle Introduction).
TIP
The incision should be 50% larger than the di-
ameter of the 11-mm trocar.
The insufflation tubing is connected to the Veress nee-
dle, the stopcock is opened, and insufflation is initi-
ated.
Fig. 2
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)
Laparoscopic Transperitoneal Radical Cystectomy 117
TIP
It is recommended to start with low flow to avoid
damage to a vital structure in case the needle is
malpositioned. Switch to high flow if the pres-
sure of insufflation is increasing at a steady and
normal level and there is also a tympanic per-
cussion of the liver area.
First Port (11 mm, optic 0°)
Once pneumoperitoneum is established, the Veress
needle is removed, and the 11-mm trocar is introduced
through the same incision, perpendicularly to the ab-
dominal wall. The optic is placed through the trocar,
and the insufflator line is connected to it.
118 Section II Laparoscopic Surgery for Malignant Urological Disorders

TiP TIP

Care must be taken not to injure the aorta or After trocar placement and obturator removal,
vena cava due to the supraumbilical trocar intro­ the trocar valve is briefly opened to check for
ductio egress of gas, confirming it is correctly placed in-
side the abdomen.

Second Port (11 mm, bipolar grasper)

A cutaneous incision is made 2 cm medial and superior

to the left anterior superior iliac spine for introduction
of the 11-mm trocar.

TIP

During trocar introduction, once the cutting tip

pierces the peritoneum, the position of the device
is secured, allowing further gliding of the trocar
to the desired position. This maneuver prevents
blockage of the movements of the working in-
Fig. 3 struments following an incorrect insertion.
Trocars in place

Fig. 4
a Sigmoid displacement. b Fixation to the abdominal wall
 Chapter 7 Laparoscopic Transperitoneal Radical Cystectomy 119

Third Port (5 mm, suction device)

A cutaneous incision is made 2 cm medial and superior
to the right anterior superior iliac spine for introduction
of the 5-mm trocar.
Fourth Port (5 mm, 
monopolar round-tipped scissors, LigaSure)
For insertion of the 5-mm trocar, a cutaneous incision
is made at a point situated at the junction of the lateral
2/3 and medial 1/3 distance between the right anterior
superior iliac spine trocar and the umbilicus trocar.
Radical Cystectomy in the Male
Bowel Displacement
The sigmoid is positioned above the promontory by
gently pushing back the loops of the small bowel with
the aid of the Trendelenburg position. If necessary, the
cecum is dissected off the posterior peritoneum to in-
crease its mobility and assist in the cranial displacement
of the small bowel. To facilitate the left-side dissection,
the sigmoid and its mesocolon can be laterally displaced
to the left side and fixed to the abdominal wall using a
monofilament 2-0 straight needle suture (Fig. 4a,b).

TiP TIP

The fourth trocar should be inserted at a safe
distance from the potential ileal conduit stoma
site.
The suture needle is passed through the skin at a
point lateral and cranial to the left port, placed
through the appendices epiploicae of the sigmoid
colon, and exited close to the entrance point. It is
held in place by a Kocher clamp.

TIP
The fixation has to be released for the left pelvic wall dis-
Pay attention to the epigastric vessels, which can section.
be visualized by pressing the right lateral part of
the abdomen.

The operating table is moved down and backward, and

the patient is placed in an extended Trendelenburg posi-
tion. Steps are placed under the surgeon, and the bipo-
lar and monopolar pedals are placed over the step. The
surgeon, positioned higher than the assistant, can ma-
nipulate the working instruments (bipolar grasper and
monopolar scissors) without being restrained by the as-
sistant holding the optic in the upper midline position
(Fig. 3). This maneuver reduces conflict between the
operative team’s arms.

Fig. 5
Posterior peritoneal (P) incision over the common iliac ar-
tery (A)
120 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 6 Fig. 7
Peritoneal incision extends to obliterated umbilical artery Right external iliac artery exposed

TIP

It is important to place traction on the perito-

neum to facilitate dissection.

The incision follows the artery caudally to a point just

lateral to the medial umbilical ligament (obliterated
umbilical artery), at the level of the crossing of the vas
deferens (Fig. 6); cranially, the incision extends to the
common iliac artery (Fig. 7).
The gonadal vessels are laterally displaced and pre-
served, and the vas deferens is coagulated and tran-
sected (Fig. 8).
Fig. 8
Left vas (V) is coagulated and transected, and gonadal ves-
sels (G) are laterally displaced
Ureteral Exposure and Division

The ureters are identified in the retroperitoneum just

 etroperitoneal Incision 
R cephalad to the common iliac vessels and exposed
and Exposure of Iliac Vessels coursing over and medially at the point of bifurcation
of the iliac vessels (Fig. 9). The right ureter is dissected
A posterior peritoneal incision is made over the right and mobilized close to its intramural insertion into the
common iliac artery, and the medial peritoneal leaf is bladder to ensure an adequate length of free ureter for
lifted to better expose the artery (Fig. 5). reimplantation.
 Chapter 7 Laparoscopic Transperitoneal Radical Cystectomy 121

Fig. 9 Fig. 10
Right ureter (U) crossing over the right iliac artery (A) Atraumatic grasping of ureter

TIP

A distal ureteral arterial branch from the hypo-

gastric or inferior vesical artery can be coagu-
lated and transected (Fig. 11).

®
The ureter is double-clipped (Ligaclip II ML) close to
the bladder and transected (Fig. 12a,b). A section of the
proximal ureteral segment (distal to the proximal clip)
is sent for frozen-section. The proximal divided ureter
is left clipped during the procedure to allow for hydro-
static ureteral dilatation, facilitating the uretero-enteric
anastomosis. The ureter is then mobilized in a cephalad
direction to prevent inadvertent injury, and the vascular
Fig. 11
supply derived laterally from the gonadal vessels should
Distal arterial branch (B) is coagulated; Ureter (U)
not be disturbed. The same dissection is done for the left
ureter.

TIP Pelvic Lymphadenectomy

To prevent ureteral wall injury, the ureter is The genitofemoral nerve, which is the lateral limit of
grasped by the atraumatic posterior part of the the node dissection, should be identified and preserved
grasper (Fig. 10). as it courses over the right iliopsoas muscle. The right
external iliac vessels are retracted medially, and the
122 Section II
Fig. 12
a Ureteral clipping. b Ureteral transection
Fig. 13
“Flat” iliac vein (V)
fascia overlying the muscle is incised medial to the
nerve. The fibroareolar tissue is lifted off the surface
of the muscle and is swept medially towards the iliac
vessels.
The fibroareolar and lymphatic tissue anterior to the
right external iliac artery is longitudinally divided using
Laparoscopic Surgery for Malignant Urological Disorders
Fig. 14
Dissected tissue (LT) is swept over the psoas (P) to the ob-
turator fossa; Iliac vein (V)
the monopolar scissors, and the tissue is dissected from
the artery at its lateral and medial aspect.
The same dissection is performed on the right exter-
nal iliac vein.
 Chapter 7 Laparoscopic Transperitoneal Radical Cystectomy 123

Fig. 15 Fig. 16
Caudal limit of the dissection Clip at nodal package

The dissection is then carried down behind the iliac ves-

sels to free the lateral and medial component attached
at their base. The vessels are carefully displaced later-
ally, and the lateral component of the fibroareolar and
lymphatic tissue is swept under the vessels and along the
psoas muscle and pelvic sidewall to the obturator fossa
(Fig. 14).
At the caudal limit of the dissection, in the angle be-
tween Cooper’s ligament and the inferior aspect of the
external iliac vein (Fig. 15), the nodal package is double-
clipped (Ligaclip II ML) and transected to reduce the
occurrence of lymphocele (Fig. 16).

TIP
Fig. 17
Node of Cloquet (C); Accessory obturator vein (V) under The node of Cloquet, representing the distal limit
the node of the dissection at this level, is dissected at the
junction of the femoral canal (Fig. 17).

TIP
The external iliac vein appears flat at the stan-
dard pneumoperitoneum pressure (12 mmHg).
To improve visualization, the pressure can be de-
creased to allow re-distention of the vessel (Fig.
13).
A circumflex iliac vein usually runs to the external iliac
vein at this location, and it can be ligated and divided if
necessary.
The obturator nerve is visualized deep to the external
iliac vein (Fig. 18), and the lymphatic package is then
carefully mobilized off the obturator neurovascular
bundle.
124 Section II Laparoscopic Surgery for Malignant Urological Disorders

TIP medial limit of the dissection. Small lymphatic vessels

Care must be taken not to injure the obturator
nerve (Fig. 19a,b).
The dissection at this level is bordered by the obliterated
umbilical artery and lateral bladder wall, which is the
are clipped with Ligaclip II ML.
The dissection progresses cephalad to the bifurcation
of the iliac vessels, and the hypogastric artery, which
is the posterior limit of the dissection, is visualized
(Fig. 20).
TIP

For an extended lymphadenectomy, the supe-

rior limit of the dissection is initiated from the
inferior mesenteric artery and extends laterally
over the inferior vena cava. The fibroareolar
and lymphatic tissue is dissected caudally off the
aorta, vena cava. and common iliac vessels over
the sacral promontory.

The lymphatic tissue is gently stripped of the hypogas-

tric artery (Fig. 21), and care must be taken not to injure
the hypogastric vein (Fig. 22).
The dissected package is then clipped (XL Hem-o-lok
clips) and transected. The specimen is removed through
the left 11-mm port after being placed into a bag (En-
Fig. 18
doCatch).The same dissection (Fig. 23) is done on the
Obturator nerve (N) visualized medial to the external iliac
vein (V); Lymphatic tissue (LT)
left side.

Fig. 19
a Obturator fossa. b Obturator artery and nerve
 Chapter 7 Laparoscopic Transperitoneal Radical Cystectomy 125

Fig. 20 Fig. 21
Hypogastric artery Hypogastric artery dissected

Fig. 22 Fig. 23
Hypogastric vein (Hy); Obturator vein (V); Nerve (N); Ar- Right-side dissection
tery (A)

Recto-Vesical Dissection infundibulopelvic ligament in women). A transversal in-

cision is made in the posterior peritoneum bordering
The lateral limit of the posterior peritoneum to be in- the lateral aspect of the sigmoid colon (Fig. 24a,b), and
cised and removed with the specimen is already defined the incision progresses to arrive at the level of the Doug-
(medial to the spermatic vessels in men and lateral to the las pouch (Fig. 25).
126 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 24
a Posterior peritoneum transversally incised. b Peritoneal incision parallel to sigmoid colon (S)

When started high enough, the dissection is able

to leave the Denonvilliers’ fascia covering the seminal
vesicles. The ampullae and seminal vesicles are not dis-
sected from the bladder and instead remain attached to
it throughout the procedure (Fig. 28).
The dissection continues posterior and lateral to the
seminal vesicles to expose the Denonvilliers’ fascia.

TIP

To maintain potency, the dissection of this plane

is done between the prostate and the Denonvil-
liers’ fascia (above the fascia), the same as for
the extraperitoneal laparoscopic radical pros-
tatectomy with neurovascular bundle preser-
Fig. 25 vation. The dissection extends posterior to the
Peritoneal incision (P) extends to Douglas pouch (DP) prostate and to the apex.

The Douglas pouch is transversally incised close to its
superior deflection, and the same procedure is made on
the left side (Fig. 26a,b).
The plane of loose areolar tissue that contains the
seminal vesicles is dissected to expose its posteroinferior
side (Fig. 27).
The posterior layer of Denonvilliers’ fascia is trans-
versally incised to expose the perirectal fatty space.
When dissecting below the fascia, the plane is followed
laterally to arrive at the lateral rectal wall, creating a
plane between the rectum and the levator ani muscles
bilaterally.
 Chapter 7 Laparoscopic Transperitoneal Radical Cystectomy 127

Fig. 26
a Douglas pouch transversally incised. b Left-side incision of posterior peritoneum

Fig. 27 Fig. 28
Exposure of loose areolar tissue Seminal vesicle (SV)

TIP The seminal vesicles, bladder, and prostate are then sep-
arated from the rectum, which will facilitate the second
The assistant positions the suction device at the part of the bladder dissection.
inferior part of the dissection and pushes down
on the tissue at every step of the dissection to
facilitate access to the right plane.
128 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 29 Fig. 30
Internal iliac artery (Hypog); Superior vesical artery LigaSure at superior vesical artery
(Sup Ves Art)

TIP

The recto-vesical dissection can be performed

before the lymphadenectomy to prevent intra-
peritoneal contents falling into the operative
field, particularly in obese patients.

 ivision of the Anterior Branches

D
of the Hypogastric Vessels—LigaSure 5mm

Following the dissection of the obturator fossa, the

lateral vascular pedicle to the bladder is ready to be
ligated and divided with the use of the LigaSure 5mm.
TIP
The LigaSure 5 mm (settings—III and 01/01)
can be used as a dissecting instrument due to its
small tip.
The hypogastric vessels are bilaterally dissected, expos-
ing the anterior branches. The initial arterial branch is
usually the superior vesical artery (Fig. 29)—the termi-
Fig. 31
LigaSure at middle vesical branches
nal section of the pervious portion of the obliterated um-
bilical artery—which is coagulated and transected (Fig.
30). Middle and inferior vesical arteries and branches of
the middle hemorrhoidal artery that anastomose with
the inferior vesical artery are also coagulated and tran-
sected (Fig. 31).
 Chapter 7 Laparoscopic Transperitoneal Radical Cystectomy 129

Fig. 32
a LigaSure at endopelvic fascia. b Endopelvic fascia opened

Using the LigaSure, the posterolateral dissection of the

bladder and prostate is extended caudally to the pros-
tatic apex; laterally, the posterior pedicle is ligated and
divided to the endopelvic fascia, which is opened adja-
cent to the prostate (Figs. 32a,b and 33).

TIP

The previous dissection of the lateral border of

the rectum allows for a safe dissection at this
time, and opening the endopelvic fascia will help
to identify the distal limit of the lateral vesical
pedicle as well as aid in the control of the vessels
of the prostatic apex.

Fig. 33
LigaSure at the prostatic pedicle (Ped); Prostate (Pr)
The same dissection is done on the contralateral side
(Fig. 34).

TIP
The hypogastric artery is not ligated to avoid
potential compromise of blood flow to the inter-
nal pudendal artery and possible vasculogenic
impotence.
Anterior Dissection 
of the Bladder—LigaSure 5 mm
At this point of the dissection, the bladder remains sus-
pended through its anterior attachments. The anterior
peritoneum lateral to the obliterated umbilical artery is
130 Section II Laparoscopic Surgery for Malignant Urological Disorders

incised from the inguinal ring to the umbilicus, and a TIP

lateral plane is developed between the prevesical fat and
the pelvic wall (Fig. 35a,b). The bladder can be filled with 200 mL of saline
to facilitate this part of the dissection.

The inverted U-shaped incision of the peritoneum con-

tinues to the contralateral side, cephalad to the bladder
and inferior to the umbilicus (Fig. 36a,b).
The urachus (median umbilical ligament) and the
obliterated umbilical artery (medial umbilical ligament)
are identified and divided. The bladder is emptied, and
the plane between the prevesical fat and the anterior ab-
dominal wall is further dissected (Retzius space).
The lateral portion of the pubis bone is visualized
(Fig. 37a,b), and the bladder is separated from the ante-
rior abdominal wall (Fig. 38).
With a combination of sharp and blunt dissection,
the space between the lateral wall of the bladder and the
pelvic side wall exposes the already opened endopelvic
fascia bilaterally and the Santorini venous plexus me-
Fig. 34
dially. The superficial branch of the deep dorsal vein is
Bladder (B) pedicles bilaterally sectioned; Rectum (R); En-
dopelvic fascia (E.fascia) opened
then coagulated and divided over the anterior aspect of
the prostate (Fig. 39).

Fig. 35
a Peritoneum lateral to the bladder incised. b Plane is developed between prevesical fat and pelvic wall
 Chapter 7 Laparoscopic Transperitoneal Radical Cystectomy 131

Fig. 36
a Supravesical peritoneal incision. b Incision extending to contralateral side

Fig. 37
a Pubic bone, right lateral portion. b Pubic bone, left lateral portion

The plane between the prostate and the endopelvic TIP

fascia is developed, and the neurovascular bundles are
dissected and preserved, depending on anatomic and
oncologic conditions.
If the patient is a candidate for nerve-sparing
radical cystoprostatectomy, the steps for neu-
rovascular bundle dissection are the same as
for nerve-sparing radical prostatectomy (see
Chap. 5).
132 Section II Laparoscopic Surgery for Malignant Urological Disorders

Fig. 38 Fig. 39
Retzius space (R); Bladder (B); Pubic bone (P) Superficial branch of the deep dorsal vein

½ 40 mm) and transected following removal of the blad-

der catheter (Fig. 41a–c).
The proximal urinary lumen is never opened, pre-
venting cell spillage; the distal urethra is left open. Fi-
nally, the distal insertions of Denonvilliers’ fascia with
rectourethral attachments are sectioned, releasing the
operative specimen.

TIP

Care must be taken not to injure the rectum at

this level.

The left lateral 11-mm port is removed for the introduc-

Fig. 40
®
tion of a 15-mm EndoCatch bag, and the specimen is
placed inside the bag. The EndoCatch arm is removed,
Dorsal venous complex ligation
leaving the bag inside, and the 11-mm port is reintro-
duced.
A careful revision of homeostasis is performed.

Apical Dissection
The puboprostatic ligaments are bilaterally cut, and the
®
dorsal vein complex is ligated with Polysorb 0 CL 802
(needle ½ 40 mm) and divided (Fig. 40).
The prostatic apex is dissected, exposing the ure-
thra, which is ligated with Polysorb 0 CL 802 (needle
The Urinary Diversion
When an ileal conduit urinary diversion is performed,
an opening is made on the mesosigmoid to allow for
the left ureter to be moved to the right side of the sig-
moid colon. A grasper is introduced through the 5-mm
 Chapter 7 Laparoscopic Transperitoneal Radical Cystectomy 133

port lateral to the umbilicus to hold the ureters; another
grasper is introduced through the right lateral port and
the distal portion of ileum that will be selected for the
fashioning of the ileal conduit is secured. The optic is
now placed at the left 11-mm port, and a grasper intro-
duced through the supraumbilical 11-mm port holds
and exteriorizes the EndoCatch bag string. The optic
and laparoscopic instruments (except the grasper at the
5-mm port) are removed, but the abdomen is left in-
flated to facilitate the opening of the abdominal wall.
A small supraumbilical midline incision is made for
the execution of the urinary diversion procedure in an
open fashion. The specimen is removed through this in-
cision.
A silicone Penrose drain is placed at the end of the
procedure.

Fig. 41
a Urethral dissection. b Urethral ligation following catheter removal. c Urethral division
134 Section II Laparoscopic Surgery for Malignant Urological Disorders

I nfundibulopelvic Ligament
Radical Cystectomy in the Female Division and Uterine Displacement

Ureteral Exposure and Division
The ureters are addressed as above.
The right ovary is grasped and tractioned upward to bet-
ter expose the infundibulopelvic ligament. The ovarian
vessels in the infundibulopelvic ligament are identified,
coagulated, and divided (Fig. 42a,b). The round liga-
ment is coagulated and divided (Fig. 43). Traction can
be placed on the uterus anteriorly with a Dermalon 00 ®
straight needle passed through the uterus.

TIP

The suture needle is passed through the skin in

a midline point in the lower abdomen, placed
through the uterus body, exited through the skin,
and loosely tied externally, allowing mobiliza-
tion of the uterus if necessary.

The same procedure is done on the left side.

