Editing Robot-assisted Laparoscopic Prostatectomy (section)

== Steps of procedure ==

* '''Position: supine (Xi) or dorsal lithotomy''' '''(Si)''', Trendelenburg (head down) to 25-28 degrees
*Words of wisdom: continuous retraction of the prostate is key to safe and speedy progress.

=== Port Planning ===
* '''Number of ports: 6''' (variations possible, depending on institution equipment and surgeon preference)
* '''Location of ports:'''
** General considerations for robotic port placement
***Port placement through the rectus muscle risks damage to the epigastric vessels.[https://www.auanet.org/documents/education/blus-handbook.pdf]
**** The epigastric vessels travel near the lateral edge of the rectus muscles in the lower abdomen and travel closer to the midline in the upper abdomen where they join the internal mammary arteries.[https://www.auanet.org/documents/education/blus-handbook.pdf]
**** Generally if trocars are not placed in the midline, they should be placed at least 6cm lateral to the midline to prevent epigastric injury.[https://www.auanet.org/documents/education/blus-handbook.pdf]
***>8 cm distance is recommended between robotic ports[https://www.laparoscopyhospital.com/docking-in-robotic-surgery.html]
****10-20 cm distance should be maintained between the ports and target anatomy
*****10 cm distance from TA is good but 20 cm distance is better
***For accessory ports, maintain at least 5 cm from the other ports[https://fcc.report/FCC-ID/2AAZF-CHB01/2607925.pdf]
**Configuration 1
***Camera (12 mm): center, above umbilicus
*** Robotic Arm 1 (8 mm): 6-8 cm right medial of camera
*** Robotic Arm 2 (8 mm): 6-8 cm left medial of camera
*** Robotic Arm 3 (8 mm): 6-8 cm left lateral of Robotic Arm 2
*** Assistant 1 (5 mm): cephalad of other ports, in between camera and arm 1
*** Assistant 2 (12 mm): 5 cm right lateral of Robotic Arm 1
***Xi capable of having ports all in the same transverse line as camera; Si will require ports in an arc, with the lateral ports being more inferior (minimum 3 fingerbreadths medial and 3 fingerbreadths superior to the anterior superior iliac spine).
**In tall males (72 inches), port sites should not be more than 18cm from the pubis[https://pubmed.ncbi.nlm.nih.gov/15333225/]

=== Abdominal Access and Robot Docking ===
*'''General anesthesia and insertion of lines.''' Use naso/orograstric tube for gastric decompression during case.
*'''Patient positioning, antiseptic preparation, draping.'''
**After induction of general anesthesia...
**Trim hair overlying operative site, if needed.
**Insert 16F foley catheter and inflate balloon.
**Meticulously apply foam pad to soft tissue and bony sites, along with careful ergonomically neutral positioning of the neck, arms, and legs 
**Secure the patient to the table.
**Prepare surgical area and drape.

*'''Veress needle access.''' Apply penetrating towel clamps to lateral aspects of umbilicus. With fingers under clamp, gently lift (as excessive elevation can cause separation of the abdominal layers and increase risk of pre-peritoneal placement). Insert Veress needle at 90 degrees in obese patients and 45 degrees in thin patients. Feel or hear (usually) 2 clicks/pops (corresponding to the penetration of the abdominal fascia and parietal peritoneum)(the protective sheath clicking when it recoils), indicating that the abdominal cavity has been entered.
**If transumbilical unsuccessful (3 attempts) or contraindicated (presence of umbilical pathology such as adhesions or herniations, peri-umbilical scars, aortic pulsations, thin patient), consider left upper quadrant (also known as Palmer’s point) entry.
*** Palmer’s point: 3cm below the left subcostal border in the mid-clavicular line
**** Contraindications to Palmer’s entry include splenomegaly, hepatomegaly, portal hypertension, gastric or pancreatic masses, history of a splenic or gastric surgery and presence or suspicion of left upper quadrant adhesions.
*****If Palmer’s point contraindicated, consider a point that is in middle of ASIS and umbilicus and translate this point superiorly to the level of the umbilicus
***If not transumbilical entry, use cautery/knife to make incision at planned entry point. Dissect down through fat to expose fascia. Use Kocher clamp to lift up on fascia. Insert Veress needle.
