Abstract

Introduction: Transperitoneal ascending laparoscopic radical prostatectomy (Heilbronn technique)

includes an ascending part, with early division of the urethra and posterolateral dissection of the prostate,

followed by incision of bladder neck and dissection of the seminal vesicles and vasa deferentia. Nowadays,

laparoscopic radical prostatecomy (LRP) has been increasingly accepted providing similar functional and

oncological results as open radical prostatectomy. We analyzed the results of our first experience with LRP

using Heilbronn technique.

Materials and Methods: In Heilbronn technique, the extraperitoneal LRP approach is similar to

transperitoneal LRP, apart from high transection of the urachus and division of both lateral umbilical

ligaments to reach the Retzius space and includes 7 steps: (I) incision of endo-pevic fascia on both sides,

control of deep dorsal vein complex, (II) dissection of prostatic apex and the neurovascular bundles that were

preserved according to oncological criteria, preoperative erectile activity and age, (III) division of urethra

followed by posterior dissection of prostate, (IV) incision of bladder neck followed by (V) dissection of vesicula

seminalis and vas deferentia combined with (VI) division of cranial pedicles of prostate and finally (VII)

creation of urethro-vesical anastomosis with continuous sutures including reconstruction of bladder neck.

The urethral catheter is removed on postoperative day 7 depending on the quality of the anastomosis

according to cystographic assessment. The following parameters were also evaluated: preoperatively body

mass index and hemoglobin level, perioperatively operative time, estimated blood loss, transfusion rate,

postoperatively duration and amount of analgesic treatment, catheterization time, perioperative morbidities

and complications, oncologic status (surgical margin). Subsequently, functional results on incontinence were

also included in this analysis for 3 and 6 months postoperatively.

Results: We performed LRP in 37 patients with organ confined prostate cancer (mean age: 62.4±6.3

years). Pelvic lymphadenectomy, bladder neck and neuro-vascular bundle-sparing dissection were performed

in 38, 35 and 32 per cent of the patients, respectively. While mean urethro-vesical anastomosis time was

33.6±9.3 minutes, the mean operative time including anastomosis was 226.4±60.3 minutes. Whilst the reduction

in hemoglobin level was 17.1%, blood transfusion rate was 10.8%. The mean hospitalization and urethral

catheterization times were 4.3±1.5 and 11.5±5.6 days, respectively. No conversion to open surgery was

necessary in either group. In the 1st patient postoperative re-intervention was required due to thermal effect of

cautery on ileum.

Conclusion: The Heilbronn technique was designed to copy the standardized technique of open anatomic

radical prostatectomy starting with an ascending part, controlling Santorini’s plexus and dividing the urethra

and distal lateral pedicles of the prostate, followed by transection of the bladder neck and retrovesical access

to the vesicula seminalis. Logically, this technique can easily be transferred without modification to

extraperitoneal approach including identical surgical steps. In conclusion, in our opinion the technique of

laparoscopic prostatectomy is transferable without loss of operative quality dependent on the concept of

laparoscopic education. Taking this training concept into consideration the learning curve will only include the

operating time but not the number of complications or the functional and oncological results of this procedure.