Pelvic Lymphadenectomy

Pelvic lymph node dissection is bilaterally performed as

described above

Fig. 42 Fig. 43
a Infundibulopelvic ligament. b Coagulation of infundibu- Round ligament
lopelvic ligament
 Chapter 7
Fig. 44
Exposure of the Douglas cul-de-sac (A); Vaginal valve (B)
Recto-Vaginal Dissection
The initial steps of the dissection are the same as for the
recto-vesical dissection in the male (see Recto-Vesical
Dissection). When the posterior peritoneal incision ap-
proaches the Douglas pouch, a valve is introduced into
Fig. 46
a Correct plane of dissection. b Wrong plane of dissection
Laparoscopic Transperitoneal Radical Cystectomy 135
Fig. 45
Peritoneal incision at the Douglas pouch level
the vagina, lifting the peritoneal fold. This maneuver
will aid in the exposure and facilitate the dissection of
the recto-vaginal plane (Fig. 44).
The posterior peritoneum at the level of the Douglas
pouch is grasped with the bipolar grasper and placed
under traction. The peritoneum is incised close to its
superior deflection (Fig. 45), and the inferior peritoneal
lip with fatty tissue attached is pulled down to expose
the correct plane of dissection (Fig. 46).
TIP
Two planes of dissection are encountered at this
level. The right one is between the fatty tissue
and the vagina, and by applying downward trac-
tion, the avascular plane of loose areolar tissue
is exposed. The wrong plane of dissection is be-
tween the fatty tissue and the rectum, and by
following this plane, the chance of rectum inju-
ries increases.
The vaginal wall is mobilized off the rectosigmoid colon
up to the level of the canal anal, and the dissection is
extended laterally to the ischiorectal fossa (Fig. 47).
136 Section II
An incision is made at the posterior vaginal wall be-
low the cervix.
TIP
Gas leakage during section of the vagina is pre-
vented by packing the vagina with a surgical
glove filled with gauze.
If necessary, a small portion of the cardinal ligament can
be coagulated and divided to facilitate exposure.
Division of the Anterior Branches 
of the Hypogastric Vessels—LigaSure 5mm
The anterior and posterior leaves of broad ligament are
sharply opened and divided lateral to the uterus. The
hypogastric vessels are bilaterally dissected, exposing
the anterior branches. The initial arterial branch is usu-
ally the superior vesical artery, which is coagulated and
transected with the use of LigaSure.
TIP
LigaSure 5mm settings—III and 01/01.
The middle and inferior vesical arteries and branches of
the middle hemorrhoidal artery that anastomose with
the inferior vesical artery are also coagulated and tran-
sected. The adventitious tissue surrounding the uterine
vessels is dissected, and the vessels are coagulated and
divided at the level of the lower uterine segment. The
lateral vaginal wall is incised.
Anterior Dissection—LigaSure 5mm
Following completion of the posterior dissection, the
anterior dissection is initiated and is analogous to the
anterior dissection in the male cystectomy.
Laparoscopic Surgery for Malignant Urological Disorders
Fig. 47
Left levator ani muscle (A); Rectum (B); Suction device (S) at
the inferior part of the dissection
TIP
The bladder is filled with 200 mL of saline to fa-
cilitate the initial dissection.
The peritoneum cephalad to the bladder and inferior to
the umbilicus is incised transversally with LigaSure, and
the urachus (median umbilical ligament) and the oblit-
erated umbilical artery (medial umbilical ligament) are
identified and divided. The inverted U-shaped perito-
neal incision extends along each side of the bladder, ex-
posing the already transected round ligaments (exposed
during lymphadenectomy). The bladder is emptied, and
the plane between the prevesical fat and the anterior
abdominal wall is developed (Retzius space), exposing
the endopelvic fascia bilaterally. The endopelvic fascia is
opened, allowing the dissection to be continued to the
lateral aspects of the urethra. If a urethrectomy is to be
performed, the pubovesical suspensory ligaments are
identified and divided (these are analogous to the pu-
boprostatic ligaments in the male). The division of the
pubovesical ligaments allows the urethra and bladder
to drop inferiorly. The deep dorsal vein of the clitoris
is identified, ligated with Polysorb 0 CL 802 (needle ½
40 mm) and divided. The urethra is then dissected from
 Chapter 7
the dorsal vein of the clitoris, so the only remaining at-
tachments of the specimen are the urethral meatus and
a small portion of the anterior vaginal wall. The urethra
is then ligated with Polysorb 0 CL 802 and divided fol-
lowing removal of the bladder catheter. The ovaries, fal-
lopian tubes, uterus, and cervix are left attached by only
a small portion of the anterior vagina that is now excised
en bloc with the specimen.
TIP
If a continent orthotopic diversion is being con-
sidered, only the bladder neck and the initial
1 cm of urethra are removed; minimal urethral
mobilization is performed distal to the urethro-
vesical junction. The exact location of the blad-
der neck is defined by in and out movements
of the Foley catheter balloon, and the urethra
is sharply transected at the level of the bladder
neck or just distal to it. Full-thickness urethral
margin biopsies are sent for frozen section.
A transvaginal approach is used if urethrectomy is to be
performed. A retractor spreads the labia, and the exter-
nal urethral meatus is encircled with an electrocautery
knife. The entire specimen is removed transvaginally,
and the vagina is laparoscopically closed with a running
Vicryl 0 suture in either a posteroanterior or a vertical
plane, depending on the amount of vagina left. Careful
hemostasis is performed, and a silicone Penrose drain is
placed at the end of the procedure.
The Urinary Diversion
The technique of urinary diversion for males is also used
for the female radical cystectomy.
Laparoscopic Transperitoneal Radical Cystectomy 137
Postoperative Considerations
Patients are usually monitored in the intensive care
unit for vital parameters and adequate pain manage-
ment during the first 24 h following the procedure or
until stable. Parenteral nutrition is continued until oral
feeding is resumed. Early assisted ambulation is imple-
mented. Drains stay in place until secretions drop below
50 mL and the ureteral stents (in an ileal loop diversion)
are removed around day 14 after surgery. Normal activ-
ity is resumed four weeks after the procedure.
Suggested Readings
1. Haber GP, Gill IS: Laparoscopic radical cystectomy for can-
cer: oncological outcomes at up to 5 years. BJU Int 2007 Jul;
100(1):137–142.
2. Gerullis H, Kuemmel C: Laparoscopic cystectomy with ex-
tracorporeal-assisted urinary diversion: experience with 34
patients. Eur Urol 2007 Jan; 51(1):193–198.
3. Cathelineau X, Jaffe J: Laparoscopic radical cystectomy
with urinary diversion: what is the optimal technique? Curr
Opin Urol 2007 Mar; 17(2):93–97.
4. Simonato A, Gregori A: Laparoscopic radical cystopros-
tatectomy: our experience in a consecutive series of 10
patients with a 3 years follow-up. Eur Urol 2005 Jun;
47(6):785–790; discussion 790–792.
5. Cathelineau X, Arroyo C: Laparoscopic assisted radical cys-
tectomy: the Montsouris experience after 84 cases. Eur Urol
2005 Jun; 47(6):780–784.
6. Moinzadeh A, Gill IS: Laparoscopic radical cystectomy in
the female. J Urol 2005 Jun; 173(6):1912–1917.
 Chapter 8
Laparoscopic Pelvic Lymph
Node Dissection
Contents
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . .
P   140
Patient Positioning and Initial Preparation  .. . .  
Trocars and Laparoscopic Instruments   .. . . . . . .  
Access and Port Placement  . . . . . . . . . . . . . . . . . . . .  
Veress Needle  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
First Port (11 mm, optic 0°)  . . . . . . . . . . . . . . . . . .  
S econd Port (11 mm, bipolar grasper)  .. . . . . .  
Third Port (5 mm, suction device)  . . . . . . . . . . .  
Fourth Port (5 mm, monopolar round-tipped
scissors)  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Transperitoneal Pelvic Lymph Node 
Dissection for Bladder Cancer   .. . . . . . . . . . . . . .  
Transperitoneal Pelvic Lymph Node 
Dissection for Prostate Cancer   .. . . . . . . . . . . . .  
Postoperative Considerations  . . . . . . . . . . . . . . . . .  
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . .  
Lymphadenectomy for Bladder Cancer  .. . . . .  
Lymphadenectomy for Prostate Cancer  . . . . .  
Introduction
139 Prostate cancer patients with a serum PSA level of less
than 10 ng/mL, a Gleason sum under 7, and a clinical
140 stage under T2c are at low risk for pelvic nodal meta-
140 static involvement and do not require a pelvic lymph
140 node dissection. However, for patients with a moderate
140 to high risk, a pelvic lymph node dissection should be
142 performed in order to improve progression-free sur-
142 vival.
142 The anatomical lymphatic drainage of the prostate
includes the obturator fossa, the external iliac, and the
142 hypogastric artery. Laparoscopic standard lymph node
142 dissection (obturator and internal and external iliac
nodes) obtains a higher total nodal count than the modi-
143 fied pelvic lymph node dissection limited to the external
iliac nodes or obturator fossa. It can be performed at the
147 same time of the definitive surgery through a transperi-
148 toneal laparoscopic approach. This minimally invasive
148 operative procedure is safe, with results and morbidity
148 equivalent to those of open surgery.
149
Radical cystectomy with bilateral pelvic lymph node dis-
section is a standard treatment for high-grade, muscle-
invasive bladder cancer. Important prognostic variables
in patients with pathologic evidence of lymph node
metastases are the extent of the primary bladder tumor
(p stage), the number of lymph nodes removed, and
the lymph node tumor burden. Although the proximal
limits of the lymph node dissection remain to be better
defined, selected patients with localized bladder tumor
and low volume, microscopic lymph node disease can be
cured with radical cystectomy and lymphadenectomy.
140 Section II
Preoperative Preparation
This procedure is usually performed at the time of trans-
peritoneal laparoscopic radical prostatectomy or trans-
peritoneal laparoscopic cystectomy. Before a patient
consents to the procedures, it is important to discuss the
specific risks of the surgery, including the potential need
to convert to the traditional open operation if difficul-
ties arise.
The patient is admitted to the hospital the night be-
fore the surgery for bowel preparation as for laparo-
scopic radical prostatectomy (see Chap. 6) or laparo-
scopic radical cystectomy (see Chap. 7). Fasting starts
at midnight before surgery. Thromboprophylaxis is
implemented with good hydration, placement of com-
pressive elastic stockings on the lower extremities,
and low-molecular-weight heparin. Enoxaparin (Clex-
® ®
ane , Lovenox ) 40 mg sc 1 × day or nadroparin (Flaxi-
® ®
parine , Fraxiparin ) 0.6 mL sc 1 × day is initiated on
day 1 after the surgery and continued daily until the pa-
tient is discharged from the hospital. In selected cases,
the treatment is continued for 30 days after the proce-
dure.
TIP
Thromboprophylaxis is important due to the
concurrent risk factors of laparoscopy, cancer,
and pelvic surgery.
Patients also receive antibiotic prophylaxis with a single
preoperative dose of intravenous second-generation
cephalosporin, unless they are allergic to penicillin.
Blood type and crossmatch are determined.
 atient Positioning and Initial 
P Veress Needle
Preparation
The surgery is performed under general anesthesia. The
base of the table must be positioned below the patient’s
hip to avoid elevation of the abdomen while in the Tren-
delenburg position. The patient is placed in the supine
position with the lower limbs in abduction, allowing
the laparoscopic cart to be moved closer to the surgeon
and intraoperative access to the perineum. The lower
Laparoscopic Surgery for Malignant Urological Disorders
buttocks must be placed at the distal end of the operat-
ing table. The upper limbs are positioned alongside the
body to avoid the risk of stretch injuries to the brachial
plexus and to allow for free movements of the operative
team. A nasogastric catheter is placed by the anesthesi-
ologist and the stomach decompressed to avoid punc-
ture during trocar placement. The abdomen, pelvis, and
genitalia are skin prepared in case conversion to an open
procedure is required. An 18Fr Foley catheter with 10
mL in the balloon is introduced after the placement of
the sterile drapes.
The surgeon operates from the patient’s left side, and
the first assistant is placed at the opposite side of the sur-
geon. The laparoscopic cart is placed at the patient’s feet,
while the instruments table and the coagulation unit are
positioned at the left side of the patient.
Trocars and Laparoscopic Instruments
• 2 × 11 mm (optic 0° and bipolar grasper)
• 2 × 5 mm (scissors and suction device)
TIP
3 × 5 mm for transperitoneal laparoscopic radi-
cal prostatectomy
• M
 onopolar round-tipped scissors, bipolar grasper,
5-mm suction device, needle drivers (2), and 10-mm
laparoscopic optic 0°
Access and Port Placement
See Figures 1 and 2.
A midline cutaneous incision superior to the umbilicus
is made for bladder cancer lymphadenectomy and at the
inferior and right margin of the umbilicus for prostate
cancer lymphadenectomy.
The Veress needle is introduced through the incision
(see Chap. 1, Veress Needle Introduction).
 Chapter 8 Laparoscopic Pelvic Lymph Node Dissection 141

Fig. 1
Lymph node dissection for bladder cancer (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright
Elsevier)

Fig. 2
Lymph node dissection for prostate cancer (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright
Elsevier)
142 Section II
The insufflation line is connected to the Veress nee-
dle, the stopcock is opened, and insufflation is initiated.
TIP
It is recommended to start with low flow to avoid
damage to a vital structure in case the needle is
malpositioned. Switch to high flow if the pres-
sure of insufflation is increasing at a steady and
normal level and there is also a tympanic per-
cussion of the liver area.
First Port (11 mm, optic 0°)
Once pneumoperitoneum is established, the Veress
needle is removed, and the 11-mm trocar is introduced
through the same incision, perpendicularly to the ab-
dominal wall. The optic is placed through the trocar,
and the insufflation tubing is connected to it.
Second Port (11 mm, bipolar grasper)
A cutaneous incision is made 2 cm medial and superior
to the left anterior superior iliac spine for introduction
of the 11-mm trocar.
Third Port (5 mm, suction device)
A cutaneous incision is made 2 cm medial and superior
to the right anterior superior iliac spine for introduction
of the 5-mm trocar.
Fourth Port 
(5 mm, monopolar round-tipped scissors)
For insertion of the 5-mm trocar, a cutaneous incision
is made at a point situated at the junction of the lateral
2/3 and medial 1/3 distance between the right anterior
superior iliac spine trocar and the umbilicus trocar.
Laparoscopic Surgery for Malignant Urological Disorders
TIP
Pay attention to the epigastric vessels, which can
be visualized by pressing the right lateral part of
the abdomen.
The operating table is moved down and backward, and
the patient is placed in an extended Trendelenburg po-
sition. Steps are placed under the surgeon, and the bi-
polar and monopolar pedals are placed over the step.
The surgeon, positioned higher than the assistant can
then use the working instruments (bipolar grasper and
monopolar scissors) without being restrained by the
assistant holding the optic in the upper midline posi-
tion.
Surgical Technique
The intestine is positioned above the promontory by
gently pushing back the loops of the small bowel with
the aid of the Trendelenburg position. If necessary, the
cecum is dissected off the posterior peritoneum to in-
crease its mobility and assist in the cranial displacement
of the small bowel. To facilitate the left-side dissection,
the sigmoid and its mesocolon are laterally displaced
and fixed to the abdominal wall using a monofilament
2-0 straight needle suture.
TIP
The suture needle is passed through the skin at a
point lateral and cranial to the left port, placed
through the appendices epiploicae of the sigmoid
colon, and exited close to the entrance point. It is
held in place by a Kocher clamp.
The fixation has to be released for the left pelvic wall dis-
section.
 Chapter 8
Fig. 3
Posterior peritoneal (P) incision over common iliac
artery (A)
Fig. 5
Right iliac artery exposed
Transperitoneal Pelvic Lymph Node
Dissection for Bladder Cancer
A standard pelvic lymphadenectomy is bilaterally per-
formed, using a “split and roll” technique. Dissecting
the lymphatic package upward, from the junction of the
femoral canal up to the level of the bifurcation of the
Laparoscopic Pelvic Lymph Node Dissection 143
Fig. 4
Peritoneal incision extends to obliterated umbilical artery
common iliac artery, allows for an avascular plane of
dissection and facilitates the laparoscopic maneuvers.
TIP
Due to technical ease, right-handed surgeons
begin the dissection with the right side of the
lymphadenectomy.
A posterior peritoneal incision is made over the right
common iliac artery, and the medial peritoneal leaf is
lifted to better expose the artery (Fig. 3).
TIP
It is important to always place traction on the
peritoneum to facilitate dissection.
The incision follows the artery caudally to a point just
lateral to the medial umbilical ligament (obliterated
umbilical artery), at the level of the crossing of the vas
deferens (round ligament in female patients) (Fig. 4);
cranially, the incision extends to the common iliac ar-
tery (Fig. 5).
144 Section II
Fig. 6
Left vas (V) is coagulated and transected, and gonadal ves-
sels (G) are laterally displaced
Fig. 8
Dissected tissue (LT) is swept over the psoas (P) to the ob-
turator fossa; Iliac vein (V)
The ureters are bilaterally dissected, clipped, and
displaced upward. In women, the infundibulopelvic
ligament, along with the ovarian vessels, has been pre-
viously ligated and divided (see Chap. 7). The gonadal
vessels are laterally displaced and preserved in the male,
Laparoscopic Surgery for Malignant Urological Disorders
Fig. 7
“Flat” iliac vein (V)
and the vas deferens (round ligament) is coagulated and
transected (Fig. 6).
The genitofemoral nerve, which is the lateral limit of
the node dissection, should be identified and preserved
as it courses over the right iliopsoas muscle. The right
external iliac vessels are medially retracted, and the fas-
cia overlying the muscle is incised medial to the nerve.
The fibroareolar tissue is lifted off the surface of the
muscle and is swept medially towards the iliac vessels.
The fibroareolar and lymphatic tissue anterior to the
right external iliac artery is longitudinally divided using
the monopolar scissors, and the tissue is dissected from
the artery at its lateral and medial aspect. The same dis-
section is performed on the right external iliac vein.
TIP
The external iliac vein appears flat at the stan-
dard pneumoperitoneum pressure (12 mmHg).
To improve visualization, the pressure can be
decreased to allow re-distention of the vessel
(Fig.7).
The dissection is then carried down behind the iliac
vessels to free the lateral and medial component at-
 Chapter 8 Laparoscopic Pelvic Lymph Node Dissection 145

Fig. 9 Fig. 10
Caudal limit of the dissection Clip at nodal package

tached at their base. The vessels are carefully displaced

laterally, and the lateral component of the fibroareolar
and lymphatic tissue is swept under the vessels and
along the psoas muscle and pelvic sidewall to the obtu-
rator fossa (Fig. 8).
At the caudal limit of the dissection, in the angle be-
tween Cooper’s ligament and the inferior aspect of the
external iliac vein (Fig. 9), the nodal package is double-
clipped (Ligaclip II ML) and transected to reduce the
occurrence of lymphocele (Fig. 10).

