Retraction of external iliac vessels and obturator nerve with the vas deferens during extended pelvic lymph node dissection in robot-assisted radical prostatectomy

Objective: To determine if the vas deferens during robot-assisted radical prostatectomy can be used to medially retract the iliac vessels and obturator nerve to achieve a dissection plane in the triangle of Marcille free of these structures while performing an extended pelvic lymph node dissection (PLND). Methods: In a single patient, an extended PLND was performed before prostatectomy. The external iliac lymph node (LN) group was dissected from the node of Cloquet to the ureteric crossing over the internal iliac artery. The vas deferens was then transected along its course medial to the external iliac artery. The vas deferens was subsequently grasped with bipolar forceps, passed under the external iliac vessels, lifted superiorly, and retracted medially in order to apply medial traction to the obturator nerve and external iliac artery and vein. Results: Retraction using the vas deferens permitted excellent visualization of the LN packets. The iliac vessels and obturator nerve were maintained far from the plane of the dissection and were retracted only using the vas deferens. This technique yielded 25 LNs and our median LN yield for high-risk individuals is 20. Surgical time was comparable to PLNDs performed using instruments for retraction. Conclusion: Use of the vas deferens for retraction during an extended PLND can be an excellent method to improve visibility without risk of damage to important structures with surgical tools and still achieve an adequate LN yield. Use of this technique in future surgeries will permit a more detailed understanding of outcomes.