***In patients with potential of significant abdominal adhesions, consider open (Hassan) entry
*'''Test Veress needle and insufflate, if appropriate.''' Aspirate and inspect for blood or fecal content. If negative, inject saline for drop test (though not reliable). Aspirate the needle again. If successful on initial testing, gently advance the needle 0.5cm. Turn on insufflation to high flow (no need to begin at low flow because the size of the Veress needle limits flow to 1.5-2L/min) and evacuate initial air in tubing that is not CO2. Connect gas tubing to needle. Check for 3 consecutive pressure readings below 10mmHg.
**If pressure >10 mm, withdraw needle slightly. If pressure decreases to <10 mm, this indicates that needle tip was against an intra-abdominal structure such as the intestine or omentum. If the pressure remains ≥10 mm Hg, the needle is not properly placed.
**With the Veress needle (before abdominal insertion), low flow should register 1 L/min and at high flow should register 2 to 2.5 L/min.[https://link.springer.com/book/10.1007/978-3-642-88454-2]
**Regardless of the insufflator setting, maximal flow through a Veress needle is only about 2.5 L/min because it is only 14 gauge.[https://link.springer.com/book/10.1007/978-3-642-88454-2]
**A Hasson cannula has a much larger internal diameter and can immediately accommodate the maximum flow rate of most insufflators (Le., >6 L/min)[https://link.springer.com/book/10.1007/978-3-642-88454-2]
*'''Achieve pneumoperitoneum''' to 15 (or 20; 20 facilitates port placement by increasing abdominal resistance, but have to remember to decrease after ports inserted) mm Hg. As the pressure slowly rises to 20, the remaining port sites are marked.
*'''Outline port sites'''. Use marking pen to denote transverse incisions for robotic (8mm for camera port and 8mm for other robotic trocar sites) and assistant ports (12mm RLQ assistant port and 5mm RUQ assistant port). Robotic ports should be at least 6cm (approx. 3 fingerbreadths; 8cm if Si[https://pubmed.ncbi.nlm.nih.gov/2241039/]) from each other and, within appropriate distance to target anatomy (15-20cm). For RUQ assistant port, draw a line from pubis and half-way between central and right medial incision; 5mm assistant port should be approx. 3cm superior and half-way in between the central and right medial incision. Make sure this port is not too close to the camera port otherwise will have lots of difficulty moving sucker laterally. The most lateral ports must be at least 3 fingers medial and 3 fingers superior to ASIS.
* '''Insert camera port.''' Once at 15mm Hg, make an incision overlying camera port. Use hemostat to dissect down through fat. Twist port into abdomen; twisting is more important than pushing. Once inside, remove obturator (should hear air coming out when opening valve on port), connect gas, and insert camera. Check that no injury made to the bowel during Varess or port access. Remove Veress needle. Check for adhesions that may interfere with port placement.
*'''Table in 30 degrees Trendelenburg.''' And then even more Trendelenburg. This moves bowel out of the way for subsequent ports.
*'''Insert remaining ports.''' For the remaining ports, inject local anesthetic to identify approximate location inside and then inject a supraperitoneal bleb for local anesthetic purposes. Insert all remaining ports under direct vision. All ports should be inserted perpendicular to the fascia. Port placement may have to be modified due to unexpected anatomy, or adhesions may need to be taken down prior to port insertion. Point camera towards patient’s left side. Begin insertion of most left lateral port (facilitates visualization of inserting left medial port). Use knife to make an 8mm transverse incision in this area. Twist port into incision under vision. Take out obturator and insert trocar until black line. Repeat steps for left medial port, taking care to avoid injury to epigastric vessels. Repeat on the right side. Note that right lateral port will be a 12mm incision for the bed-side assistant port. Once the bed-side assistant port is in, switch the gas to this port. Insert right medial robotic port. Insert 5mm assistant port.
*'''Dock robot and insert instruments.''' Attach camera port to robot. Insert and attach camera. Target camera to prostate. Hold camera port steady and allow robot to adjust. Adjust [https://vimeo.com/544900363 boom rotation], as needed. Attach remaining ports to robot. Insert monopolar scissors in right robot arm, bipolar Maryland graspers in left robotic arm, and Prograsp graspers in 4th arm. Connect monopolar and bipolar electric cords. Advance instruments under direct vision. Rotate the patient [https://www.youtube.com/watch?v=Bj_NjtsjUsI&t=164 clearance] joints on arms #1 and #4 toward the patient to maximize arm movement[https://pubmed.ncbi.nlm.nih.gov/2241039/].
**Alternatively, if more space between the arm and the patient is desired, rotate the patient clearance joints clockwise away from the patient and the preceding arm, resulting in the external arms assuming a steeper angle[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6193435/]
**See https://www.laparoscopyhospital.com/docking-in-robotic-surgery.html for detailed instructions
*'''Lysis of adhesions, if needed.''' Check for adhesions and take any down if needed.