TIP

The node of Cloquet, representing the distal limit

of the dissection at this level, is dissected at the
junction of the femoral canal (Fig. 11). Fig. 11
Node of Cloquet (C); Accessory obturator vein (V) under
the node

A circumflex iliac vein usually runs to the external iliac

vein at this location, and it can be ligated and divided if
necessary.
The obturator nerve is visualized deep to the external TIP
iliac vein (Fig. 12), and the lymphatic package is then
carefully mobilized off the obturator neurovascular Care must be taken not to injure the obturator
bundle. nerve (Fig. 13a,b).
146 Section II
The dissection at this level is bordered by the obliterated
umbilical artery and lateral bladder wall, which is the
medial limit of the dissection. Small lymphatic vessels
are clipped with Ligaclip II ML.
The dissection progresses cephalad to the bifurcation
of the iliac vessels, and the hypogastric artery, which
Fig. 12
Obturator nerve (N) visualized medial to the external iliac
vein (V); Lymphatic tissue (LT)
Fig. 13
a Obturator fossa. b Obturator artery and nerve
Laparoscopic Surgery for Malignant Urological Disorders
is the posterior limit of the dissection, is visualized
(Fig. 14).
TIP
For an extended lymphadenectomy, the superior
limit of the dissection is the inferior mesenteric
artery, and the dissection extends laterally over
the inferior vena cava. The fibroareolar and
lymphatic tissue is dissected caudally off the
aorta, vena cava, and common iliac vessels over
the sacral promontory.
The lymphatic tissue is gently stripped of the hypogas-
tric artery (Fig. 15), and care must be taken not to injure
the hypogastric vein (Fig. 16).
The dissected package is then clipped (XL Hem-o-lok
clips) and transected. The specimen is removed through
the left 11-mm port after being placed into a bag (Endo-
Catch). The same dissection is done on the left side.
 Chapter 8 Laparoscopic Pelvic Lymph Node Dissection 147

Transperitoneal Pelvic Lymph Node
Dissection for Prostate Cancer
A standard pelvic lymphadenectomy is bilaterally per-
formed using a “split and roll” technique. A posterior
peritoneal incision is made over the right common iliac
artery, and the medial peritoneal leaf is lifted to better
expose the artery (Fig. 3).
The gonadal vessels are laterally displaced and pre-
served, and the vas deferens is coagulated and tran-
sected (Fig. 6).
The genitofemoral nerve, which is the lateral limit of
the node dissection, should be identified and preserved
as it courses over the right iliopsoas muscle. The right
external iliac vessels are medially retracted, and the fas-

TIP

It is important to always place traction on the

peritoneum to facilitate dissection.

The incision follows the artery caudally to a point just

medial to the medial umbilical ligament (obliterated
umbilical artery), at the level of the crossing of the vas
deferens (Fig. 4). Cranially, the incision extends to the
bifurcation of the iliac vessels (cephalad limit of the dis-
section) (Fig. 5). The ureter is exposed at the location
where it crosses the iliac artery, and it is then medially
displaced together with the medial leaf of the posterior
peritoneum.
Fig. 14
Hypogastric artery

Fig. 16
Fig. 15 Hypogastric vein (Hy); Obturator vein (V); Nerve (N);
Hypogastric artery dissected Artery (A)
148 Section II
cia overlying the muscle is incised medial to the nerve.
The fibroareolar tissue is lifted off the surface of the
muscle and is swept medially towards the iliac vessels.
The fibroareolar and lymphatic tissue anterior to the
right external iliac artery is longitudinally divided using
the monopolar scissors, and the tissue is dissected from
the artery at its lateral and medial aspect.
The same dissection is performed on the right exter-
nal iliac vein.
TIP
The external iliac vein appears flat at the stan-
dard pneumoperitoneum pressure (12 mmHg).
To improve visualization, the pressure can be
decreased to allow re-distention of the vessel
(Fig. 7).
The dissection is then carried down behind the iliac ves-
sels to free the lateral and medial component attached
at their base. The vessels are carefully displaced later-
ally, and the lateral component of the fibroareolar and
lymphatic tissue is swept under the vessels and along the
psoas muscle and pelvic sidewall to the obturator fossa
(Fig. 8).
At the caudal limit of the dissection, in the angle be-
tween Cooper’s ligament and the inferior aspect of the
external iliac vein (Fig. 9), the nodal package is double-
clipped (Ligaclip II ML) and transected to reduce the
occurrence of lymphocele (Fig. 10).
TIP
The node of Cloquet, representing the distal limit
of the dissection at this level, is dissected at the
junction of the femoral canal (Fig. 11).
A circumflex iliac vein usually runs to the external iliac
vein at this location, and it can be ligated and divided if
necessary.
The obturator nerve is visualized deep to the external
iliac vein (Fig. 12), and the lymphatic package is then
Laparoscopic Surgery for Malignant Urological Disorders
carefully mobilized off the obturator neurovascular
bundle.
TIP
Care must be taken not to injure the obturator
nerve (Fig 13a,b).
The dissection at this level is bordered by the obliterated
umbilical artery, which is the medial limit of the dissec-
tion and should be preserved. Small lymphatic vessels
are clipped with Ligaclip II ML.
The dissection progresses cephalad to the bifurcation
of the iliac vessels, and the hypogastric artery, which
is the posterior limit of the dissection, is visualized
(Fig. 14). The lymphatic tissue is gently stripped of the
hypogastric artery (Fig. 15), and care must be taken not
to injure the hypogastric vein (Fig. 16).
The dissected package is then clipped (XL Hem-o-lok
clips) and transected. The specimen is removed through
the left 11-mm port after being placed into a bag (Endo-
Catch). The same dissection is done on the left side.
Postoperative Considerations
After surgery, the patient should be treated as described
in Chaps. 6 and 7.
Suggested Readings
Lymphadenectomy for Bladder Cancer
1. Haber GP, Gill IS: Laparoscopic radical cystectomy for can-
cer: oncological outcomes at up to 5 years. BJU Int 2007 Jul;
100(1):137–142.
2. Stein JP, Penson DF: Radical cystectomy with extended
lymphadenectomy: evaluating separate package versus en
bloc submission for node positive bladder cancer. J Urol
2007 Nov; 52(5):1347–55.
3. Stein JP: Lymphadenectomy in bladder cancer: how high is
“high enough”? Urol Oncol 2006 Jul–Aug; 24(4):349–355.
 Chapter 8
4. Finelli A, Gill IS: Laparoscopic extended pelvic lymphad-
enectomy for bladder cancer: technique and initial out-
comes. J Urol 2004 Nov; 172(5 Pt 1):1809–1812.
5. Stein JP, Skinner DG: The role of lymphadenectomy in
high-grade invasive bladder cancer. Urol Clin North Am
2005 May; 32(2):187–197.
6. Bochner BH, Herr HW: Impact of separate versus en bloc
pelvic lymph node dissection on the number of lymph
nodes retrieved in cystectomy specimens. J Urol 2001 Dec;
166(6):2295–2296.
7. Vieweg J, Gschwend JE: Pelvic lymph node dissection can
be curative in patients with node positive bladder cancer.
J Urol 1999 Feb; 161(2):449–454.
Laparoscopic Pelvic Lymph Node Dissection 149
Lymphadenectomy for Prostate Cancer
1. Heidenreich A, Ohlmann CH: Anatomical extent of pelvic
lymphadenectomy in patients undergoing radical prosta-
tectomy. Eur Urol 2007 Jul; 52(1):29–37.
2. Lattouf JB, Beri A: Laparoscopic extended pelvic lymph
node dissection for prostate cancer: description of the
surgical technique and initial results. Eur Urol 2007 Nov;
52(5):1347–55.
3. Touijer K, Rabbani F: Standard vs limited pelvic lymph
node dissection for prostate cancer in patients with a pre-
dicted probability of nodal metastasis greater than 1%.
J Urol 2007 July; 178(1):120–124.
4. Wyler SF, Sulser T: Laparoscopic extended pelvic lymph
node dissection for high-risk prostate cancer. Urology 2006
Oct; 68(4):883–887.
5. Häcker A, Jeschke S: Detection of pelvic lymph node me-
tastases in patients with clinically localized prostate can-
cer: comparison of [18F] fluorocholine positron emission
tomography-computerized tomography and laparoscopic
radioisotope guided sentinel lymph node dissection. J Urol
2006 Nov; 176(5):2014–8; discussion 2018–2019.
6. Stone NN, Stock RG: Laparoscopic pelvic lymph node dis-
section for prostate cancer: comparison of the extended and
modified techniques. J Urol 1997 Nov; 158(5):1891–1894.
Section III

Laparoscopic Surgery
for Benign Urological
Disorders
 Chapter 9

Transperitoneal
Laparoscopic Pyeloplasty

Contents
Introduction
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   153 Open pyeloplasty, once the reference standard for the
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . .
P   153 correction of ureteropelvic junction (UPJ) obstruction,
Patient Positioning and Initial Preparation   . . .   154 has fallen out of favor despite long-term success rates
Trocars and Laparoscopic Instruments   .. . . . . . .   154 due to the postoperative morbidity associated with open
Access and Port Placement  . . . . . . . . . . . . . . . . . . . .   155 flank surgery. Laparoscopic dismembered flap pyelo-
Veress Needle  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   155 plasty is now a viable alternative for patients with UPJ
First Port (11 mm, optic 0°)  . . . . . . . . . . . . . . . . . .   157 obstruction, with the benefits of shorter hospital stays,
S econd Port (5 mm, monopolar  reduced postoperative pain, and faster convalescence.
round-tipped scissors)  . . . . . . . . . . . . . . . . . . . . . .   157 The laparoscopic approach is capable of addressing vari-
Third Port (11 mm, bipolar grasper)  . . . . . . . . .   158 ous clinical situations of UPJ obstruction, and depend-
Fourth Port (5 mm, suction device)  .. . . . . . . . .   158 ing on expertise level, has proved to be equally effica-
Final Position of the Ports  . . . . . . . . . . . . . . . . . . .   158 cious in treating scarred, obstructed UPJ that had failed
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . . .   158 open surgery.
Colon Mobilization  .. . . . . . . . . . . . . . . . . . . . . . . . .   158
Identification of the Ureter
and Ureteropelvic Junction (UPJ)  .. . . . . . . . . . .   159
Ureteral Transection/Renal Pelvis Excision  .. .   160
Preoperative Preparation
Anastomosis   .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   160 Before a patient consents to a laparoscopic pyeloplasty,
Stenting   .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   162 it is important to discuss the specific risks of the surgery,
Postoperative Considerations  . . . . . . . . . . . . . . . . .   164 including the potential need to convert to the traditional
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . .   164 open operation if difficulties arise.
The patient is admitted to the hospital the day before
the surgery for bowel preparation, which includes 2 L
®
of Colopeg (1 envelope/L) p.o. and a Fleet enema. ®
Fasting starts at midnight before surgery. Patients also
receive antibiotic prophylaxis with a single preoperative
dose of intravenous second-generation cephalosporin,
unless they are allergic to penicillin. Blood type and
crossmatch are determined.
154 Section III
Patient Positioning and Initial Preparation
The patient is initially positioned supine for intravenous
access, the induction of general anesthesia, and endotra-
cheal intubation. An orogastric tube is placed and the
stomach decompressed to avoid puncture during trocar
placement and to allow additional space during abdom-
inal insufflation. An 18Fr Foley catheter with 10 mL in
the balloon is introduced for decompression of the blad-
der. During skin preparation, the entire flank and abdo-
men are included in case conversion to an open proce-
dure is required. The umbilicus is placed over the break
in the operating table, and the patient is positioned in a
modified lateral decubitus position.
TIP
For left-side pyeloplasty, the patient is placed in
a strict lateral decubitus position.
The table can be flexed as needed or an inflatable bal-
loon is positioned under the patient at the level of the
umbilicus. Padding is used to support the buttocks and
torso, and all potential pressure points are cushioned.
Fig. 1
a Patient position. b Padding
Laparoscopic Surgery for Benign Urological Disorders
An axillary roll is placed to prevent brachial plexus in-
jury, and the arms are positioned as far away from the
trunk as possible so as not to disturb the movement of
the operative team. The patient is held in position with
strips of cloth tape (Fig. 1a,b).
The surgeon operates from the abdominal side of the
patient, and the first assistant is placed caudally to the
surgeon. The laparoscopic cart is positioned at the back
of the patient’s chest, with the operative team facing the
video monitor. The instruments table is positioned be-
hind the operative team, and the assistant is positioned
higher than the surgeon to prevent instruments from
conflicting (Fig. 2a–c).
Trocars and Laparoscopic Instruments
Right-side pyeloplasty:
• 2 × 11 mm (optic 0° and bipolar grasper)
• 3 × 5 mm (monopolar scissors, suction device, and
liver retractor grasper)
Left-side pyeloplasty:
• 2 × 11 mm (optic 0° and bipolar grasper)
• 2 × 5 mm (monopolar scissors and suction device)
 Chapter 9
• M
 onopolar round-tipped scissors, bipolar grasper,
liver retractor grasper, 5-mm suction device, needle
drivers (2), and 10-mm laparoscopic optic 0°
Access and Port Placement
Four ports are generally enough to perform the proce-
dure, although a fifth port may be used for liver retrac-
tion in those cases of secondary reconstruction with
long length of proximal ureteral stenosis, where the
right kidney must be fully mobilized (Fig. 3). Before the
introduction of the trocars, the abdomen is insufflated
using a Veress needle.
Transperitoneal Laparoscopic Pyeloplasty 155
Fig. 2
a Patient and laparoscopic cart. b Steps below assistant.
c Instruments table behind operative team
TIP
In case of previous surgery, the Veress needle is
not inserted, and an open access procedure is
done for the placement of the first trocar.
Veress Needle
A cutaneous incision is made two fingerbreadths below
the costal margin arch in the midaxillary line, lateral to
the ipsilateral rectus muscle (see Chap. 1, Veress Needle
156 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 3
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)

Fig. 4
a Veress needle at the costal margin arch. b Veress needle inserted
 Chapter 9
Introduction). The needle is introduced through the in-
cision (Fig. 4a,b).
TIP
The skin incision should be 50% larger than the
diameter of the 11-mm trocar.
First Port (11 mm, optic 0°)
Once pneumoperitoneum is established, the Veress
needle is removed, and the 11-mm trocar is introduced
through the same incision, perpendicularly to the ab-
dominal wall (Fig. 5).
TIP
Pneumoperitoneum is established with an intra-
abdominal pressure higher than 10 mmHg.
Fig. 5
Perpendicular introduction of the trocar
Transperitoneal Laparoscopic Pyeloplasty 157
The optic is introduced through the device, and the ab-
domen is then inspected for any injury due to insertion
of the Veress needle or the trocar, and to identify adhe-
sions in areas where the secondary ports will be placed.
The insufflator line is then connected to the trocar.
Second Port (5 mm, 
monopolar round-tipped scissors)
The triangulation rule must be followed for the place-
ment of the trocars as the body habitus is different for
each patient. Four fingerbreadths should be between the
optic trocar and the working trocars (Fig. 6), and five
fingerbreadths should be between the working trocars
(Fig. 7a,b).
TIP
The 5-mm port is usually reserved for the most
skilled hand, as the movements of the working
instruments inside the smaller ports must be
precise.
Fig. 6
Triangulation rule, four fingers
158
Fig. 7
a Triangulation rule, five fingers. b Ports in place
Fig. 8
Left-side ports in position
Third Port (11 mm, bipolar grasper)
The triangulation rule must be followed as above
(Fig. 7a,b).
Fourth Port (5 mm, suction device)
A cutaneous incision is made approximately midline
Section III Laparoscopic Surgery for Benign Urological Disorders
between the umbilicus trocar and the anterior superior
iliac spine on the side of the procedure for the introduc-
tion of the 5-mm trocar.
Final Position of the Ports
The ports are tied to the skin with Vicryl 2-0 to prevent
accidental removal.
Surgical Technique
Colon Mobilization
A traditional Anderson-Hynes dismembered pyelo-
plasty is the usual preferred technique for patients who
have a large renal pelvis, a high ureteral insertion, or a
posterior crossing vessel at the ureteropelvic junction.
For a left pyeloplasty, the plane between the descending
colon and the underlying Gerota’s fascia is developed to
allow the colon to fall medially (Fig. 9a,b). On the right,
the ascending colon is mobilized and dissected from the
underlying Gerota’s fascia.
 Chapter 9
TIP
The lateral attachments of the kidney to the ab-
dominal wall should not be freed at this time to
avoid the kidney falling medially into the oper-
ating field.
TIP
In thin patients, a transmesocolic approach can
be used, and the colon is not mobilized.
Colon mobilization continues caudally to the common
iliac vessels.
Identification of the Ureter
and Ureteropelvic Junction (UPJ)
Gerota’s fascia is carefully incised at the level of the
lower pole of the kidney for the dissection of the ure-
teropelvic junction and potential associated crossing
vessels. Otherwise, the ureter can be searched inferior
Fig. 9
a Colon adhesions to peritoneum. b Plane between colon and Gerota’s fascia
Transperitoneal Laparoscopic Pyeloplasty 159
to the lower pole of the kidney and followed to the ure-
teropelvic junction. The Gerota’s fatty tissue at the level
of the lower pole is incised and lifted to locate the psoas
muscle.
TIP
The correct maneuver to expose the psoas muscle
is the continuous upper movement of the laparo-
scopic instruments to lift the fatty tissue.
The psoas is followed to expose the gonadal vessels and
the ureter just lateral and deep to these vessels.
TIP
In case of previous surgery or difficulty in find-
ing the ureter, it should be dissected in a lower
location.
The ureter is carefully dissected from the gonadal ves-
sels, and attachments between these structures are re-
leased with the aid of monopolar scissors.
160 Section III
Fig. 10
Pelvic junction and crossing vessel
TIP
The ureteral blood supply is usually anteromedi-
ally located in the proximal third, medially lo-
cated in the middle third, and laterally located
in the distal third.
The ureter is then lifted and, along with the visualization
of the psoas muscle, followed cranially to the lower pole
and to the ureteropelvic junction.
Ureteral Transection/Renal Pelvis Excision
Following identification of the ureteropelvic pathol-
ogy, the pelvic junction and the renal pelvis are care-
fully dissected to allow mobilization of these structures
(Fig. 10).
After determining that there is adequate ureteral
length for the anastomosis, the ureter is transected close
to the UPJ. The ureteropelvic junction is incised, and the
redundant renal pelvis is diagonally excised from its lat-
eral side (Fig. 11a–c).
Laparoscopic Surgery for Benign Urological Disorders
TIP
Care must be taken not to excise too much renal
pelvis, especially when resecting along its lateral
aspect to avoid anastomosis tension.
The ureter wall is opened longitudinally and spatulated
for about 1.5 to 2.0 cm along its lateral margin (Fig. 12).
TIP
If no urine exits from the proximal end of the
transected ureter, an intrinsically related prob-
lem is the most likely cause of the UPJ stenosis.
Anastomosis
After proper alignment of the ureter and renal pelvis,
the first Vicryl 4-0 suture is placed through the apex of
the “V” in the spatulated ureter and through the tip of
the inferior renal pelvic flap (Fig. 13a,b).
TIP
The suture is placed from the outside of the lu-
men of the ureter to the inside of the lumen of
the renal pelvis.
Tying of the first suture advances and reduces the ten-
sion on the anastomosis.
TIP
In case of anastomosis tension, the ureter can be
further freed distally to allow for cranial mobi-
lization.
The needle is then passed under the ureter to perform
the posterior side of the anastomosis.
 Chapter 9 Transperitoneal Laparoscopic Pyeloplasty 161

Fig. 11
a Ureteropelvic junction incision. b Redundant pelvis di-
agonally incised. c Redundant pelvis excised

Fig. 12
Ureteral spatulation along lateral margin
162 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 13
a Suture placed at ureter. b Initial ureteropelvic suture

A watertight running suture is done following a cepha-

lad course.

TIP

The initial suture at the renal pelvis is placed

from the outside to the inside of the lumen; the
suture is then introduced from the inside of the
lumen of the ureter and again to the outside of
the lumen of the renal pelvis (Fig. 14). To avoid
the crossing of the suture during this stage, the
standing part of the thread is positioned in the
center of the anastomosis facing the renal pelvis.

