How to: A Minor Modification to Facilitate Posterior Dissection in Radical Prostatectomy Performed Using the Montsouris Technique

Purpose:

To demonstrate that a minor modification to the Montsouris technique facilitates easier and safer dissection of the posterior plane of the prostate and Denonvilliers’ fascia.

Rationale:

In the standard technique, the procedure begins with a posterior approach, advancing behind the seminal vesicles to enter the plane between the prostate and the rectum. Denonvilliers’ fascia is then incised, allowing complete separation of the prostate from the rectum. However, in patients with posterior prostatic fibrosis, often related to previous infections, surgical interventions, or biopsy procedures, this step may be technically challenging: (i) the working space can be limited, particularly in purely laparoscopic procedures; (ii) the prostate may remain relatively fixed by surrounding structures such as the bladder and lateral pedicles, making mobilization difficult; and (iii) insufficient visualization of the lateral surface of the prostate may increase the risk of dissection outside the intended surgical plane.

Method:

In this modification, after posterior dissection of the seminal vesicles, the dissection is advanced up to Denonvilliers’ fascia, but the fascia is not opened. The procedure then continues anteriorly according to the standard Montsouris steps. After bladder neck dissection, the previously mobilized seminal vesicles are elevated, and Denonvilliers’ fascia is incised at this point. This sequence provides a wider operative field, improved prostate mobility, and better visualization of the lateral prostate surface, facilitating more precise dissection within the correct surgical plane.

Conclusion:

This simple modification may enable safer and more effective control of the posterior prostate during radical prostatectomy, particularly in cases with posterior prostatic fibrosis.

No conflicts of interest or commercial associations to report.

Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure.