Robotic Prostatectomy: The Posterior Approach
For over 15 years, urologists have described individual techniques for the laparoscopic approach to the seminal vesicles. These approaches have received the greatest attention over the last 10 years as the robotic approach to radical prostatectomy has gained popularity. Despite the differences in technique preferred and professed by individual surgeons, the dissection of the seminal vesicles during robotic prostatectomy can be broken down into two basic approaches: dissection posteriorly where the surgeon performs this portion of the operation below the bladder prior to opening the extraperitoneal space or dissection anteriorly where the surgeon performs this portion of the procedure through the posterior bladder neck after opening the extraperitoneal space and dissecting the prostate off of the bladder. There have been published articles, podium lectures, and editorials, including a point counterpoint written by myself and Dr. David Lee, espousing the personal preferences of experienced surgeons. To date, there is no consensus on a “superior” technique, only opinion as to advantages of each approach in the hands of individuals. Having learned my laparoscopic prostatectomy technique from the time I spent in the operating room with Drs. Guilloneau and Vallancian in 2000, I have always approached the seminal vesicles posteriorly, under the bladder, prior to opening the extraperitoneal space. When I made the transition from laparoscopy to robotics in 2004, I transferred my laparoscopic technique to the robotic platform and have continued to use the posterior approach to the seminal vesicles in over 2100 robotic prostatectomies to date. In listening to the debate over whether the anterior or posterior approach is superior, it is my opinion that the answer is neither. Each technique has its merits in the hands of individual surgeons. However, when looking at the two techniques from the perspective of consistency, efficiency, and complexity one can begin to appreciate the assets of the posterior approach.