After completing the posterior anastomosis (Fig. 15),

Fig. 14
the knot is tied, and a double J stent is introduced.
Posterior side of the anastomosis

TIP
The backside of the needle is passed first when
moving the needle under the ureter to perform
the posterior side of the anastomosis.
Stenting
A straight tip guide wire introduced through the work-
ing 11-mm port is inserted into the ureter and down to
the bladder (Fig. 16). A 7Fr double-pigtail stent (26–30
cm long) is placed in an antegrade fashion over the
 Chapter 9
Fig. 15
Posterior anastomosis completed
Fig. 17
Proximal part of stent placed into the renal pelvis
guide wire into the bladder, and following removal of
the guide wire, the proximal part of the stent is placed
into the renal pelvis (Fig. 17).
Transperitoneal Laparoscopic Pyeloplasty 163
Fig. 16
Guide wire inserted
TIP
The guide wire and the proximal ureter should
be aligned along the same axis to facilitate wire
introduction.
TIP
Approximation of the 11-mm port close to the
lumen of the ureter facilitates stent introduction.
The visualization of a reflux of methylene blue
instilled into the bladder at the ureterotomy site
can be used to verify the correct placement of the
stent in the bladder.
Alternatively, a nephroureteral catheter is inserted ret-
rogradely through a thin renal parenchyma overlying a
calyx and is exteriorized while the distal part is inserted
into the ureter.
The anterior anastomosis is then performed (Fig. 18).
A watertight cranially oriented running suture is placed
from the outside of the lumen of the renal pelvis to the
164 Section III
Fig. 18
Anterior anastomosis
inside of the lumen of the ureter, and the knot is tied
(Fig. 19).
A Penrose drain is introduced through the 11-mm
port, positioned adjacent to the repair, and exited
through the most caudal port. The aponeurosis of the
11-mm port is closed with a Dexon II HGU-46 su-
ture, and the skin is closed with running intradermic
Monocryl 3-0. The drain is fixed to the skin with Flex-
idene 2-0, and the skin incisions are closed with Opsite ®
dressing.
Postoperative Considerations
A short hospitalization is associated with laparoscopic
pyeloplasty. The Foley catheter is removed on the sec-
ond postoperative day, and the Penrose drain is usually
removed before discharge. The double-J stent is left in-
dwelling for six weeks, and objective assessment of the
repair is done with diuretic nuclear renography after a
three months’ follow-up.
Laparoscopic Surgery for Benign Urological Disorders
Fig. 19
Final result
Suggested Readings
1. Williams B, Tareen B: Pathophysiology and treatment of
ureteropelvic junction obstruction. Curr Urol Rep 2007
Mar; 8(2):111–117.
2. Stein RJ, Gill IS: Comparison of surgical approaches to
ureteropelvic junction obstruction: endopyeloplasty versus
endopyelotomy versus laparoscopic pyeloplasty. Curr Urol
Rep 2007 Mar; 8(2):140–149.
3. Castillo OA, Vitagliano G: Transmesocolic pyeloplasty: ex-
perience of a single center. J Endourol 2007 Apr; 21(4): 415–
418.
4. Simforoosh N: Laparoscopic management of ureteropelvic
junction obstruction by division of anterior crossing vein
and cephalad relocation of anterior crossing artery. J En-
dourol 2005 Sep; 19(7): 827–830.
 Chapter 10
Transperitoneal
Laparoscopic Donor
Nephrectomy
Contents
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   165
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . .  
P 165
Patient Positioning and Initial Preparation   . . .   166
Trocars and Laparoscopic Instruments  . . . . . . . .   167
Access and Port Placement  . . . . . . . . . . . . . . . . . . . .   167
Veress Needle  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   169
First Port (11 mm, optic 0°)  . . . . . . . . . . . . . . . . . .   169
S econd Port   . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   169
Third Port   .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   170
Fourth Port (5 mm, suction device)  .. . . . . . . . .   170
Fifth Port (5 mm, liver retractor grasper)  .. . . .   172
Final Position of the Ports  . . . . . . . . . . . . . . . . . . .   172
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . . .   172
Colon Mobilization  .. . . . . . . . . . . . . . . . . . . . . . . . .   172
Ureter and Gonadal Vessels Identification  . . .   173
Exposure and Dissection of the Renal Hilum    174
M obilization of the Kidney and Ureter
Transection  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   174
Renal Hilum Ligature   . . . . . . . . . . . . . . . . . . . . . . .   175
K idney Extraction  . . . . . . . . . . . . . . . . . . . . . . . . . . .   177
Abdominal Closure  .. . . . . . . . . . . . . . . . . . . . . . . . .   178
Postoperative Considerations  . . . . . . . . . . . . . . . . .   178
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . .   178
Introduction
Laparoscopic living donor nephrectomy has become the
standard procedure for renal transplantation. The lapa-
roscopic technique is less invasive for the donor, allow-
ing lower postoperative analgesic requirements and a
faster return to daily activities. Concerns about adequate
length of the right renal vein have resulted in more lapa-
roscopic donor nephrectomies being performed on the
left side, conflicting with the principle of leaving the do-
nor with the best kidney. Although right nephrectomies
are not more technically challenging than left nephrec-
tomies, the short length of the right renal vein restrains
the routine use of the right kidney for transplantation
purposes. Preservation of the maximum length of the
right renal vein continues to be a challenge for the sur-
geon, and the technique described utilizes a modified
Endo GIATM 30 Universal stapler for this purpose.
Preoperative Preparation
Before a patient consents to a laparoscopic nephrectomy,
it is important to discuss the specific risks of the surgery,
including the potential need to convert to the traditional
open operation if difficulties arise.
The patient is admitted to the hospital the day before
the surgery for bowel preparation, which includes 2 L of
® ®
Colopeg (1 envelope/L) p.o. and a Fleet enema. Fast-
ing starts at midnight before surgery. Thromboprophy-
laxis is implemented with good hydration, placement of
compressive elastic stockings on the lower extremities,
and low-molecular-weight heparin. Enoxaparin (Clex-
® ®
ane , Lovenox ) 40 mg sc 1 × day or nadroparin (Flaxi-
® ®
parine , Fraxiparin ) 0.6 mL sc 1 × day is initiated on
day 1 after the surgery and continued daily until the
166 Section III
patient is discharged from the hospital. In selected cases,
the treatment is continued for 30 days after the proce-
dure. Patients also receive antibiotic prophylaxis with a
single preoperative dose of intravenous second-genera-
tion cephalosporin, unless they are allergic to penicillin.
Blood type and crossmatch are determined.
Patient Positioning and Initial Preparation
The patient is initially positioned supine for intravenous
access, the induction of general anesthesia, and endotra-
cheal intubation. An orogastric tube is placed and the
stomach decompressed to avoid puncture during trocar
placement and to allow additional space during abdom-
inal insufflation. An 18Fr Foley catheter with 10 mL in
the balloon is introduced for decompression of the blad-
der. During skin preparation, the entire flank and abdo-
men are included in case conversion to an open proce-
dure is required. The umbilicus is placed over the break
in the operating table, and the patient is positioned in a
modified lateral decubitus position.
Fig. 1
a Patient position. b Padding
Laparoscopic Surgery for Benign Urological Disorders
TIP
For left-side nephrectomy, the patient is placed
in a strict lateral decubitus position.
The table can be flexed as needed or an inflatable bal-
loon is positioned under the patient at the level of the
umbilicus. Padding is used to support the buttocks and
torso, and all potential pressure points are cushioned.
An axillary roll is placed to prevent brachial plexus in-
jury, and the arms should be positioned as far away from
the trunk as possible so as not to disturb the movement
of the operative team. The patient is held in position
with strips of cloth tape (Fig. 1a,b).
The surgeon operates from the abdominal side of the
patient, and the first assistant is placed caudally to the
surgeon. The laparoscopic cart is positioned at the back
of the patient’s chest, with the operative team facing
the video monitor. The instruments table is positioned
behind the operative team, and the assistant is posi-
tioned on steps to prevent instruments from conflicting
(Fig. 2a–c).
 Chapter 10 Transperitoneal Laparoscopic Donor Nephrectomy 167

Fig. 2
a Patient and laparoscopic cart. b Steps below assistant.
c Instruments table behind operative team

• M
 onopolar round-tipped scissors, bipolar grasper,
Trocars and Laparoscopic Instruments liver retractor grasper, 5-mm suction device, needle
Right-side nephrectomy: drivers (2), 10-mm laparoscopic optic 0°, 10-mm clip
• 1 × 11 mm (optic 0°) applier (non-disposable), and Multifire Endo GIATM
• 1 × 12 mm (Endo GIA and bipolar grasper) 30 stapler
• 3 × 5 mm (monopolar scissors, suction device, and
liver retractor grasper)

Left-side nephrectomy:
• 2 × 11 mm (optic 0°, bipolar grasper, and 10-mm clip
applier)
• 2 × 5 mm (monopolar scissors and suction device)
Access and Port Placement
Four ports are generally enough to perform the proce-
dure, although a fifth trocar may be necessary for liver
retraction during right-side nephrectomy (Fig. 3). Be-
168 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 3
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)

Fig. 4
a Cutaneous incision below costal margin. b Insertion of Veress needle
 Chapter 10
Fig. 5
Perpendicular introduction of the trocar
fore trocars are placed, the abdomen is insufflated using
a Veress needle.
TIP
In case of previous surgery, the Veress needle is
not inserted, and an open access procedure is
done for the placement of the first trocar.
Veress Needle
A cutaneous incision is made two fingerbreadths below
the costal margin arch, at the level of the lateral border
of the rectus muscle (Fig. 4a,b).
TIP
The skin incision should be 50% larger than the
diameter of the 11 mm trocar.
The Veress needle is introduced through the incision
(see Chap. 1, Veress Needle Introduction).
Transperitoneal Laparoscopic Donor Nephrectomy 169
Fig. 6
Triangulation rule, four fingers
First Port (11 mm, optic 0°)
Once pneumoperitoneum is established, the Veress
needle is removed, and the 11-mm trocar is introduced
through the same incision, perpendicularly to the ab-
dominal wall (Fig. 5).
TIP
Pneumoperitoneum is established with an intra-
abdominal pressure higher than 10 mmHg.
The optic is introduced through the device, and the ab-
domen is then inspected for any injury due to insertion
of the Veress needle or the trocar, and to identify adhe-
sions in areas where the secondary ports will be placed.
The insufflator line is then connected to the port.
Second Port
• F or a left-side nephrectomy: 11 mm (10-mm clip ap-
plier and bipolar grasper)
• For a right-side nephrectomy: 5 mm (monopolar
round-tipped scissors)
170
Fig. 7
a Triangulation rule, five fingers. b Ports in place
Fig. 8
Right-side ports
The triangulation rule must be followed for the place-
ment of the trocars as the body habitus is different for
each patient. Four fingerbreadths should be between the
optic trocar and the working trocars (Fig. 6), and five
fingerbreadths should be between the working trocars
(Fig. 7a,b).
Section III Laparoscopic Surgery for Benign Urological Disorders
TIP
The 5-mm port is usually reserved for the most
skilled hand, because the movements of the
working instruments inside the smaller ports
must be precise.
Third Port
• F or a left-side nephrectomy: 5 mm (monopolar
round-tipped scissors)
• For a right-side nephrectomy: 12 mm (Multifire
Endo GIA 30 stapler and bipolar grasper)
The triangulation rule must be followed as above.
Fourth Port (5 mm, suction device)
A cutaneous incision is made approximately midline
between the umbilicus trocar and the anterior superior
iliac spine on the side of the procedure for the introduc-
tion of the 5-mm trocar.
 Chapter 10 Transperitoneal Laparoscopic Donor Nephrectomy 171

Fig. 9
Left-side ports

Fig. 10
a Colon attachments to abdominal wall. b Release of the
colon attachments to abdominal wall. c Colon is dissected
from Gerota’s fascia (Gerota is not freed from abdominal
wall)
172 Section III
Fig. 11
a Spleen is released from kidney. b En bloc spleen dissection
Fifth Port (5 mm, liver retractor grasper)
A cutaneous incision is made approximately two fin-
gerbreadths below the level of the second port for in-
troduction of a 5-mm port in case a liver retraction is
performed during a right-side nephrectomy (Fig. 8).
Final Position of the Ports
See Figures 8 and 9.
The ports are finally tied to the skin with Vicryl 2-0 to
prevent accidental removal.
Surgical Technique
Colon Mobilization
For a left-side nephrectomy, the plane between the
des­cending colon and the underlying Gerota’s fas-
Laparoscopic Surgery for Benign Urological Disorders
cia is developed to allow the colon to fall medially
(Fig. 10a–c).
TIP
The lateral attachments of Gerota’s fascia to the
abdominal wall should not be freed at this time
to avoid the kidney falling medially into the op-
erating field.
This plane of dissection is carried out cranially. The spl-
enorenal and lienocolic ligaments are incised, allowing
the spleen and the tail of the pancreas to be separated
from the upper pole of the kidney. The en bloc dissection
of the colon, spleen, and pancreas must be completed
for adequate exposure of the renal hilum (Fig. 11a,b).
For a right-side nephrectomy, the liver is cranially
retracted using a grasper that is fixed to the abdomi-
nal wall (Fig. 12). The ascending colon is mobilized
and dissected from the underlying Gerota’s fascia. Co-
lon mobilization continues caudally to the common
iliac vessels.
 Chapter 10
Ureter and Gonadal Vessels Identification
Following the medial mobilization of the colon and me-
socolon, the gonadal vessels are visualized underneath
Gerota’s fascia. The Gerota’s fatty tissue at the level of the
lower pole of the kidney is incised and lifted to locate
the psoas muscle (Fig. 13).
Fig. 12
Grasper retracting liver
Fig. 14
a Dissection of ureter and gonadal vessels. b Psoas muscle
Transperitoneal Laparoscopic Donor Nephrectomy 173
TIP
The correct maneuver to expose the psoas muscle
is the continuous upper movement of the laparo-
scopic instruments to lift the fatty tissue.
Fig. 13
Lifting of fatty tissue to expose psoas muscle
174 Section III
Fig. 15
Renal hilum
The psoas is followed to expose the ureter just lateral
and deep to the gonadal vessels (Fig. 14a,b).
By tracking the cephalad course of the ureter, to-
gether with the gonadal vessels on the left side, the plane
is followed up to the renal hilum (Fig. 15).
Caudally, the ureter is dissected and freed until the
crossing of the iliac vessels. The ureter and gonadal ves-
sels are not divided at this time.
Exposure and Dissection of the Renal Hilum
For a left-side nephrectomy, the renal vein is dissected
along with the lumbar, gonadal, and adrenal veins
(Fig. 16).
TIP
Care must be taken with: (1) the lumbar vessels
that are usually located posterior and inferior to
the renal vein and that cross over the renal ar-
tery and (2) the adrenal vein that usually drains
at the superior margin of the renal vessel. These
vessels are cut to increase the length of the renal
vein.
Laparoscopic Surgery for Benign Urological Disorders
Fig. 16
Left gonadal (G), adrenal (A), and renal (R) veins
The left renal artery is dissected and exposed posterior
to the veins (Fig. 17a,b).
For a right-side nephrectomy, the duodenum is medi-
ally mobilized by performing a Kocher maneuver until
the vena cava is clearly visualized.
TIP
For a right-side nephrectomy, the vena cava is
mobilized laterally, and the left renal vein is dis-
sected and gently displaced to expose the plane
between the aorta and the inferior vena cava.
The right renal artery is dissected and exposed
at its origin. The aim is to attain maximal length
of the donor vessel (Fig. 18).
The right renal vein is dissected at the lateral border of
the vena cava.
Mobilization of the Kidney 
and Ureter Transection
The dissection continues cranially to the upper pole of
the kidney, and the adrenal gland is separated from it.
 Chapter 10
Fig. 17
a Renal artery exposed. b Renal artery dissected
Fig. 18
Vena cava (A); Left renal vein (B); Right renal artery (C); In-
tercavoaortic Space (D); Liver (L)
This is accomplished by incising Gerota’s fascia anteri-
orly just above the hilum and then carefully peeling off
the Gerota’s fat circumferentially above the upper pole
of the kidney.
Transperitoneal Laparoscopic Donor Nephrectomy 175
TIP
At this point during the dissection, care must be
taken with the short adrenal vein on the right
side that drains into the inferior vena cava at its
posterolateral side.
For a right-side nephrectomy, superior retraction of the
liver facilitates the dissection of the plane between the
liver and the upper pole of the kidney (Fig. 19).
The attachments of the kidney to the posterior and
lateral abdominal wall are released by blunt and sharp
dissection, taking care to coagulate the bleeding vessels.
Inferiorly, the ureter is ligated with one large (L) Hem-o-
®
lok clip applied to its most distal portion, and it is then
transected to allow the kidney to be fully mobilized.
Renal Hilum Ligature
A 6–8 cm lower ilioinguinal incision is made, but the
muscle attached to the peritoneum is not incised to pre-
serve the pneumoperitoneum. A large laparoscopic bag
®
(EndoCatch II 15 mm, Tyco Autosuture) is introduced
through the small opening of the peritoneum at the il-
176 Section III
Fig. 19
Dissection plane between liver and kidney upper pole
ioinguinal incision. The kidney, attached only to the hi-
lum, is placed into the bag, and the EndoCatch arm is
pulled out to partially close the metal ring around the
hilum (Fig. 20).
TIP
A Kocher clamp is placed at the EndoCatch arm
to hold the metal ring in place to prevent its
opening.
TIP
The string of the EndoCatch must not be touched
to avoid detachment of the bag.
At this time, two extra-large (XL) Hem-o-lok clips are
applied to the proximal portion of the renal artery with-
out cutting it.
Laparoscopic Surgery for Benign Urological Disorders
Fig. 20
Right renal vein (A); Vena cava (B); Right renal artery (C);
EndoCatch metal ring (D)
TIP
As soon as the clip is applied to the artery, the
warm ischemia begins.
The right renal vein is gently stretched. The vein is then
stapled and divided using the Multifire Endo GIATM 30
12-mm stapler (Autosuture) introduced through the
third port (12 mm). The tension on the renal vein places
the row of staples on the lateral part of the vena cava,
increasing the donor vein length (Fig. 21). The left re-
nal vein is proximally clipped with two extra-large (XL)
Hem-o-lok clips and then transected, leaving a 2-mm
vein margin to prevent the slipping of the clips.
TIP
No clips are placed at the kidney side of the renal
artery and vein.
 Chapter 10 Transperitoneal Laparoscopic Donor Nephrectomy 17 7

Fig. 21 Fig. 22
Vena cava (A); Stapled cuff of vena cava (B); Loose sta- Superior fixation of the pusher intact (A); Inferior fixation
ples (C) of the pusher sectioned (B); Clip pusher (C)

Following transection of the renal vein, the renal artery

is then cut.