=== Posterior Approach ===
* Take down any adhesions that may interfere with surgery.
*'''Posterior Dissection'''
**'''Incise rectovesical pouch and identify seminal vesicle (SV).''' Use Prograsp to grasp peritoneum in midline and tent up rectovesical pouch. Identify line of perirectal fat. Use left hand to retract and right hand hot scissors to dot a transverse U incision 1-1.5cm (2 scissor breadths) above perirectal fat (visible through peritoneum). Make incision in rectovesical pouch. Dissect along inferior peritoneal incision towards seminal vesicles which will appear gray-blue, in contrast to the fat.
***If vas deferens can be identified, it can be followed from lateral to medial to get to the SV/vas deferens junction. 
***Be careful of ureteric injury if too lateral. 
**'''Dissect seminal vesicles posteriorly then anteriorly, from medial to lateral.''' Once SV identified on one side, dissect it posteriorly from medial to lateral. Continue to lateral edge of SV. Use bipolar when possible, particularly laterally. After one side done posteriorly, dissect other side posteriorly. After both sides are done posteriorly to the lateral edge of SV, dissect along SV anteriorly, from medial to lateral to get to tip of SVs.
***If SV not easily identified, identify vas deferens and use the vas deferens to guide you towards the SV. 
***Do not dissect in between the vas and SV. 
***Stick right on vas/SV, okay to burn vas or SV.  
***If nerve-sparing, try to avoid using monopolar current laterally as the neurovascular bundles are lateral to the seminal vesicles.
**'''Ligate and divide vas deferens.''' Once at the lateral tip of the SV, develop space between vas and SV. Use Maryland to coagulate the vas and then divide vas laterally at tip of SV.
**'''Dissect seminal vesicles laterally from lateral tip toward ejaculatory duct.''' If nerve-sparing, place hem-o-lock clip on vascular pedicle on stay side at edge of SV.  Do not need to do too much distally/anteriorly, or will get into prostate. After one seminal vesicle done anteriorly, vas ligated and divided, and seminal vesicle dissected laterally, begin these steps on contralateral side.
***If nerve-sparing, try to avoid using monopolar current laterally as the neurovascular bundles are lateral to the seminal vesicles.
*'''Drop bladder'''
**'''Develop the lateral avascular Space of Retzius down towards the pubic bone.''' Identify medial umbilical ligament. Use Prograsp to retract medial umbilical ligament medially at the level of inguinal ring, which should create a space of pneumoperitoneum in the Space of Retzius. Incise the peritoneum in the pneumoperitoneum/avascular area, lateral to the medial umbilical ligament, medial to inguinal ring ('''CAUTION: to avoid inferior epigastric vessels'''). Develop this avascular space from the urachas down to the vas deferens, inferiorly and medially, medial to inguinal ring and lateral to medial umbilical ligament. Goal is to expose and be inside pubis. If doing lymph node dissection, continue peritoneal incision to the ureter. Repeat on contralateral side.
***'''Always stay lateral to medial umbilical ligament'''
**** The ureter travels over the iliac vessels to run medial and deep to the medial umbilical ligament. Therefore, as long as dissection is lateral to the medial umbilical ligament, the ureter will not be at risk.
**** '''CAUTION: Do not be too lateral or you will encounter external iliac vessels.'''
***See [https://link.springer.com/chapter/10.1007/978-3-030-28599-9_2/figures/2 Figure]
**'''Divide the urachas.''' Use Prograsp to retract midline peritoneum/fat. Use Maryland graspers to coagulate urachus as high as you can. Then divide with hot scissors.
**'''Develop the medial Space of Retzius down towards the pubic bone.''' Develop space in avascular plane in midline, along posterior aspect of fat towards bladder.  Continue to drop bladder laterally. Superiorly, do not get too close to the abdominal wall musculature anteriorly. Inferiorly, stay close to pubic bone anteriorly. Expose pubic bone even if covered with fat to avoid hidden vessels. Continue developing sides and endopelvic fascia, leave midline to the end. Goal is to clear fat off of endopelvic fascia. Work lateral to medial.
