Based on published nomograms and our own experience, pelvic lymphadenectomy is omitted in selected patients at low risk for lymph node metastases based on preoperative serum prostate-specific antigen (PSA), tumor grade, and palpable tumor extent. Generally, lymphadenectomy is omitted in patients with AUA or D’Amico low-risk criteria. Such patients have a minuscule risk of positive nodes and omission of lymphadenectomy in patients with these characteristics does not increase the likelihood of biochemical failure [4]. For prognostic and potential therapeutic purposes, an extended lymphadenectomy is performed in all patients not meeting the low risk criteria. The dissection includes the tissue medial to the external iliac artery, all tissue surrounding the external iliac, the internal iliac artery superiorally, the bifurcation of the external and internal iliac veins cephalad, the origin of the superficial circumflex iliac vein caudally, and the pelvic sidewall in the obturator fossa deeply. In addition, the nodes immediately medial to the common iliac artery are excised. The extent of the dissection is guided by the study by Mattei et al. showing that the nodes within these boundaries constitute 75 % of the primary lymphatic drainage of the prostate [5]. Frozen section analysis is not routinely performed unless the nodes are grossly suspicious, and only if a finding of positive nodes would result in aborting the prostatectomy.

The apical dissection begins with vertical incisions of the endopelvic fascia at the apex bilaterally (Fig. 4.4). The attachments of the levator muscles to the lateral surface of the prostate are taken down sharply with scissors. Blunt dissection of these attachments should be avoided to prevent shearing of small blood vessels, which may be difficult to control. The puboprostatic ligaments are divided.

Next, the lateral pelvic fascia (the visceral portion of the endopelvic fascia) covering the prostate is incised bilaterally beginning from the initial incision in the apical endopelvic fascia and extending to the base of the prostate (Fig. 4.5). The incision is performed high on the lateral surface of the prostate to avoid injuring the neurovascular bundles (NVBs). When completed, this maneuver allows clear visualization of the prostatourethral junction and location of the NVBs and facilitates bunching of the ramifications of the dorsal vein over the prostate. The cut edges of the lateral fascia are then grasped with Turner-Babcock clamps, incorporating the branches of the venous plexus on the dorsolateral surface of the prostate (Fig. 4.6a). The bunched tissue is suture-ligated with two individual figure-of-8 0-chromic ligatures (Fig. 4.6b, c). This technique is a modification of the dorsal venous plexus bunching technique originally described by Myers [6]. It prevents back-bleeding when the dorsal vein is divided and helps identify the plane between the dorsal vein and urethra. The prostate is next retracted superiorly with a sponge stick, and the fat between the puboprostatic ligaments is gently removed to expose the superficial dorsal vein which is then divided between clips.

The dorsal vein and urethra are closely approximated and passage of an instrument between them carries the risk of damaging the anterior-striated sphincter. Therefore, the dorsal vein is next divided with scissors, exposing the anterior surface of the urethra (Fig. 4.7a). The distal portion of the incised dorsal vein is then oversewn with a figure-of-8 suture using a 3-0 absorbable monofilament suture on a 26 mm 5/8 circle needle (Fig. 4.7b). When correctly performed this technique does not compromise the anterior prostatic margin and results in excellent visualization of the urethra (Fig. 4.7c).