TIP

The Multifire Endo GIA 30 stapler is used for

securing and transecting the main right renal
vein, but the triple staggered rows of staples of
the kidney side are removed to allow for a lon-
ger donor vein (Fig. 22). The rows of staples can
be individually removed using a thin needle or Fig. 23

by cutting the fixation of the pusher at its base
with a scalpel and then firing it to release the
staples. The empty rows are yellow colored, fa-
cilitating the visualization of the correct side of
the Endo GIA that will be applied to the renal
vein (Fig. 23).
Yellow colored empty rows (Y)
Kidney Extraction
Once all of the hilar vessels have been divided, a simple
digital avulsion of the muscle and peritoneum around
the arm of the EndoCatch opens completely the ilioin-
guinal incision, allowing the EndoCatch with the speci-
men inside to be easily removed. The kidney is then
178 Section III
taken to the bench, where it is flushed with a preserva-
tion solution (Custodiol HTK, Tramedico).
Abdominal Closure
The abdominal wall is closed using running Vicryl 2-0
SH 1 Plus (needle ½ 21.8 mm) for the peritoneum, Vic-
ryl 0 suture in “X” for the muscle, and a running Vic-
ryl 1 CT Plus (needle ½ 39.9 mm) for the aponeurosis.
Once the abdominal wall is closed, pneumoperitoneum
is re-established, and the optic is introduced for revi-
sion of the hemostasis. A silicone Penrose drain is in-
serted. After evacuation of the pneumoperitoneum and
removal of the trocars, the aponeurosis of the 11-mm
and 12-mm ports are closed with a Dexon II HGU-46
suture. The skin incisions are closed with subcuticular
Monocryl 3-0 C 423 and routinely infiltrated with 0.25%
bupivacaine.
Postoperative Considerations
The nasogastric tube is removed at the end of the proce-
dure, and the intravenous perfusion is stopped on day 1.
Pain is controlled with scheduled intramuscular nonste-
roidal anti-inflammatory drugs (NSAIDs) and oral an-
algesics. Intramuscular NSAIDs are often discontinued
after 24 h. A light diet can generally be resumed on day
1 after surgery. The Foley catheter is removed on day 1
Laparoscopic Surgery for Benign Urological Disorders
after surgery and the Penrose drain on the second post-
operative day. Patients leave the hospital on the third
or fourth postoperative day. Normal light activities are
resumed after hospital discharge, but vigorous activities
and heavy lifting are limited for at least one month after
surgery.
Suggested Readings
1. Bollens R, Mikhaski D: Laparoscopic live donor right ne-
phrectomy: a new technique to maximize the length of the
renal vein using a modified Endo GIA stapler. Eur Urol
2007 May; 51(5):1326–1331.
2. Sundaram CP, Martin GL: Complications after a 5-year
experience with laparoscopic donor nephrectomy: the
Indiana University experience. Surg Endosc 2007 May;
21(5):724–728.
3. Breda A, Veale J: Complications of laparoscopic living do-
nor nephrectomy and their management: the UCLA expe-
rience. Urology 2007 Jan; 69(1):49–52.
4. Chin EH, Hazzan D: Laparoscopic donor nephrectomy:
intraoperative safety, immediate morbidity, and delayed
complications with 500 cases. Surg Endosc 2007 Apr;
21(4):521–526.
5. Fisher PC, Montgomery JS: 200 consecutive hand assisted
laparoscopic donor nephrectomies: evolution of operative
technique and outcomes. J Urol 2006 Apr; 175(4):1439–
1443.
 Chapter 11

Hand-Assisted
Bilateral Laparoscopic
Intraperitoneal
Nephrectomy

Contents
Introduction
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   179 Bilateral nephrectomy is occasionally indicated in
I ndications  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   179 symptomatic autosomal dominant polycystic kidney
Preoperative Preparation  .. . . . . . . . . . . . . . . . . . . . .   179 disease (ADPKD) patients with end-stage renal disease.
Patient Positioning and Initial Preparation  .. . .   180 These patients are subject to hypertension, hemorrhage
Trocars and Laparoscopic Instruments   .. . . . . . .   181 into the renal cysts, recurrent renal calculi formation,
Access and Port Placement  . . . . . . . . . . . . . . . . . . . .   181 pain, and infection. Laparoscopic hand-assisted bilat-
Veress Needle  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   181 eral nephrectomy provides many advantages over staged
First Port (11 mm, optic 0°, scissors, nephrectomies, including the single administration of
LigaSure)  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   181 general anesthesia. It is a safe and reliable option with
Cutaneous Incision (hand introduction)  . . . . .   183 lower morbidity, reduced hospitalization, and superior
S econd Port (11 mm, optic and suction cosmesis when compared with open nephrectomy. De-
device)  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   183 spite the technical difficulties in removing bilateral giant
Third Port (11 mm, optic)  .. . . . . . . . . . . . . . . . . . .   184 kidneys in a single setting, the laparoscopic hand-as-
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . . .   184 sisted technique is a feasible option for providing effec-
R ight Kidney  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   185 tive relief of symptoms in ADPKD patients.
Left Kidney  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .   185
Bilateral Ureterectomy  . . . . . . . . . . . . . . . . . . . . . .   185
K idney Extraction   .. . . . . . . . . . . . . . . . . . . . . . . . . .   186
Closure of the Abdominal Wall  . . . . . . . . . . . . . .   186
Indications
Postoperative Considerations  . . . . . . . . . . . . . . . . .   186 • G iant symptomatic autosomal dominant polycystic
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . .   186 kidney disease (ADPKD)
• Acquired cystic kidney disease (ACKD) and inciden-
tal renal tumors

Preoperative Preparation
Before a patient consents to a laparoscopic hand-as-
sisted bilateral nephrectomy, it is important to discuss
the specific risks of the surgery, including the potential
need to convert to the traditional open operation if dif-
ficulties arise.
The patient is admitted to the hospital the night be-
fore the surgery for bowel preparation, which includes
180 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 1 Fig. 2
Patient’s position Operative team’s position

Fig. 3
Dark-colored gloves

2 L of Colopeg (1 envelope/L) p.o. and a Fleet enema. dure. Patients also receive antibiotic prophylaxis with a
Fasting starts at midnight before surgery. Thrombopro- single preoperative dose of intravenous second-genera-
phylaxis is implemented with good hydration, placement tion cephalosporin, unless they are allergic to penicillin.
of compressive elastic stockings on the lower extremi- Blood type and crossmatch are determined.
ties, and low-molecular-weight heparin. Enoxaparin
® ®
(Clexane , Lovenox ) 40 mg sc 1 × day or nadroparin
® ®
(Flaxiparine , Fraxiparin ) 0.6 mL sc 1 × day is initiated
Patient Positioning and Initial Preparation
on day 1 after the surgery and continued daily until the
patient is discharged from the hospital. In selected cases, The surgery is performed under general anesthesia. The
the treatment is continued for 30 days after the proce- base of the table must be positioned below the patient’s
 Chapter 11
hip to avoid elevation of the abdomen while in the Tren-
delenburg position. The patient is placed in the supine
position with the lower limbs in abduction, allowing the
surgeon to be placed between the legs of the patient. The
lower buttocks must be placed at the distal end of the
operating table. The upper limbs are positioned along-
side the body to avoid the risk of stretch injuries to the
brachial plexus and to allow for free movements of the
operative team (Fig. 1).
A nasogastric catheter is placed by the anesthesiolo-
gist and the stomach decompressed to avoid puncture
during trocar placement and to allow additional space
during extraperitoneal insufflation. The abdomen, pel-
vis, and genitalia are skin prepared in case conversion
to an open procedure is required. An 18Fr Foley cath-
eter with 10 mL in the balloon is introduced before the
placement of the sterile drapes.
The surgeon is positioned between the patient’s legs;
the first assistant initially stands at the patient’s left side
(Fig. 2) and then moves to the right side for the left ne-
phrectomy stage. For the right nephrectomy stage, the
laparoscopic cart is placed to the right side, lateral to the
patient’s head, while the instruments table and the coag-
ulation unit are positioned at the left side of the patient.
For the left-side nephrectomy, the monitor is placed at
the patient’s left side.
Trocars and Laparoscopic Instruments
• 3 × 11 mm (optic 0°, scissors, suction device, and Li-
gaSure)
• Monopolar round-tipped scissors, suction device,
needle drivers (2), 10-mm laparoscopic optic 0°, Li-
gaSure 5 mm.
TIP
The surgeon uses dark-colored surgical gloves
to reduce light reflection while performing the
hand-assisted procedure (Fig. 3).
Hand-Assisted Bilateral Laparoscopic Nephrectomy 181
Access and Port Placement
Veress Needle
A cutaneous incision is made at the level of the inferior
margin of the umbilicus.
TIP
The skin incision should be 50% larger than the
diameter of the 11-mm trocar.
The Veress needle is introduced through the incision
(see Chap. 1, Veress Needle Introduction). The insuffla-
tion line is connected to the Veress needle, the stopcock
is opened, and insufflation is initiated.
TIP
It is recommended to start with low flow to avoid
damage to a vital structure in case the needle is
malpositioned. Switch to high flow if the pres-
sure of insufflation is increasing at a steady and
normal level and there is also a tympanic per-
cussion of the liver area.
First Port (11 mm, optic 0°, scissors, LigaSure)
Once pneumoperitoneum is established, the Veress
needle is removed, and the 11-mm trocar is introduced
through the same incision, perpendicularly to the ab-
dominal wall.
TIP
Pneumoperitoneum is established with an intra-
abdominal pressure higher than 10 mmHg.
The optic is introduced through the trocar, and the ab-
domen is then inspected for any injury due to insertion
182 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 4
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)

Fig. 5 Fig. 6
Ilioinguinal cutaneous incision Peritoneal puncture made with Mayo scissors
 Chapter 11
Fig. 7
a Gel applied to fingers. b Hand inserted
Fig. 8
Hand inside abdomen aids with trocar insertion
of the Veress needle or the trocar, and to identify adhe-
sions in areas where the secondary ports will be placed.
The insufflation tubing is then connected.
Cutaneous Incision (hand introduction)
A right ilioinguinal cutaneous incision is made, and the
planes are opened to expose the muscle and the perito-
neum attached to it (Fig. 5).
Hand-Assisted Bilateral Laparoscopic Nephrectomy 183
TIP
If a kidney graft is already in place, the hand
port is medially displaced.
With the aid of Mayo scissors, a peritoneal punc-
ture is made at the incision for the insertion of one
finger (Fig. 6), and, following successive introduction
of the other fingers, the full left hand is introduced
(Fig. 7a, b).
TIP
Jelly is applied to the fingers to facilitate their
introduction, and the hand must snugly fit into
the incision to avoid air leakage.
Second Port (11 mm, optic 
and suction device)
A skin incision is made four fingerbreadths above the
umbilicus in the midline, and an 11-mm trocar is in-
troduced under vision and with the aid of the hand in-
serted into the abdominal cavity (Fig. 8).
184 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 9
a Trocars in place. b Trocars and hand in place

TIP

The incision should be 50% larger than the di-

ameter of the 11-mm trocar.

An 11-mm trocar is introduced under vision and with

the aid of the hand inserted into the abdominal cavity
(Fig. 9a,b).

Surgical Technique
Sequence of dissection:
• 1. Right kidney lower pole
Fig. 10
• 2. Right kidney upper pole
Instruments in place
• 3. Left kidney lower pole
• 4. Left kidney upper pole

TIP

Third Port (11 mm, optic) This dissection sequence will avoid excessive en-
larging of the abdominal cavity incision, reduc-
A skin incision is made four fingerbreadths to the left of ing the possibility of air leakage.
the umbilicus.
 Chapter 11 Hand-Assisted Bilateral Laparoscopic Nephrectomy 185

TIP

The instrument is introduced through the um-

bilical port.

The ureter is clipped and transected.

When approaching the pedicle, the optic is placed
in the supraumbilical port, and the suction device is
placed in the left lateral port (Fig. 10). The renal vas-
cular pedicle is carefully dissected, clipped, and tran-
sected.

Left Kidney
Fig. 11
Change of position of instruments for bilateral ureterec-
tomy
The monitor is placed at the left side of the patient, the
assistant moves to the right, and the instruments table
is placed behind the surgeon. The left colon is dissected
from Gerota’s fascia. Then, the left hand is passed under
the inferior, lateral, and superior kidney side to free the
specimen while the LigaSure 5 mm (set at III 01/01) aids
with the dissection.

TIP

Care must be taken to avoid spleen damage

while releasing the left kidney.

The ureter is clipped and transected. The renal vascu-

lar pedicle is carefully dissected, clipped, and tran-
Fig. 12
sected.
Specimen removal

Bilateral Ureterectomy

Right Kidney When performing an associated bilateral ureterec-

The right colon is dissected from Gerota’s fascia, and
the duodenum is mobilized (Kocher maneuver). Then,
the left hand is passed under the inferior, lateral, and
superior kidney side to free the specimen while the Li-
gaSure 5 mm (set at III 01/01) aids with the dissection
(Fig. 10).
tomy, the surgeon moves to the patient’s left side while
the assistant is repositioned to the right. The laparo-
scopic cart is positioned at the patient’s feet. A 5-mm
trocar is inserted four fingerbreadths to the right of the
umbilicus and approximately in line with the contralat-
eral third port. The optic is placed in the supraumbilical
port, the bipolar grasper is placed at the left-side port,
186 Section III Laparoscopic Surgery for Benign Urological Disorders

Postoperative Considerations
The nasogastric tube is removed at the end of the pro-
cedure, and the intravenous perfusion is stopped on day
1. Pain is usually controlled with scheduled intravenous
analgesics, which are replaced by the oral route after 24
hours. A light diet can generally be resumed on day 1
after surgery. The Foley catheter is removed on day 1 af-
ter surgery and the Penrose drain on day 2 after surgery.
Patients leave the hospital on the third or fourth postop-
erative day and can resume normal light activities. Vig-
orous activities and heavy lifting are limited for at least
one month after surgery.

Fig. 13
Final result Suggested Readings
1. Lipke MC, Bargman V: Limitations of laparoscopy for bilat-
eral nephrectomy for autosomal dominant polycystic kid-
ney disease. J Urol 2007 Feb; 177(2):627–631.
the monopolar scissors are placed at the umbilical port, 2. Ghasemian SR, Pedraza R: Bilateral laparoscopic radical
and the suction device is placed at the right-side port nephrectomy for renal tumors in patients with acquired
(Fig. 11). cystic kidney disease. J Laparoendosc Adv Surg Tech A
2005 Dec; 15(6):606–610.
3. Luke PPW, Spodeka J: Hand-assisted laparoscopic resec-
Kidney Extraction tion of the massive autosomal dominant polycystic kidney
disease. Urology 2004 Feb; 63(2):369–372.
The kidneys are removed through the lower ilioingui- 4. Lee DI, Clayman RV: Hand-assisted laparoscopic nephrec-
nal incision, and the laparoscopic bag is not needed tomy in autosomal dominant polycystic kidney disease.
(Fig. 12). J Endourol 2004 May; 18(4):379–382.
5. Gill IS, Kaouk JH: Laparoscopic bilateral synchronous ne-
phrectomy for autosomal dominant polycystic kidney dis-
Closure of the Abdominal Wall ease: the initial experience. J Urol 2001 Apr; 165(4):1093–
1098.
The abdominal wall is closed using running Vicryl 2-0
SH 1 Plus (needle ½ 21.8 mm) for the peritoneum, Vic-
ryl 0 suture in “X” for the muscle, and a running Vic-
ryl 1 CT Plus (needle ½ 39.9 mm) for the aponeurosis.
Once the abdominal wall is closed, pneumoperitoneum
is re-established, and the optic is introduced for revi-
sion of the hemostasis. A silicone Penrose drain is in-
serted. After evacuation of the pneumoperitoneum and
removal of the trocars, the aponeurosis of the 11-mm
port is closed with a Dexon II HGU-46 suture. The skin
incisions are closed with subcuticular Monocryl 3-0 C
423 (Fig. 13).
 Chapter 12
Laparoscopic Promontory
Fixation
Contents
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . .
P   187
Patient Positioning and Initial Preparation  .. . .  
Trocars and Laparoscopic Instruments   .. . . . . . .  
Access and Port Placement  . . . . . . . . . . . . . . . . . . . .  
Veress Needle  .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
First Port (11 mm, optic 0°)  . . . . . . . . . . . . . . . . . .  
S econd Port (11 mm, bipolar grasper)  .. . . . . .  
Third Port (5 mm, suction device)  . . . . . . . . . . .  
Fourth Port (5 mm, monopolar 
round-tipped scissors)  . . . . . . . . . . . . . . . . . . . . . .  
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Bowel Displacement   .. . . . . . . . . . . . . . . . . . . . . . .  
Subtotal Hysterectomy and Anexectomy  .. . .  
Posterior Dissection (Rectovaginal Plane)  . . .  
Fixation of the Posterior Mesh  .. . . . . . . . . . . . . .  
Anterior Dissection (Vesicovaginal Plane)  . . .  
Fixation of the Vaginal Mesh  . . . . . . . . . . . . . . . .  
Exposure of the Promontory   .. . . . . . . . . . . . . . .  
Promontory Fixation  . . . . . . . . . . . . . . . . . . . . . . . .  
Closure of the Posterior Peritoneum   . . . . . . . .  
Postoperative Considerations  . . . . . . . . . . . . . . . . .  
S chematic mesh position . . . . . . . . . . . . . . . . . . . . . . .  
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . .  
Introduction
187 Genitourinary prolapse occurs when the mechanisms
for vaginal and uterine support begin to wear off. The
188 most common prolapse is cystourethrocele, followed by
188 uterine descent and rectocele. The correction of symp-
189 tomatic moderate and severe genitourinary prolapse by
189 the laparoscopic promontory fixation technique consists
190 of placing two polyester (PET) meshes that pull the pro-
190 lapsed bladder and rectum up. The distal part of the an-
190 terior mesh is fixed at the anterior vaginal wall, and the
posterior mesh is fixed distally at the levator ani muscle
190 bilaterally. The proximal part of the anterior and pos-
191 terior mesh is anchored to the sacral promontory. The
191 posterior dissection extends deep into the rectovaginal
192 space, and the transperitoneal laparoscopic access al-
194 lows for a good visualization of the operative field, as
195 opposed to the open procedure.
196
197
197
198
Preoperative Preparation
200 The patient is admitted to the hospital the day before
200 the surgery for bowel preparation, which includes 2 L of
201 ® ®
Colopeg (1 envelope/L) p.o. and a Fleet enema. Fast-
201 ing starts at midnight before surgery. Thromboprophy-
laxis is implemented with good hydration, placement of
compressive elastic stockings on the lower extremities,
and low-molecular-weight heparin. Enoxaparin (Clex-
® ®
ane , Lovenox ) 40 mg sc 1 × day or nadroparin (Flaxi-
® ®
parine , Fraxiparin ) 0.6 mL sc 1 × day is initiated on
day 1 after the surgery and continued daily until the pa-
tient is discharged from the hospital. In selected cases,
the treatment is continued for 30 days after the proce-
dure. Patients also receive antibiotic prophylaxis with a
single preoperative dose of intravenous second-genera-
188 Section III
Fig. 1
Shoulder support
tion cephalosporin, unless they are allergic to penicillin.
Blood type and crossmatch are determined.
Patient Positioning and Initial Preparation
The surgery is performed under general anesthesia. The
patient is placed in the supine position with the lower
limbs in abduction, allowing the laparoscopic cart to
be moved toward the surgeon and intraoperative access
to the perineum. The lower buttocks must be placed at
the distal end of the operating table. The upper limbs
are positioned alongside the body to avoid the risk of
stretch injuries to the brachial plexus and to allow for
free movements of the operative team. Shoulder sup-
port over the acromium clavicular joint is placed for the
Trendelenburg position (Fig. 1).
Laparoscopic Surgery for Benign Urological Disorders
Fig. 2
Placement of the drapes
A nasogastric tube is placed by the anesthesiologist
and the stomach decompressed to allow additional space
for the placement of the small bowel above the promon-
tory. An 18Fr Foley catheter with 10 mL in the balloon is
introduced after placement of the sterile drapes (Fig. 2).
The surgeon and the second assistant operate from
the patient’s left side, and the first assistant is placed at
the opposite side of the surgeon. The laparoscopic cart
is positioned at the patient’s feet, while the instruments
table and the coagulation unit are positioned at the left
side of the patient.
Trocars and Laparoscopic Instruments
• 2 × 11 mm (optic 0° and bipolar grasper)
• 2 × 5 mm (scissors and suction device)
 Chapter 12 Laparoscopic Promontory Fixation 189

• M
 onopolar round-tipped scissors, bipolar grasper, • Polyester multifilament mesh (Fig. 3)
dissector, 5-mm suction device, needle drivers (2),
and 10-mm laparoscopic optic 0°
Access and Port Placement
See Figure 4.

Veress Needle

A cutaneous incision is made at the inferior margin

of the umbilicus, and the Veress needle is introduced
through the incision (see Chap. 1, Veress Needle Intro-
duction).

TIP

The incision should be 50% larger than the di-

ameter of the trocar.

