The Window Sign: An Aid in Laparoscopic and Robotic Radical Prostatectomy

Abstract

Aim:Certain steps of laparoscopic radical prostatectomy (LRP) and robotic radical prostatectomy (RRP), such as identification of seminal vesicles, bladder neck and retroprostatic dissections are technically challenging specially during initial experience. We describe an important land mark : “Window sign”, which helps significantly during the procedure. Methods: The seminal vesicles can be dissected either through the transperitoneal, subperitoneal or extraperitoneal approach. In transperitoneal approach the vas deferens, seminal vesicles and Denonvillier’s fascia are dissected posteriorly, and this plane is re-entered after division of the prostate from the posterior bladder neck, and with division of the Denonvillier’s fascia. The communication between the anteriorly and posteriorly dissected planes in the retrovesical and retroprostatic space is termed “the window.” Alternatively, in the RRP technique, bladder neck is divided anteriorly and posteriorly and vas deferens and seminal vesicle pulled out through this window. We have found that this window in transperitoneal, subperitoneal or extraperitoneal approach whether done during laparoscopic or robotic radical prostatectomy, allows to retract the vas deferens and seminal vesicles to elevate the prostate, facilitates control of the prostatic pedicles, helps in dissection of the prostate and assists in the identification and careful avoidance of the neurovascular bundles. Results: This window sign was identified on the basis of our experience of over 450 cases of laparoscopic and robotic anatomical radical prostatectomies. We have followed this step in all of the cases by either technique. Conclusion: The “window sign” is an important aid while performing laparoscopic and robotic radical prostatectomy. This technique helps the surgeon to achieve both the anatomic and oncologic goals of the nerve sparing, during anatomic radical prostatectomy.