***'''Accessory pudendal arteries may be identified at this stage''', which travel longitudinally along the anteromedial aspect of the prostate. Attempt at preservation of these arteries is important for erectile function because in some men these arteries may be the dominant source of arterial blood supply to the corpora cavernosa
* '''Coagulate and divide the superficial branches of the DVC, if present'''
*'''Defat anterior prostate.''' Dissect the anterior prostatic fat from the anterior prostatic capsule from the apex to the bladder neck to help visualize the border between the prostate and bladder neck. Skeletonize the puboprostatic ligaments for optimal visualization of the apex.
** Anterior prostatic fat is sent for a pathologic examination in case the pathologist reports a positive surgical margin. If a positive surgical margin is seen anteriorly, the fat can be evaluated for residual cancer.
** About 15% of men will have lymph nodes in the anterior prostatic fat and that in 2% to 3% of men, this will be the only site of metastasis.
* At this point, visible landmarks include:
** Anterior aspect of the bladder and prostate
** Puboprostatic ligaments
** Endopelvic fascia
** Pubis/superior pubic ramus
* '''Incise endopelvic fascia/retrograde nerve-sparing.''' Retract the prostate medially and anteriorly and use scissors to make an incision in the middle of the endopelvic fascia. 
**'''If nerve-sparing''', make incision more medially
***This exposes the neurovascular bundles (NVBs)
****The periprostatic vasculature within the interfascial space has been used as a macroscopic landmark and visual surrogate for identifying and preserving the cavernous nerves.
*****The interfascial plane is between capsular artery and fascia. 
***Critical to nerve preservation is holding the prostate with Prograsp forcep grapsers, sharply releasing the nerve from the prostate without traction.
**Care should be taken to preserve the levator muscle fibers attached to the lateral and apical portions of the prostate by bluntly dissecting them from the surface of the prostate.
**Extend the incision to identify the base of the prostate. 
**Electrocautery is avoided, if possible, to minimize thermal damage to the external sphincter and nearby NVBs (heat may be needed for vessels or muscle in the way).  
*'''Oversew DVC (can also be performed after prostate removed).''' Exchange for robotic needle drivers. Use a 2-0 Stratafix suture oversew the DVC. 
**Use left hand to retract right side of prostate medially. Hold needle so that tip is perpendicular to DVC. Pass needle under DVC and over urethra from right to left, with needle tip remaining perpendicular. Once needle through to other side, use left hand to retract left side of prostate medially and retrieve needle with right hand, following the curve of the needle. Do not rotate needle all the way out. Ask ask assistant to move catheter and ensure that able to move. After confirming that catheter can be moved, retrieve needle. Pass needle under DVC and over urethra again, making sure that catheter can move before retrieving needle. Pass needle through tail loop. Cinch. Pass needle under DVC and over urethra again, making sure that catheter can move before retrieving needle. Lock stich. Cinch. Cut suture.
*'''Lymph node dissection, if applicable.''' 
**Extend peritoneal incision to ureter. 
**Retract fat medially and expose medial aspect of external iliac vein, which is usually slightly posterior and medial to the external iliac artery.
**Identify obturator nerve. Do not cut/clip anything until nerve identified.
**Develop and divide nodal packet distally, at the node of cloquet.
**Develop and divide node proximally.
**Obtain hemostasis.
*'''Incise anterior bladder neck.''' Exchange for robotic scissors and bipolar.
**Identify the approximate location of the bladder neck by (4):[https://pubmed.ncbi.nlm.nih.gov/23859125/]
**#Assessing the proximal midline aspect where the anterior prostatic fat was removed
**#Retracting the foley catheter to visualize the distal end of the balloon
**#Holding the detrusor in the anterior midline of the bladder and gently tugging it cephalad to display the insertion into the anterior prostate base
**#Placing the robotic right and left hand instruments on each side of the prostate contour and drawing them slowly in a cephalad and medial direction until they converge at the bladder neck
**Once location identified, advance foley completely, use bipolar to coagulate in midline then use scissors to make a transverse incision in this area. Transection of the bladder from the prostate is facilitated with retraction of the left hand with continuous sufficient force to maximize visualization. Continue dissecting in midline towards the catheter. 
**The anterior bladder neck incision should not be carried too far laterally because branches of the bladder pedicle are often encountered, resulting in unwanted bleeding.
**Once the catheter has been identified, deflate the balloon and retract the catheter towards the anterior abdominal wall using the fourth arm to suspend the prostate.
**Complete lateral dissection of the anterior bladder neck.
* '''Inspect interior of the bladder.''' 