Fig. 3
Polyester mesh

Fig. 4
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)
190 Section III
The insufflation tubing is connected to the Veress
needle, the stopcock is opened, and insufflation is initi-
ated.
TIP
It is recommended to start with low flow to avoid
damage to a vital structure in case the needle is
malpositioned. Switch to high flow if the pres-
sure of insufflation is increasing at a steady and
normal level and there is also a tympanic per-
cussion of the liver area.
First Port (11 mm, optic 0°)
Once pneumoperitoneum is established, the needle is
removed, and the 11-mm trocar is introduced through
the same incision, perpendicularly to the abdominal
wall.
TIP
Pneumoperitoneum is established with an intra-
abdominal pressure higher than 10 mmHg.
Fig. 5
Camera (1); Bipolar grasper (2); Suction device (3); and Scis-
sors (4)
Laparoscopic Surgery for Benign Urological Disorders
The optic is inserted through the trocar, and the insuf-
flation line connected to it.
Second Port (11 mm, bipolar grasper)
A cutaneous incision is made 2 cm medial to the left an-
terior superior iliac spine for introduction of the 11-mm
trocar.
TIP
During trocar introduction, once the cutting tip
pierces the peritoneum, it secures the position of
the device, allowing further gliding of the trocar
to a desired site. This maneuver prevents block-
age of the movements of the working instruments
following an incorrect insertion.
Third Port (5 mm, suction device)
A cutaneous incision is made 2 cm medial to the right
anterior superior iliac spine for introduction of the 5-
mm trocar.
Fourth Port (5 mm, 
monopolar round-tipped scissors)
For insertion of the 5-mm trocar, a cutaneous inci-
sion is made at a point situated at the junction of the
lateral 2/3 and medial 1/3 distance between the right
anterior superior iliac spine trocar and the umbilicus
trocar (see Fig.5).
TIP
Pay attention to the epigastric vessels, which can
be visualized by pressing the right lateral part of
the abdomen.
The operating table is moved down and backward, and
the patient is placed in an extended Trendelenburg po-
 Chapter 12
Fig. 6
a Suture through appendices epiploicae. b External fixation of the sigmoid to abdominal wall
sition. Steps are placed under the surgeon, and the bi-
polar and monopolar pedals are placed over the step.
The surgeon, positioned higher than the assistant, can
then use the working instruments (bipolar grasper and
monopolar scissors) without being restrained by the as-
sistant holding the optic in the upper midline position.
This maneuver reduces the conflict between the opera-
tive team’s arms.
Surgical Technique
Bowel Displacement
The sigmoid is positioned above the promontory by
gently pushing back the loops of small bowel with the aid
of the Trendelenburg position. If necessary, the cecum
is dissected off the posterior peritoneum to increase its
mobility and facilitate cranial displacement of the small
bowel.
Laparoscopic Promontory Fixation 191
TIP
When facing difficulties retracting the bowels
or when the patient cannot handle the extended
Trendelenburg position, a fifth trocar (5 mm)
can be introduced in the right iliac fossa, and a
bowel retractor can then be used by the second
assistant.
The sigmoid and its mesocolon are laterally displaced
and fixed to the abdominal wall using a monofilament
suture of 2-0 straight needle (Fig. 6a,b).
TIP
The suture needle is introduced through the skin
at a point lateral and caudal to the left port,
placed through the appendices epiploicae of the
sigmoid colon, and exited close to the entrance
point to be tied externally.
A valve is introduced into the vagina to aid in the ex-
posure of the Douglas cul-de-sac and to facilitate the
dissection of the rectovaginal and vesicovaginal plane
(Figs. 7 and 8).
192 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 7
Vaginal valve

Subtotal Hysterectomy and Anexectomy

If a subtotal hysterectomy with anexectomy is per-

Fig. 8
formed, the ureters are identified coursing down into
Douglas cul-de-sac (A); Valve in the vagina (B)
the pelvis. The ovary is grasped and tractioned upward
to better expose the infundibulopelvic ligament. The
pedicle is then fully coagulated with the aid of the bipo-
lar grasper and cut with monopolar scissors (Figs. 9a,b
and 10a,b).
The dissection continues to expose the round liga- close to the uterus. The vesicoperitoneal fold is lifted
ment, which is coagulated and cut (Fig. 11). and incised, mobilizing the bladder off the vagina. The
The anterior and posterior leaves of broad ligament uterine vessels are visualized and cut following coagula-
are dissected down to the vesicouterine fold and cut tion with the bipolar grasper (Fig. 12).

Fig. 9
a Infundibulopelvic ligament. b Bipolar coagulation
 Chapter 12 Laparoscopic Promontory Fixation 193

Fig. 10
a Infundibulopelvic ligament coagulated. b Ligament transected

Fig. 11 Fig. 12
Round ligament Uterine artery (A)

TIP
In case of bleeding, applying traction to the tis-
sue reduces the blood flow, and bleeding then
can be controlled with the bipolar grasper.
The same procedure is done at the other side, and the
uterus is transected with monopolar scissors above the
cervix (Fig. 13).
The specimen is then placed higher than the level of
the promontory to be removed at the end of the proce-
dure.
194 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 13 Fig. 14
Transected cervix (A) Douglas pouch incised

Fig. 15 Fig. 16
Correct plane of dissection (A); Wrong plane of dissec- Levator ani muscle (A); Rectum (B); Suction device (S) at the
tion (B) inferior part of the dissection

TIP  osterior Dissection 

To facilitate its removal, the uterus is grasped by
opposite sides and cut throughout its axis with
a N°15 scalpel that is fixed to a needle holder.
It is then placed inside a laparoscopic bag and
removed through an enlargement of the left
11-mm port incision.
P
(Rectovaginal Plane)
When the uterus is in place, it must be mobilized off the
pelvic cavity for the posterior dissection. The uterus is
then fixed to the anterior abdominal wall using a mono-
filament 2-0 straight needle suture that transfixes its
body.
 Chapter 12
Fig. 17
Left (A) and right (B) levator ani muscles; Rectum (C)
TIP
The suture needle is introduced through the
skin at a midline point above the pubis, placed
through the uterus, and exited close to the en-
trance point to be tied externally.
The valve is inserted inside the vagina and is lifted to
expose the Douglas pouch. The posterior peritoneum is
grasped by the bipolar grasper and is placed under trac-
tion. The peritoneum is incised close to its superior de-
flection, and the inferior peritoneal lip with the fatty tis-
sue attached is pulled down to expose the correct plane
of dissection (Fig. 14).
TIP
Two planes of dissection are encountered at this
level. The right one is between the fatty tissue
and the vagina, and by applying downward trac-
tion, the avascular plane of loose areolar tissue
is exposed (Fig. 15). The wrong plane of dissec-
tion is between the fatty tissue and the rectum,
and by following this plane, the chance of rectum
injuries increases.
Laparoscopic Promontory Fixation 195
The vagina is dissected from the rectum up to the level
of the canal anal. The superior plane is followed laterally
to arrive at the lateral wall of rectum, exposing the leva-
tor ani muscles bilaterally (Figs. 16 and 17).
TIP
The assistant positions the suction device at the
inferior part of the dissection and pushes down
on the tissue at every step of the dissection to
facilitate access to the right plane.
Fixation of the Posterior Mesh
Following exposure of the levator ani muscle, the poste-
rior mesh is introduced through the left 11-mm trocar,
and it is bilaterally fixed to the uppermost part of the
®
muscle using Ti-Cron 2-0 sutures (needle ½ 26 cm).
TIP
The position of the needle on the needle holder
is 2/3 posterior and at a 45º angle. To insert the
needle on the muscle, it first must be pushed
in to load the needle onto the tissue. Then, the
needle is turned, and the other needle holder
is positioned below the exit point of the needle,
grasping and fixing its tip (Fig. 18a,b). Finally,
the needle is removed from the muscle following
its curvature to prevent rectum damage.
TIP
The knot must be loosely tied to avoid postop-
eratory pain at the level of the anus.
The broad part of the prosthesis is spread out over the
rectum and placed as close to the vaginal deflection as
possible (Fig. 19).
The Douglas pouch’s peritoneum is closed us-
ing a U-shaped running suture of Vicryl 0. The mesh
196 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 18
a Needle position for the right side. b Needle position for the left side

Fig. 19 Fig. 20
Posterior mesh over rectum Closure of posterior peritoneum

is included in the suture, fixing it to the peritoneum Anterior Dissection (Vesicovaginal Plane)
(Fig. 20).
The valve is introduced into the vagina and is lifted to
put traction on the peritoneum. The peritoneum of the
vesicouterine fold is transversely incised to expose the
 Chapter 12 Laparoscopic Promontory Fixation 197

avascular plane of loose areolar tissue that separates the

posterior surface of the bladder and the anterior vaginal
wall (Fig. 21).

TIP

The muscle fibers of the anterior vagina wall

must be preserved to decrease the risk of mesh
erosion.

The dissection of this plane is carried out along the mid-

line and extends laterally and inferiorly to the bladder
trigone, taking care not to injure the bladder, vagina, or
ureter.
Fig. 21
TIP
Valve in the vagina (A); Bladder (B)
The ureter courses anteromedially after it passes
under the uterine vessels, progressing toward the
trigone of the bladder through a fascial tunnel
on the anterior vaginal wall. In case the bladder
TIP
or the vagina is accidentally opened, a running
Vicryl 0 suture is used for repair. When the uterus is left in situ, the mesh is par-
tially divided. Each arm of the anterior mesh is
passed through the broad ligament at the level
of the isthmus on both sides of the organ, but
from a safe distance from the uterine vessels. In
Fixation of the Vaginal Mesh case of asymmetric prolapse, the cervix can be
slightly displaced to compensate for the asymme-
The anterior mesh is introduced through the left 11-mm try. In this case, the suture is placed at different
trocar. After the mesh is spread out to cover the anterior levels on both sides of the cervix.
vaginal wall, it is fixed to the apex and bilateral anterior
vaginal wall using running Ti-Cron 2-0 sutures (needle
½ 26 mm) (Fig. 22a,b).

TIP Exposure of the Promontory

The suture should not transfix the vaginal wall.
If a subtotal hysterectomy is performed, the uterine cer-
vix is also incorporated in this suture.
The promontory is either visualized or felt by palpation
with the tip of the instruments. A longitudinal incision
is performed on the posterior prevertebral parietal peri-
toneum to expose the anterior vertebral or presacral
ligament, taking particular care not to injure the iliac
vessels and the presacral (medium sacral vein) vessels.
The incision on the peritoneum is then extended from
the promontory to the right side of the Douglas pouch
198 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 22
a Left-side fixation. b Right-side fixation

Fig. 23
a Promontory dissection. b Promontory (P) exposed

to further cover the mesh at the end of the procedure Promontory Fixation
(Fig. 23a,b).
A full-length Ti-Cron 1 suture (needle ½ 37 mm) is
TIP passed through the presacral ligament.

The “true horizon” of the optic must be correctly

TIP
placed at this time to avoid unintentional dissec-
tion of the right common iliac artery instead of The position of the needle on the needle holder is
the promontory. 1/3 anterior and at a 45º angle.
 Chapter 12 Laparoscopic Promontory Fixation 199

The needle must be inserted from the right to the left
with small and continuous movements of the needle on
the anterior vertebral ligament (Fig. 24).
TIP
The needle is introduced from right to left and
with small movements because the left common
iliac artery is more laterally located at this site,
and the point of exit of the needle is less con-
trolled than the entrance point.
should follow the curvature of the sacrum to respect the
physiological movement of the Douglas pouch, avoid-
ing postoperatory dyschesia. The anterior mesh should
have medium tension applied to it, and the exact ten-
sion is confirmed by touching the mesh with the left
needle holder. The knot is done extracorporeally using
a half-hitch type knot (Weston knot). By passing both

The needle runs only through the fibrous layer of the

aponeurosis, avoiding perforation of the disc itself and
the risk of iatrogenic spondylodiscitis.
After passing the suture, traction is applied to the
thread to check that it is solidly anchored. The needle is
positioned facing the head of the table and passed first
through the posterior mesh and then passed through the
anterior mesh. The needle charged with both prosthesis
and with the tip facing the optic is placed at the prom-
ontory, simulating a hook, to determine the tension at
the anterior and posterior mesh (Fig. 25a,b).
The right needle holder secures the meshes at the
Fig. 24
promontory while the left needle holder tests the ten-
Needle position for promontory fixation
sion. The posterior mesh should have no tension, and it

Fig. 25
a Needle position. b Mesh held in place
200 Section III
ends of the suture line through the right paraumbili-
cal port (5 mm), the loose knot is descended through
the port to the promontory. Then, the left needle holder
grasps and pulls down the knot, and with the aid of the
right needle holder, the knot is tied in place at the level
of the promontory. Another four intracorporeal knots
fix the mesh in place.
Closure of the Posterior Peritoneum
The posterior peritoneum and the peritoneum of the
vesicouterine cul-de-sac are closed with a running su-
ture of Vicryl 0. If the uterus is left in situ, the perito-
neum covering the bladder is initially closed followed by
the posterior part. In hysterectomized patients, a single
running suture is done.
TIP
The order of the posterior peritoneal suture
is the following: (1) right distal edge of perito-
neum, (2) right side of the mesh, (3) right side
of the peritoneum covering the bladder, (4) left
side of the peritoneum covering the bladder, (5)
left side of the mesh, and (6) left distal edge of
posterior peritoneum.
Fig. 26
a Posterior peritoneal closure. b Mesh covered by peritoneum
Laparoscopic Surgery for Benign Urological Disorders
The first knot is done, and then a running cranially ori-
ented suture is performed, taking care to pass the needle
at the edge of the peritoneum to avoid transfixing the
ureter at the level of the promontory. The goal is to leave
the mesh in a subperitoneal position to avoid small-
bowel complications (Fig. 26a,b).
The aponeurosis of the 11-mm port is closed with a
Polysorb 0 suture, and the skin is closed with running
intradermic Monocryl 3-0.
Postoperative Considerations
The nasogastric tube is removed at the end of the pro-
cedure. The patient is given appropriate analgesia as per
protocol (intravenous paracetamol during the first 24 h
and major analgesics administered if necessary). The in-
travenous perfusion is stopped on day 1 after surgery,
and a light diet can generally be resumed on the same
day. The bladder catheter is removed on the second
postoperative day. An osmotic laxative is prescribed for
a few months and normal activity is resumed four weeks
after the surgery.
 Chapter 12 Laparoscopic Promontory Fixation 201

Schematic mesh position

Fig. 27
Schematic mesh position (By permis-
sion of T. Darnies, Sofradim Produc-
tion)

Suggested Readings
1. Rozet F, Mandron E: Laparoscopic sacral colpopexy ap-
proach for genito-urinary prolapse: experience with 363
cases. Eur Urol 2005 Feb; 47(2):230–236.
2. Grynberg M, Dedecker F: Laparoscopic sacral colpopexy:
comparison of nonresorbable prosthetic tape (Mersuture)
and a SIS collagen matrix (Surgisis ES). Prog Urol 2005 Sep;
15(4):751–755; discussion 755.
3. Antiphon P, Elard S: Laparoscopic promontory sacral col-
popexy: is the posterior, recto-vaginal, mesh mandatory?
Eur Urol 2004 May; 45(5):655–661.
4. Bruyere F, Rozenberg H: Laparoscopic sacral colpopexy: an
attractive approach for prolapse repair. Prog Urol 2001 Dec;
11(6):1320–1326 [Article in French].
5. Paraiso MF, Falcone T: Laparoscopic surgery for enterocele,
vaginal apex prolapse and rectocele. Int Urogynecol J Pelvic
Floor Dysfunct 1999; 10(4):223–229.
 Chapter 13
Extraperitoneal
Laparoscopic Prostatic
Adenomectomy
Contents
I ntroduction  . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .  
 reoperative Preparation  .. . . . . . . . . . . . . . . . . . . . .
P   203
Patient Positioning and Initial Preparation  .. . .  
Trocars and Laparoscopic Instruments   .. . . . . . .  
Access and Port Placement  . . . . . . . . . . . . . . . . . . . .  
Final Position of Trocars  . . . . . . . . . . . . . . . . . . . . .  
Surgical Technique  .. . . . . . . . . . . . . . . . . . . . . . . . . . . .  
Peritoneum Displacement and Exposure
of the Bladder Neck  . . . . . . . . . . . . . . . . . . . . . . . . .  
Bladder Neck Dissection and Division  . . . . . . .  
Adenoma Dissection  . . . . . . . . . . . . . . . . . . . . . . . .  
Prostatic Fossa Hemostasis  .. . . . . . . . . . . . . . . . .  
Closure of the Prostatic Capsule  .. . . . . . . . . . . .  
Postoperative Considerations  . . . . . . . . . . . . . . . . .  
Suggested Readings  .. . . . . . . . . . . . . . . . . . . . . . . . . .  
Introduction
203 Extraperitoneal laparoscopic prostatic adenomectomy
is a straightforward surgery indicated for the treatment
204 of symptomatic benign prostatic hyperplasia (BPH) in
205 patients with large-volume glands. The access and initial
206 operative steps are the same as for extraperitoneal lapa-
206 roscopic radical prostatectomy (see Chap. 5). Minimal
206 bleeding and hence reduced transfusion rate, shorter
hospitalization, and faster recovery are additional ad-
206 vantages. This minimally invasive technique is a reason-
208 able and effective alternative to open prostatectomy.
209
211
212
213
Preoperative Preparation
213 Before a patient consents to a laparoscopic prostatic ad-
enomectomy, it is important to discuss the specific risks
of the surgery, including the potential need to convert to
the traditional open operation if difficulties arise.
The patient is admitted to the hospital the day before
the surgery for bowel preparation, which includes 2 L of
® ®
Colopeg (1 envelope/L) p.o. and a Fleet enema. Fast-
ing starts at midnight before surgery. Thromboprophy-
laxis is implemented with good hydration, placement of
compressive elastic stockings on the lower extremities,
and low-molecular-weight heparin. Enoxaparin (Clex-
® ®
ane , Lovenox ) 40 mg sc 1 × day or nadroparin (Flaxi-
® ®
parine , Fraxiparin ) 0.6 mL sc 1 × day is initiated on
day 1 after the surgery and continued daily until the pa-
tient is discharged from the hospital. In selected cases,
the treatment is continued for 30 days after the proce-
dure. Patients also receive antibiotic prophylaxis with a
single preoperative dose of intravenous second-genera-
tion cephalosporin, unless they are allergic to penicillin.
Blood type and crossmatch are determined.
204 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 1 Fig. 2
Patient position Position of the legs

Fig. 3
Shoulder support

Patient Positioning and Initial Preparation

The surgery is performed under general anesthesia. The
base of the table must be positioned below the patient’s
hip to avoid elevation of the abdomen while in the Tren-
delenburg position (Fig. 1).
Fig. 4
The patient is placed in the supine position with the
Laparoscopic cart at patient’s feet
lower limbs in abduction, allowing the laparoscopic cart
 Chapter 13
to be moved closer to the surgeon and intraoperative ac-
cess to the perineum (Fig. 2).
The lower buttocks must be placed at the distal end
of the operating table. The upper limbs are positioned
alongside the body to avoid the risk of stretch injuries to
the brachial plexus and to allow for free movements of
the operative team. Shoulder support is properly posi-
tioned for the Trendelenburg position (Fig. 3).
A nasogastric catheter is placed by the anesthesiolo-
gist and the stomach decompressed to allow additional
space during extraperitoneal insufflation. The abdomen,
pelvis, and genitalia are skin prepared in case conver-
sion to an open procedure is required. An 18Fr Foley
catheter with 10 mL in the balloon is introduced after
the placement of the sterile drapes.
Fig. 5
Access and port placement (This figure was published in Wein: Campbell-Walsh Urology, 9th ed., Copyright Elsevier)
Extraperitoneal Laparoscopic Prostatic Adenomectomy 205
The surgeon and the second assistant operate from
the patient’s left side, and the first assistant is placed at
the opposite side of the surgeon. The laparoscopic cart is
placed at the patient’s feet, while the instruments table
and the coagulation unit are positioned at the left side of
the patient (Fig. 4).
Trocars and Laparoscopic Instruments
• 2 × 11 mm (optic 0° and bipolar grasper)
• 3 × 5 mm (scissors, suction device, and palpator)
• Monopolar round-tipped scissors, bipolar grasper,
dissector, 5-mm suction device, needle drivers (2),
and 10-mm laparoscopic optic 0°
206 Section III Laparoscopic Surgery for Benign Urological Disorders

Access and Port Placement Surgical Technique

The access and port placement is the same as for ex-
traperitoneal laparoscopic radical prostatectomy – see  eritoneum Displacement and Exposure
P
Chapter 5, Figure 5. of the Bladder Neck

Final Position of Trocars The peritoneum is cranially mobilized to increase the

The operating table is moved down and backward, and
the patient is placed in a slight Trendelenburg posi-
tion. Steps are placed for the surgeon, and the bipolar
and monopolar pedals are placed over the step (Fig.
7a,b).
extraperitoneal space. The fibroareolar and fatty tissue
layers between the superolateral aspect of the bladder
and the medial aspect of the external iliac vein are bilat-
erally released. This maneuver, along with reduction of
any visible pelvic wall hernia, allows for further perito-
neum displacement.

TIP

Every effort should be made to thoroughly coag-

ulate the bleeding vessels during this dissection
to avoid image decay throughout the procedure.

The fatty tissue around the prostate is freed, starting lat-

erally from the reflection of the endopelvic wall toward
the midline on both sides (Fig. 8).
The fibroareolar and fatty tissue attached at the level
of the Santorini plexus and over the anterior surface of
the prostate are pulled down toward the bladder neck
with gentle but firm traction with the bipolar grasper.
The superficial branch of the deep dorsal vein complex
is coagulated with the bipolar grasper and cut with the
cold scissors (Fig. 9).

TIP

The superficial branch is transected at a safe

distance from the pubic bone to prevent retrac-
tion of the vein and to permit easy vessel control
in case of bleeding.

The maneuver of downward traction and pulling of

the fatty tissue continues until resistance is encoun-
tered, signaling the approach of the bladder neck. The
dissected fatty tissue is then lifted and divided in the
Fig. 6
midline to facilitate the coagulation and transection of
Trocars in place
the vessels that overlie the bladder neck. The fatty tis-
 Chapter 13 Extraperitoneal Laparoscopic Prostatic Adenomectomy 207

Fig. 7
a Steps under the surgeon. b Operative team’s position

Fig. 8 Fig. 9
Fatty tissue around the prostate Coagulation of the superficial branch of the deep dorsal
vein complex
208 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 10 Fig. 11
Anterior prostatic surface free of fatty tissue The bladder neck is situated under the crossing of the fi-
bers of the puboprostatic ligaments

Fig. 12
a Bladder neck opened with catheter inside. b Catheter removed

sue removal facilitates visualization and dissection of
the bladder neck (Fig. 10), which is usually located un-
der the crossing of the fibers of the puboprostatic liga-
ments (Fig. 11).
Bladder Neck Dissection and Division
A transversal incision with the monopolar scissors
along with forceful counter pressure with the bipolar
grasper, which is placed over the bladder, opens the su-
 Chapter 13
Fig. 13
a Medium lobe. b Plane of dissection – medium lobe
Fig. 14
Adenoma (A) – lateral lobe enucleation
perficial layer and exposes the correct plane of dissec-
tion. The anterior aspect of the urethra is exposed and
incised. The catheter is removed, and the locations of
the ureteral orifices, bladder neck, and adenoma are de-
termined (Fig. 12a,b).
Extraperitoneal Laparoscopic Prostatic Adenomectomy 209
Fig. 15
Anterior dissection of lateral lobes
Adenoma Dissection
A transverse incision is made at the mucosa of the blad-
der neck, and the monopolar scissors are used to dissect
210 Section III
Fig. 16
Right lateral lobe is released
Fig. 18
Urethral mucosa (U) incised and adenoma (A) removed
the median lobe (if present) from the overlying prostatic
capsule (Fig. 13a,b).
The dissection is deepened posteriorly to the level of
the adenoma and extended sideways to permit complete
enucleation of the lateral lobes (Fig. 14).
Once a well-defined plane is developed, the grasper
instrument lifts the prostatic capsule to further develop
the plane. The anterior commissure at the apex is in-
Laparoscopic Surgery for Benign Urological Disorders
Fig. 17
Adenoma (A) is rolled to the side
Fig. 19
Empty prostatic fossa
cised, separating the lateral lobes of the prostate anteri-
orly (Fig. 15).
The urethral mucosa over the right lateral lobe is in-
cised at the level of the apex, and the right lateral lobe is
released (Fig. 16).
The left lateral lobe is freed by the same approach,
and care should be taken not to injure the muscle fibers
of the external urinary sphincter.
 Chapter 13
TIP
It is important to grasp the adenoma, rolling it
to the sides to facilitate the dissection (Fig. 17).
Posteriorly, the dissection is advanced proximal to the
verumontanum; the urethral mucosa is incised, and the
adenoma is removed (Fig. 18).
Extraperitoneal Laparoscopic Prostatic Adenomectomy 211
Fig. 20
a Right lateral capsular suture. b Needle exiting inside
prostatic fossa. c Left lateral capsular suture
Prostatic Fossa Hemostasis
The prostatic fossa is inspected to confirm that the ad-
enoma has been completely removed (Fig. 19).
A full thickness interrupted suture of Vicryl 0 is placed
at the lateral sides of the prostatic capsule (at the 9 and 3
o’clock positions) to secure hemostasis (Fig. 20a–c).
The bladder mucosa is then advanced into the pros-
tatic fossa and sutured at the 6 o’ clock position with
212 Section III Laparoscopic Surgery for Benign Urological Disorders

Fig. 21
a Bladder mucosa advanced into prostatic fossa. b Trigonization of prostatic fossa

Vicryl SH 2-0, followed by bilateral full thickness inter-
rupted sutures that complete the trigonization of the
prostatic fossa (Fig. 21a,b).
TIP
Pay attention to the ureteral orifices when per-
forming these sutures.
The balloon is now filled with 30 mL and positioned in-
side the bladder. Continuous irrigation with saline solu-
tion is initiated to avoid blood clot formation.
®
An EndoCatch bag is introduced through the left
11-mm port, and the adenoma is placed into the bag.
The prostate is removed by enlarging the left iliac spine
port site.

Closure of the Prostatic Capsule

A 22Fr three-way Foley catheter with a 30-mL balloon is

inserted through the anterior urethra and prostatic fossa
into the bladder (Fig. 22).
The balloon is initially filled with 10 mL. Starting
at the left side, the prostatic capsule is closed with full
thickness running sutures of Polysorb 2-0 GL 123 (nee-
dle ½ 26 mm) (Fig. 23a,b).

TIP

A long suture thread should be used. Fig. 22

Foley catheter inside bladder
 Chapter 13
Fig. 23
a Closure of the prostatic capsule. b Final result
TIP
To enlarge the incision for the passage of the
bag containing the prostate, the skin is cut at its
medial end and the fascia at the lateral end to
avoid injury to the epigastric vessels.
A Penrose drain is placed close to the prostate capsule
and exited through the right iliac spine port site. The
aponeurosis of the 11-mm ports is closed with Polysorb
0 UL 877 sutures (needle 5/8), and the skin is closed
with a running intradermic Monocryl 3-0. The Penrose
is sutured to the skin with Flexidene 2-0, and the skin
®
incisions are covered with Opsite bandages. The ure-
thral catheter is secured to the leg.
Postoperative Considerations
The patient is given appropriate analgesia as per proto-
col, including intravenous paracetamol during the first
24 h and major analgesics administered as necessary.
The intravenous perfusion is stopped on day 1, oral flu-
ids are started the morning after surgery, and a light diet
can generally be resumed on day 1. The drain is usually
Extraperitoneal Laparoscopic Prostatic Adenomectomy 213
removed after 48–72 h or after secretions are below 50
mL. The irrigation of the bladder is suspended on post-
operative day 1 or 2 and the bladder catheter is removed
on day 3 if urine is clear. When residual haematuria per-
sists, a cystogram is performed. Normal activity is re-
sumed four weeks after surgery.
Suggested Readings
1. Baumert H, Ballaro A: Laparoscopic versus open simple
prostatectomy: a comparative study. J Urol 2006 May;
175(5):1691–1694.
2. Porpiglia F, Terrone C: Transcapsular adenomectomy (Mil-
lin): a comparative study, extraperitoneal laparoscopy ver-
sus open surgery. Eur Urol 2006 Jan; 49(1):120–126.
3. Rehman J, Khan SA: Extraperitoneal laparoscopic prosta-
tectomy (adenomectomy) for obstructing benign prostatic
hyperplasia: transvesical and transcapsular (Millin) tech-
niques. J Endourol 2005 May; 19(4):491–496.
4. Van Velthoven R, Peltier A: Laparoscopic extraperitoneal
adenomectomy (Millin): pilot study on feasibility. Eur Urol
2004 Jan; 45(1):103–109.
 Subject Index

A – needles and sutures used in  212, 213

abdomen  3, 22, 50, 64, 92, 116, 140, 166, 181, 205 – pain control  213
– insufflation  22, 36, 50, 64, 92, 140, 166, 205 – positioning  204
– insufflation pressure  66 – postoperative control  213
– open access  11 – preoperative preparation  203
– pressure  4 – surgical technique  206
– pressure effects  4 – sutures  211, 212
– tympanic percussion  12 – trocars used  205
abdominal  3, 4, 8, 12, 22, 50, 64, 92, 140, 166, 205 adrenal  60, 61, 174
– insufflation  22, 36, 50, 64, 92, 140, 166, 205 – adrenalectomy  32, 61, 174
– pressure  8 – gland  31, 32, 60, 61, 174
– space  3 – left adrenal vein  31
– volume  8 – vein  32, 60, 175
abdominal wall  5, 11–13, 32, 47, 61, 62, 95, 119, 130, air  66
136, 142, 175, 178, 186, 194 air leakage  66
– closure  33, 47, 62, 178, 186 airway  4
– layer  11 airway pressure  4
– scar  11 ampullae  126
– vessel  5 anal  135
acidosis  3 anal canal  135
– respiratory  3 analgesia  7
acquired cystic disease  179 Anderson-Hynes dismembered pyeloplasty;
adenoma  209–212 see also pyeloplasty
– dissection  209 anesthesia, laparoscopic surgery  6
– lateral lobe  210 – air embolism  6
– median lobe  210 – hypercapnia  3, 6
adenomectomy  203, 205, 206, 211–213 – problems  6
– access  206 – recovery period  7
– advantage  203 anexectomy  192
– analgesia  213 antibiotic  22, 50, 64, 92, 116, 140, 153, 166, 180, 187,
– bowel preparation  203 203
– haematuria  213 – prophylaxis  22, 36, 50, 64, 92, 116, 140, 153, 166,
– hemostasis  211 180, 187, 203
– informed consent  203 antidiuretic hormone  4
– initial preparation  204 antiemetics  7
– instruments  205
216 Subject Index

aorta  174 – displacement technique  95, 119, 142, 191

– aneurysm  5 – injury  12, 63
aponeurosis  13, 33, 62, 66, 164, 178, 186, 200, 213 – obstruction  63
– closure  13, 66 – puncture  5, 12
ascites  63 – retraction  191
autosomal dominant polycystic kidney disease  179 – small  200
axillary roll  22, 36, 50, 154, 166 – thermal injury  5
brachial plexus injury  22, 50, 64, 92, 116, 140, 154,
B 166, 181, 188, 205
Bell muscle  76, 101 broad  136, 192
bipolar grasper  5, 7, 9, 24, 27, 40, 52, 55, 59, 65, 67, – ligament  136, 192
70, 93, 94, 116, 118, 140, 142, 154, 158, 167, 169, 170, bulldog clamp  106
185, 188–190, 205, 208
bladder  5, 50, 61, 113, 120, 121, 126, 127, 129, 130, C
136, 139, 140, 143, 163, 166, 187, 192, 197, 200, 206, calculi; see autossomal dominant polystic kidney
213 disease
– access for  140 camera  13
– anterior dissection  129, 136 carbon dioxide  3, 6, 15
– closure  61 – absorption  3
– cuff  61 – embolism  6
– decompression  22, 36, 50, 166 – end-tidal concentration  6
– injury  197 carbonic acid  3
– mobilization  192 cardiac output  4
– opening of  197 cardinal ligament  136
– perforation  5 catheter  163
– retractor  66 – nephroureteral  163
– sutures used in  61, 197 cephalosporin  22, 50, 64, 92, 116, 140, 153, 166, 180,
bladder cancer  66, 88, 139, 143 188, 203
– high-grade  115, 139 cervix  136, 137
– muscle-invasive  115 checklist  7, 8
– pelvic lymphadenectomy  142, 143 – preinsufflation  7
– prognostic variables  139 circulatory system; see potential clinical outcomes,
– superficial  115 pneumoperitoneum
bladder neck  73, 76, 86, 99, 100, 109, 137, 206, 208, circumflex iliac vein  123, 145, 148
209 clamp  35, 41, 44, 84
– anastomosis  86, 88, 109, 112 – bulldog  84
– dissection  76, 100, 208 – Satinsky vascular  37, 41, 44
– division  76, 100, 208 Clexane  21, 36, 49, 64, 91, 116, 140, 165, 180, 187, 203
– exposure  73, 99, 206 clip applier forcep  10
– reconstruction  86, 109 clip hemostasis  32, 33, 61, 84, 97, 105, 124, 146, 148,
blood  4, 5, 12 176
– aspiration  12 clitoris  136, 137
– flow  4 – deep dorsal vein  136
body buffers  3 – suture and needle used, ligation of  137
Bogros space  67, 70 Cloquet node  97, 123, 145, 148
bowel  5, 11, 12, 63, 95, 119, 142, 165, 191, 200 colon  41, 43, 56, 58, 158, 172, 185
– adhesion  11 – en bloc dissection  28, 58, 172
 Subject Index 217

Colopeg  21, 36, 49, 63, 91, 116, 153, 165, 180, 187, EndoCatch  33, 47, 85, 132, 133, 146, 148, 175–177,
203 212
Cooper ligament  96, 123, 145, 148 Endo GIA  10, 165, 167, 170, 176, 177
costal arch  13, 25, 38, 53, 155, 169 endopelvic  74, 78, 99, 102, 129–131, 136, 206
cul-de-sac; see Douglas pouch – fascia  74, 78, 99, 102, 129–131, 136
cystectomy; see radical cystectomy – wall  74, 206
cystogram  213 Enoxaparin; see Clexane, Lovenox
cystoprostatectomy; see radical cystectomy Ensure  116
cystourethrocele  187 epigastric  65, 67, 72, 95, 119, 142, 190
cytokine level  4 – vessel  65, 67, 72, 95, 119, 142, 190
epigastric vessel, inferior  5
D – bleeding control  5
Denonvillier’s fascia  76, 77, 98, 101, 126, 132 – gauze bolster  5
– exposure  76, 101 – iatrogenic injury  5
Dermalon  134 – suture  5
detrusor muscle  61 external oblique muscle  11
dexamethasone  7
Dexon  33, 47, 62, 164, 178, 186 F
diversion fallopian tubes  137
– ileal conduit  133 femoral canal  97, 123, 143, 145, 148
– ontinent orthotopic  137 femoral vein  4
dorsal vein  75, 130, 136 filter, in-line  7
– deep  75, 130, 136 Flagyl  116
– superficial branch  75, 130 Flaxiparine  21, 36, 50, 64, 91, 116, 140, 165, 180, 187,
dorsal vein complex  74, 79, 85, 99, 132, 206 203
– division  85, 109 Flexidene  48, 164, 213
– ligature  79 Fraxiparin  21, 36, 50, 64, 91, 116, 140, 165, 180, 187,
– superficial branch  74, 99, 206 203
– suture and needle used in  132
Douglas  97, 125, 126, 135, 191, 195 G
– exposure  191 gas  3, 6, 7, 9, 15, 73
– incision  97 – egress  15
– pouch  97, 125, 126, 135, 195 – embolus  6
Douglas pouch  66; see also cul-de-sac – evacuation, residual gas  7
Douglas semicircular line  66 – flow  8
dyschesia  199 – inflating  3
– leakage  9
E – tank  7
electrocautery  7 – valve  7
electrosurgical unit  7, 9 genitofemoral nerve  96, 121, 144, 147
– settings  7 genitourinary prolapse  187; see also promontory
embolism  4 fixation
– pulmonary  4 Gerota’s fascia  28, 43, 46, 58, 158, 159, 172, 173, 185
– signs, air embolism  6 Gibson insicion  33, 49, 61
emphysema  6 Gleason  139
– subcutaneous  6 gonadal  28, 43, 58–60, 120, 144, 147, 159, 173
endobag  10, 109; see also EndoCatch – left gonadal vein  30, 43, 60
218 Subject Index

– right gonadal vein  30, 59 I

– vessel  28, 43, 58, 120, 144, 147, 159, 173 ileal conduit  132, 133
grasper  5, 10; see also bipolar grasper ileum  133
ileus paralyticus  4
H iliac  139, 143, 147, 172
hand-assisted bilateral ureterectomy  185; see iliac artery  96, 122, 139, 143, 147, 172
also ureterectomy – common artery  96, 122, 143, 147, 172
hand-assisted nephrectomy  179, 181, 183–185; – external  122, 139
see also nephrectomy, bilateral, hand-assisted – internal  139
– access  181 iliac spine  27, 40, 67, 70, 72, 83, 85, 86, 88, 94, 95, 105,
– advantage  179 109, 112, 118, 119, 142, 158, 170, 190, 212, 213
– bowel preparation  179 iliac vein  145, 148
– dissection sequence  184 iliac vessel  29, 43, 58, 120, 146, 147, 172, 174
– first port  181 – exposure technique  120
– hand introduction technique  183 ilioinguinal  175, 177, 183, 186
– indication  179 – incision  175, 177, 183, 186
– informed consent  179 – muscle  33
– initial preparation  180 iliopsoas muscle  121, 144, 147
– instrument  181 infundibulopelvic ligament  125, 134, 144, 192
– needles and sutures used  186 inguinal ring  67, 130
– pain control  186 instrument; see also specific instrument
– positioning  180 insufflation  7
– postoperative control  186 – pressure  7, 12
– preoperative preparation  179 – tubing  7
– second port  183 insufflator  7, 8
– surgical technique  184 – false reading  9
– third port  184 – flow rate  8
Hem-o-lok  32, 33, 61, 96, 97, 124, 146, 148, 176 – pressure  8
Hem-o-lok clip  84, 105 – settings  7, 8
hemorrhoidal artery  128, 136 – tips  8
heparin, low-molecular-weight  21, 36, 49, 64, 91, 116, – tubing  7
140, 165, 180, 187, 203 ischiorectal fossa  135
hernia  5, 13
– diaphragmatic  5 K
– incisional  13 kidney  28, 35, 41, 43, 44, 46, 58, 59, 60, 160, 165, 172,
– inguinal  5 174, 176, 177, 179, 184, 185
hypercapnia; see also anesthesia, laparoscopic   – autosomal dominant polycystic disease  179
surgery – end-stage renal disease  179
– management  6 – extraction  177, 186
hypogastric  97, 124, 128, 129, 136, 139, 146, 148 – haemostatic technique  35
– anterior branch  128, 136 – hilum  29, 43, 44, 59
– artery  97, 124, 129, 139, 146, 148 – hilum dissection  30
– vein  124, 146, 148 – left kidney  184, 185
– vessel  128, 136 – lower pole  43
hysterectomy  192 – nephron-sparing surgery  35
– subtotal  192 – right kidney  184, 185
 Subject Index 219