**Evaluate for median lobe of prostate. If present, see section below.
**Identify locations of ureteric orifices, to avoid injury during vesicourethral anastamosis. 
***In patients with prior TURP, the ureteric orifice may be much closer to the bladder neck.
***If difficult to identify ureteric orifices, can use 5ml of intravenous indigo carmine to facilitate identification[https://pubmed.ncbi.nlm.nih.gov/18455623/ §]
* '''Incise and dissect posterior bladder neck.''' Continue dissection to enter the muscular/ vascular space behind the detrusor (or the posterior bladder neck). 
**Immediately behind the posterior bladder are the longitudinal muscle (up and down fibers) and multiple vessels that need cauterization. This muscular/ vascular layer is later incorporated into the Rocco stitch. 
**Goal is to keep thick posterior bladder neck.
**The bladder neck incision is completed and the prostate is now free at the base. The Foley catheter is withdrawn so only the tip is visible.
* '''Dissect prostate from rectum.''' Suspend the seminal vesicles with Prograsp forcep grapsers. Grasp Denonvilliers and make a sharp incision through the fascia, approximately 0.5cm below the base of the seminal vesicles.[https://pubmed.ncbi.nlm.nih.gov/10647644/] 
**The incision is above the fascia for aggressive nerve-sparing, and below the fascia until perirectal fat is seen for aggressive cancer. 
**'''CAUTION: Be careful of rectal injury.''' Dissection of the plane between the prostate and rectum is facilitated by the surgeon’s left hand elevating the prostate as the assistant retracts gently but firmly on the rectum with the sucker as needed. 
**The dissection is carried distally to the apex.
* '''Pedicles.''' Create windows in the pedicles, apply clips, and gradually divide posterolateral pedicles. Will see fat when getting close to nerves. Ask assistant to retract with sucker at 5 or 7 o'clock.
*'''Antegrade nerve sparing.''' If nerve sparing, sweep/push neurovascular bundles away from prostate. Follow prostate contour. 
*'''Develop space lateral to puboprostatic ligaments to clear off muscle from apex.'''
*'''Complete development of space posteriorly at apex.''' Prostate should now be free anteriorly, posteriorly, and laterally, with the remaining attachment apically.
**Apical dissection will be more difficulty if posterior dissection not well completed.
*'''Apical dissection'''
**At the apex, release Myer’s muscle completely to visualize and protect the apex, neurovascular bundles, and urethra when transecting the dorsal venous complex (DVC) and remaining apical structures.
**'''Divide DVC'''. Consider using 30 degree lens. Ensure foley catheter inserted. 
***Use fourth arm to grasp and retract both cut medial edges of the endopelvic fascia inferiorly in the midline.
***Use left hand to retract prostate and right hand to cut straight through puboprostatics and DVC. 
****Coagulate any arterial bleeding
****Adjust retraction with fourth arm, as needed
****If significant bleeding encountered, increase pneumoperitoneum to 20 mm Hg (and remember to decrease after controlling bleeding).
***When DVC gives, change angle of scissors and follow curve of prostate.
**'''Divide lateral to urethra''', taking care not to injure the nerve bundles.
**'''Urethral transection.''' 
***Cut through anterior urethra, will eventually identify catheter. 
***Withdraw catheter so only the tip is visible
***Ensure that prostate does not extend behind posterior urethra
***Continue to transect urethra and down to rectourethralis muscle with scissors perpendicular to the urethra.
**'''Divide rectourethralis.''' Develop space posterior to urethra with Maryland graspers. Lift rectourethralis with open jaws of Maryland posteriorly to keep rectum away. Divide remaining posterior attachments.
***'''CAUTION: Be careful of rectal injury.''' 
**See [https://www.youtube.com/watch?v=HL-7fb7gG7I Video (Dr. Edward Schaeffer)]
* '''Deliver specimen'''. A laparoscopic entrapment sac is introduced by the assistant through the 12 mm assistant trocar; the specimen is placed in the sac and the string brought out through the midline incision.
* '''Oversew DVC, if needed.''' Exchange for robotic needle drivers. Use a 2-0 V lock on V-20/SH running suture to oversew the DVC in all cases to prevent late or delayed venous bleeding. After DVC has been oversewn, decrease pneumoperitoneum to 15 mm Hg.
* '''Obtain hemostasis.''' Arterial bleeding along the nerves sutured with 4-0 vicryl. The prostatic pedicles are oversewn with a 3-0 V-lock suture for arterial but more importantly venous hemostatic security.
* '''Reduce bladder neck, if needed.''' See Special Scenarios below.
*'''Posterior urethral support.''' 
**Use a 3-0 double-arm suture and with one end, take a figure of 8 stitch on the cut edge of Denonvilliers, approximately 1.5 cm from urethral stump. 