– tumor  35, 44 levator ani  126, 195

– upper pole  28, 41, 58, 172 – muscle  126
Kocher maneuver  185 – muscle exposure  195
– needle insertion technique  195
L lienocolic ligament  58, 172
laparoscope  7 Ligaclip  61, 97, 121, 123, 124, 145, 146, 148
– image  7 LigaSure  115, 116, 119, 128, 129, 136, 181, 185
– white balance  7 – advantage  115
laparoscopic  3, 5–9, 11, 13, 15, 16, 21, 22, 24, 28, linea alba  66
33, 35–37, 43, 49, 50, 63–65, 91, 93, 115, 116, 140, liver  5, 12, 13, 24, 52, 58, 167
153–155, 165, 166, 179, 181, 187, 188, 203, 205 – bleeding  5
– advantage  153, 165, 187, 203 – puncture  13
– approach  49 – retractor grasper  24, 27, 37, 40, 52, 55, 154, 167,
– bag  33 172
– cart  22, 37, 50, 64, 93, 116, 140, 154, 166, 181, 188, Lovenox  21, 36, 49, 64, 91, 116, 140, 165, 180, 187,
205 203
– conversion  22, 36, 50, 181, 205 lumbar vein  31, 43, 60
– informed consent  115, 140, 203 lung  3
– instrument  9, 10, 24, 65, 93, 116, 140, 154 lymphadenectomy  91, 96, 97, 121, 123, 124, 136, 140,
– instruments table  11, 22, 37, 50, 154 142–147
– intraperitoneal access  5 – “split and roll” technique  96, 143, 147
– oncological outcomes  115 – access  140
– oncologic efficacy  21 – bowel preparation  140
– pelvic procedure  11 – extended  124, 146
– sealer/divider  10 – first port  142
– suturing technique  15, 16 – fourth port  142
– tower  7 – informed consent  140
– upper tract procedures  13 – initial preparation  140
laparoscopy  3–7, 9, 11, 13, 15, 16, 35, 37, 49, 50, 63, – pelvic  121
65, 91, 93, 115, 140, 153, 154, 165, 166, 179, 187, 188, – positioning  140
203, 205 – postoperativ control  148
– absolute contraindications  5 – preoperative preparation  140
– access complications  5 – second port  142
– closed access technique  8 – standard  96, 143, 147
– complications  5 – surgical technique  142
– crossing of instruments  13 – third port  142
– equipment  7 – transperitoneal approach  147
– insufflation  6 lymphatic
– intraperitoneal access  5 – anatomical drainage  139
– open access (technique)  8 lymph node dissection  139
– pneumoperitoneum deflation  6 – modified  139
– problems  6 – standard  139
– relative contraindications  5 lymphocele  97, 123, 145, 148
– tumor seeding  6
– vascular injury  5 M
– vessel ligation  10 mesenteric artery, inferior  124, 146
220 Subject Index

mesh  187, 189, 195, 197–200 – oncologic efficacy  21

– anterior mesh, fixation technique  197 – padding  22, 36, 50, 166
– composition  189 – pain control, living donor nephrectomy  178
– cover technique  198 – pancreas, living donor nephrectomy  172
– erosion  197 – partial  21, 35, 37, 43, 44; see partial nephrectomy
– fixation, needle position  195, 198 – polar artery  44
– fixation, suture used  195 – positioning  22, 36, 166
– fixation technique  197 – postoperative control, living donor
– needle and suture used  197, 198 nephrectomy  178
– positioning  200 – preoperative preparation  35, 165
– posterior mesh, fixation technique  195 – preservation solution, living donor
– tension  199 nephrectomy  178
methylene blue  163 – radical  21; see also radical nephrectomy
Monocryl  34, 48, 62, 88, 112, 178, 186, 200, 213 – right-side  24, 37, 52, 54, 167, 174
monopolar scissors  7, 9, 24, 26, 39, 52, 54, 72, 93, 95, – right renal vein, living donor nephrectomy  177
116, 119, 140, 142, 154, 155, 157, 167, 169, 170, 181, – second port,living donor nephrectomy  169
186, 190, 205, 208 – surgical technique, living donor nephrectomy  172
– sutures used, partial nephrectomy  47
N – third port, living donor nephrectomy  170
nadroparin; see Flaxiparine, Fraxiparin – triangulation rule  27, 39, 40, 170
Navidish  116 – trocar, living donor nephrectomy  167
needle drivers  24, 37, 52, 65, 93, 116, 140, 155, 167, – tumor resection, partial nephrectomy  44
181, 189, 205 – vessel length, living donor nephrectomy  165
needle holder  9, 15, 195 nephroureterectomy  49, 50, 52, 54–56, 58, 61
Neomicine  116 – access  52, 56
nephrectomy  21, 22, 33, 35, 37, 43, 165, 166, 169, 170, – bowel preparation  49
172–174, 176, 177, 179 – closure  62
– access  37, 167 – colon mobilisation  56
– advantage, laparoscopic approach, living donor – fifth port  55
nephrectomy  165 – first port  53
– biliteral, hand-assisted  179 – fourth port  55
– bowel preparation, living donor nephrectomy  165 – informed consent  49
– colon mobilization, living donor nephrectomy  172 – initial preparation  50
– extracorporeal clamp approach, partial – instruments  52
nephrectomy  35 – left-side  50, 52, 54–56
– fifth port, living donor nephrectomy  172 – liver  55
– first port, living donor nephrectomy  169 – needles and sutures used  62
– fourth port, living donor nephrectomy  170 – pain control  62
– informed consent  35, 165 – pancreas  58
– initial preparation, living donor nephrectomy  166 – positioning  50
– instruments, living donor nephrectomy  167 – postoperative control  62
– ischemia time  46 – preoperative preparation  49
– left-side  22, 24, 36, 37, 54, 166, 167 – right-side  52, 54, 55, 58
– liver, living donor nephrectomy  172 – second port  54
– living donor  165 – surgical technique  56
– needles and sutures used, living donor – technique of distal ureteral dissection  61
nephrectomy  178 – third port  55
 Subject Index 221

– transperitoneal approach  49 – parenchymal reconstruction  46

– triangulation rule  55 – positioning  36
– trocars  52 – postoperative control  48
nerve-sparing; see radical cystectomy, radical – second port  39
prostatectomy – sixth port  41
nerve-sparing radical cystoprostatectomy  131 – surgical technique  41
neurovascular bundle  78, 80, 102, 104, 131 – third port  40
– identification  80, 104 – wedge resection  46
– preservation  78, 80, 102, 104 pelvic fibrosis  5
nodal  139; see lymph node pelvis  181
nonsteroidal anti-inflammatory drugs (NSAIDs)  34, – pelvic procedures  11
48, 62, 178 penis  78, 79, 99, 103, 104
– dorsal venous complex  103
O Penrose  33, 34, 48, 62, 88, 112, 113, 133, 137, 164,
obturator  97, 123, 124, 128, 139, 145, 148 178, 186, 213
– fossa  97, 128, 139, 145 peritoneal  3, 5, 12, 63, 120, 135, 143, 147, 183, 200
– nerve  97, 123, 124, 145, 148 – cavity  12
ondansetron  7 – fold  135
Opsite  48, 164, 213 – incision  120, 143, 147
optic  24, 25, 37, 38, 52–55, 65, 66, 93, 94, 116, 117, – preperitoneal space  12
140, 142, 154, 155, 157, 167, 169, 181, 183–186, 188, – puncture  183
190, 198, 205 peritoneum  5, 11, 33, 61, 73, 96–99, 120, 125, 129,
– “true horizon”  198 130, 136, 175, 177, 195, 196, 206
– image decay  74, 206 – anterior  98
– insertion technique  66 – closure  195
ovarian vessels  134, 144 – needle and suture used, peritoneum closure  200
ovary  134, 137 – posterior  97, 125
– technique of incision  195
P pneumoperitoneum  3, 4, 6, 123, 144, 157, 181
pain  7 – barotrauma  4
– anesthetic infiltration  7 – carbon dioxide pressure  4
– management  7 – central nervous system, potential clinical
palpator  65, 93, 95, 205 outcomes  4
partial nephrectomy  21, 35, 37, 43; see – circulatory system, potential clinical outcomes  4
also nephrectomy partial – complications  6
– bowel preparation  36 – deep venous thrombosis  4
– calyx reconstruction  46 – gastrointestinal system, potential clinical
– closure  47 outcomes  4
– first port  38 – immunologic system, potential clinical outcomes  4
– fourth port  40 – induction  22, 36, 50
– initial preparation  36 – oxygen pressure  4
– lateral margins  44 – physiologic effects  3
– liver  40 – pressure  4, 123, 144
– localization of tumor  44 – pressure effects  4
– needles and sutures in calyx reconstruction  46 – pulmonary system, potential clinical outcomes  4
– pain control  48 – renal system, potential clinical outcomes  4
– pancreas  41 – sympathetic system, potential clinical outcomes  4
222 Subject Index

– upper urinary tract procedures  13 – cancer  63, 91, 139, 147

pneumothorax  4, 6 – capsule closure  212
Polysorb  66, 79, 86, 88, 104, 109, 112, 132, 136, 200, – hyperplasia  203
212, 213 – planes of dissection  77, 78, 102
port  13 – posterior surface  77, 78, 102
– placement; see specific surgical procedures prostate specific antigen  139
– primary  13 prostatic  78, 82–84, 103, 105, 106, 132, 203, 210–212
– secondary  13 – apex  78, 103, 132, 210
– working  13 – approach techniques to pedicles  82–84, 105, 106
potency  126, 129 – bleeding control  84
– preservation  126, 129 – capsule  210, 211
presacral  197, 198 – fossa  211, 212
– ligament  197, 198 – pedicle  82, 83, 105, 106
– vessel  197 prosthesis  12; see mesh
prolapse  187, 197 PSA  139
– asymmetric  197 psoas muscle  43, 58, 70, 96, 145, 159, 173, 174
– correction  187 pubis  67
– genitourinary  187 puboprostatic ligament  75, 78, 99, 103, 132, 208
promontory fixation  190–200 pubovesical ligament  136
– access  189 pudendal artery, internal  129
– advantage  187 pyeloplasty  153–155, 158–160, 162, 163
– analgesia  200 – access  155
– anterior dissection  196 – advantage  153
– bowel preparation  187 – Anderson-Hynes technique  158
– exposure technique  197 – antegrade insertion  162
– first port  190 – anterior anastomosis  163
– fixation technique  187 – bowel preparation  153
– fourth port  190 – crossing vessels  159
– initial preparation  188 – dismembered pyeloplasty  153
– instrument position  188 – first port  157
– needle insertation technique  195 – fourth port  158
– pain control  200 – informed consent  153
– positioning  188 – initial preparation  154
– postoperative control  200 – instruments  154
– preoperative preparation  187 – left-side  154
– second port  190 – liver  154
– surgical technique  191 – needle and suture  164
– suture and needle used  195 – pelvic flap  160
– third port  190 – positioning  154
– transperitoneal access  187 – postoperativ control  164
prostate  63, 74, 77, 78, 82–84, 91, 99, 102, 103, 105, – preoperative preparation  153
106, 127, 129–132, 139, 140, 147, 203, 206, 210–212; – reconstruction  160
see also radical prostatectomy – reflux  163
– anterior surface  74, 99, 206 – right-side  154
– apex  129 – second port  157
– apical dissection  132 – surgical technique  158
 Subject Index 223

– third port  158 – triangulation rule  26

– transmesocolic approach  159 radical prostatectomy  8, 63, 65, 66, 70, 72–76, 78–80,
– triangulation rule  157, 158 83–86, 88, 91, 95–101, 103–106, 109, 111, 112
– access  65, 93, 116
R – advantage  91
radical cystectomy  115, 116, 118–120, 123, 124, 126, – analgesia  113
127, 129–132, 134–137, 139 – bowel preparation  63, 91
– analgesia  137 – complications  63
– apical dissection  132 – extraperitoneal approach  63, 65, 66, 70, 72–80,
– bowel preparation  115 83–86, 88
– female  134 – extraperitoneal endoscopic  63
– first port  117 – fifth port, extraperitoneal approach  72
– fourth port  119 – fifth port, transperitoneal approach  95
– informed consent  115 – first port, extraperitoneal approach  65
– initial preparation  116 – first port, transperitoneal approach  94
– male  119 – fourth port, extraperitoneal approach  70
– nerve-sparing technique  131 – fourth port, transperitoneal approach  95
– pain control  137 – haematuria  88, 113
– parenteral nutrition  137 – informed consent  63, 91
– pelvic lymphadenectomy  121 – initial preparation  64, 92
– positioning  116 – insuflation pressure, extraperitoneal approach  8
– postoperative control  137 – intraperitoneal bleeding  63
– preoperative preparation  115 – needles and sutures used  88, 112
– second port  118 – pain control  113
– surgical technique  119 – positioning  64, 92
– third port  119 – postoperative control  88, 113
– trocar used  116 – preoperative preparation  63
radical nephrectomy – purse-string suture  66
– access  24 – retropubic  63
– advantages, laparoscopic approach  21 – second port, extraperitoneal approach  66
– bowel preparation  21 – second port, transperitoneal approach  94
– colon mobilization  27 – surgical technique  73, 95, 99
– fifth port  27 – third port, extraperitoneal approach  67
– first port  25 – third port, transperitoneal approach  95
– fourth port  27 – transperitoneal  63
– informed consent  21 – transperitoneal approach  91, 95–101, 103–106,
– initial preparation  22 109, 111, 112
– liver  27 rectal wall  126
– needles and sutures used  33 rectocele  187
– pain control  34 rectosigmoid  135
– pancreas  28 rectourethral  132
– postoperative control  34 rectovaginal  135, 187, 191, 194
– preoperative preparation  21 – dissection  191
– second port  26 – plane  191, 194
– surgical technique  27 – posterior dissection  194
– third port  27 – space  187
224 Subject Index

rectovesical scissors  8, 37, 54, 65, 93, 116, 140, 181, 188, 205
– dissection  125 seminal vesicle  76, 77, 97, 98, 101, 126, 127
rectum  126, 127, 187, 195 – dissection  97, 98
– dissection  195 – technique of dissection  76, 77, 101
– lateral wall  195 shunt  5
– perirectal fatty space  126 sigmoid  95, 119, 125, 132, 142, 191
rectus fascia  11 – fixation  95, 119, 142, 191
rectus muscle  13 – mesocolon  191
renal  21, 28, 35, 41, 43, 46, 49, 58, 60, 160, 165, skin incision  15, 33, 62, 178, 186
172, 174, 176, 177, 179; see also potential clinical specimen  10, 33, 47, 137, 177
outcomes, pneumoperitoneum – retrieval device  10
– artery  32, 60, 176 spermatic vessels  125
– carcinoma  21, 49 spleen  5, 28, 41, 58, 172
– early stage, carcinoma  21 – bleeding  5
– end-stage disease  179 – en bloc dissection  43
– haemostatic techniques  35 splenorenal ligament  58, 172
– hilum  32, 60, 172 spondylodiscitis  199
– hilum dissection  30, 43, 60, 174 stapler  10, 165, 167, 170, 176, 177
– incidental tumor  179 – pusher  177
– left renal vein  176 staples  176, 177
– length preservation, right renal vein  165 – row  177
– locally advanced disease  21 stent  162–164
– nephron-sparing surgery  35 – guide wire  162, 163
– pelvis  49, 160 stomach decompression  22, 36, 50, 64, 92, 116, 140,
– perfusion  4 166, 181, 188, 205
– right renal artery  174 stoma site  116
– right renal vein  165, 176 stone formation; see autossomal dominant polycystic
– transitional cell carcinoma  49 kidney disease
– transplantation  165 suction device  7, 24, 27, 37, 40, 52, 55, 65, 67, 93, 95,
– tumor  35, 44 116, 119, 140, 142, 154, 155, 158, 167, 170, 181, 183,
– vein  21, 28, 31, 32, 58, 59, 60 188–190, 205
renal system  4; see also potential clinical outcomes, surgicel  47
pneumoperitoneum – bolster  47
– blood flow  4 – hemostasis  47
– glomerular filtration rate  4 suture  15, 16
– sodium retention  4 – knot  16
– urine output  4 – loop construction  15
renin  4
renography; see pyeloplasty T
– diuretic nuclear  164 thromboprophylaxis  21, 36, 49, 63, 91, 116, 140, 153,
Retzius space  70, 98, 130, 136 165, 187, 203
– anterior dissection  98 Ti-Cron  195, 197, 198
round ligament  143, 144, 192 transversalis fascia  11
Trendelenburg  6, 64, 92, 116, 140, 181, 188, 190, 191,
S 204
Santorini’s plexus  74, 79, 99, 100, 130, 206 – position  6, 64, 92, 116, 140, 181, 188, 190, 191, 204
– superficial veins  100 – position problems  6
 Subject Index 225

trigonization  212 – transection  33, 160, 185

trocar  5, 6, 8, 11–13, 15, 22, 24, 37, 50, 52, 55, 64–66, – transitional cell carcinoma  49
92, 93, 116, 140, 154, 158, 166, 167, 181, 183, 188, ureteral  56, 61, 76, 101, 120, 137, 160, 209
190, 191, 205, 206 – orifices  76, 101, 209
– blunt tip  13 – stent  137
– diameter  11, 13, 15 – wall  160
– fixation  6 ureterectomy  185; see hand-assisted bilateral
– injury  13 ureterectomy
– introduction  8 – bilateral  185
– introduction angle  12 uretero-enteric anastomosis  121
– introduction technique  13, 15 ureteropelvic  159
– obturator tip  13 ureteropelvic junction obstruction  153
– placement  22, 36, 50, 64, 92, 116, 140, 166, 181, urethra  76, 85, 86, 101, 109, 132, 136, 137, 209, 212
205 – anterior wall  101
– positioning  13 – division  85, 109
– primary  13 – frozen section  137
– secondary  13 – margin biopsy  137
– size  13 – suture and needle used in  132
– technique for blockage prevention  190 – urethrectomy  136, 137
– tests of correct introduction  15 – wall  209
– type  13 urethral  76, 101, 136, 137, 209, 211
– valve  15 – meatus  137
– mucosa  211
U – wall  76, 209
umbilical  61, 97, 98, 120, 124, 129, 130, 136, 143, urethrectomy  136, 137
146–148 – suture and needle used  137
– artery  97, 98, 120, 124, 129, 130, 136, 143, 146–148 – transvaginal approach  137
– ligament  61, 98, 120, 130, 136, 143, 147 urethrovesical junction  137
urachus  98, 130, 136 urinary  76, 101, 132, 133
ureter  28, 29, 43, 56, 58, 61, 97, 120, 121, 132, 133, – diversion  132, 133
144, 147, 159, 160, 173, 174, 185, 192, 197 – perioperative retention  76, 101
– blood supply  160 urinary sphincter, external  210
– dissection  56, 61 urine output  4
– distal ureter  49 uterine  134, 136, 187, 192
– division  120 – descent  187
– en bloc resection  49 – vessel  136, 192
– exposure  120 uterus  5, 134, 137, 192–194
– frozen-section  121 – fixation  194
– identification  192 – mobilization  194
– injury  197 – puncture  5
– intramural  61 – removal  193
– ligatur  185 – suture and needle used, uterus fixation  134
– lower ureter  56 – transection  193
– oncologic control  49
– position  197 V
– spatulation  160 vagina  135, 137, 195, 197
– technique of distal dissection  61 – dissection  195
226 Subject Index

– injury  197 verumontanum  211

– opening of  197 vesical artery  128, 136
– suture and needle used  137 – inferior  128, 136
– wall  137 – middle  128
vaginal wall  135, 197 – superior  128, 136
vas deferens  61, 97, 120, 143, 144, 147 vesicoperitoneal  192
– dissection technique  97 vesicouterine  192, 196, 200
vena cava  21, 30, 32, 124, 146, 174, 175 – cul-de-sac  200
– thrombi(us)  21 – fold  192, 196
veress needle  5–7, 9, 11–13, 25, 38, 53, 93, 117, 140, – incision  192
155, 169, 181, 189 – incision technique  196
– blunt tip  11 vesicovaginal  191, 196
– closed access  11 – plane  191, 196
– cutaneous incision  13 – plane dissection  197
– disposable  11 vessel  5, 12
– hollow cannula  11 – injury  5
– introduction  11 – puncture  12
angle  13 Vicryl  33, 61, 62, 82–84, 86, 105, 109, 160, 178, 186,
technique  12 195, 197, 200, 211, 212
– introduction technique  11, 13 video  22, 50, 154, 166
– misplacement  6
– needle tip  7 W
– reusable  11 Weston knot  199
– subumbilical incision  11
– vessel puncture  12