**Pull suture so that tied ends in the middle are brought down to figure of 8.
**Leave the needle that did not take the bite to the left side.
**Using the needle that did take the bites, take a bite on the left side of the rectourethralis; goal is to incorporate as much of the muscular structural support behind the urethra as possible. 
**Repeat bite on previous figure of 8 on Denonvilliers fascia, then bite slightly medial on rectourethralis. Repeat bite on previous figure of 8. 
**Repeat bite slightly lateral on rectourethralis. Repeat bite on previous figure of 8.
**Cinch and leave suture on right side.
* '''Vesicourethral anastomosis.''' 
**5 to 7 o' clock: Take the other end of the double arm suture that did not take bites and take a 7 o'clock outside-in bite on the bladder. Be sure to get good bladder thickness and mucosa. Next bite is 7 o'clock on urethra inside-out, then 6 o'clock on bladder outside-in, 6 o'clock on urethra inside-out, 5 o clock on bladder outside-in. Now there are 3 bites on the bladder side. Now cinch down.
***'''CAUTION: Only the bladder is pulled toward the urethra to avoid pulling and tearing out from the urethral side.'''
**Take inside-out bite on urethra at 5 o'clock. Cinch further. Tie to previous stitch.
**Remaining anastomosis: Use a new 3-0 double-arm barbed suture to take outside-in bite on bladder at 4 o'clock. Even up both sides of the suture. 
**Leave other needle (one that did not take bite) on right side. This needle will be used to run the anastomosis from 4 o'clock towards 1 o'clock.
**Transpose the needle that did complete the bite to the other side. Take a bite on urethra inside-out at 4 o'clock, then 6 o'clock on bladder outside-in, then 7 o'clock on urethra inside-out. Cinch.
**7 o'clock to 10 o'clock: Run the anastomosis from 7 o'clock to 1 o'clock. Cinch along the way.
**Complete the anastomosis from 4 o'clock to 1 o'clock. Start on bladder outside-in at 4-430 o'clock. Cinch along the way.
**As anastomosis completed, insert final catheter. Sutures are cinched.
**Videos
*** [https://www.youtube.com/watch?v=mEWm2wCqLe8 Video (Dr. Ketan Bedani)]
*** [https://www.youtube.com/watch?v=UtxeCIsfeLA Video (Dr. Edward Shaeffer)]
*** [https://www.youtube.com/watch?v=s6dL8ZgHtYs Video (Dr. Kevin Zorn)]
*** [https://www.youtube.com/watch?v=oXgWGvZQrOM Video (Dr. Alexandre Mottrie)]
*** [https://www.youtube.com/watch?v=DIInGEl9lac Video (Dr. Jim Hu)]
*** [https://pubmed.ncbi.nlm.nih.gov/29792882/ Guided written instructions with video] (USC Robotic vesicourethral anastomosis tutorial - see Supplemental Data)
* '''Closure'''. Catheter is irrigated with 3 full syringes. 
**If satisfied with irrigation, inflate balloon is inflated with 20cc NS. 
**All needles are removed from the patient. 
**Ensure hemostasis.
***Consider application of hemostatic products to anastamosis and lymph node dissection areas.

=== Anterior Approach ===
* Take down any adhesions that may interfere with surgery.
*'''Divide urachas.''' Cauterize the urachas high above the bladder then transect it.
* '''Drop the bladder.''' Incise the peritoneum lateral to the medial umbilical ligament, from the urachas down to the vas deferens, medial to the inguinal canal. If doing lymph node dissection, continue peritoneal incision to the ureter. Develop the avascular space of Retzius down towards the pubic bone. Superiorly, do not get to close to the aterior abdominal wall musculature. Inferiorly, stay close to pubic bone anteriorly. Use the Prograsp fenestrated graspers in Robotic Arm 3 to retract the urachas posteriorly and superiorly. Expose endopelvic fascia bilaterally.
** '''Always stay lateral to medial umbilical ligament'''
*** The ureter travels over the iliac vessels to run medial and deep to the medial umbilical ligament. Therefore, as long as dissection is lateral to the medial umbilical ligament, the ureter will not be at risk.
*** Do not be too lateral or you will encounter external iliac vessels.
** Accessory pudendal arteries traveling longitudinally along the anteromedial aspect of the prostate are easily recognized during RALP. Attempt at preservation of these arteries is important for erectile function because in some men these arteries may be the dominant source of arterial blood supply to the corpora cavernosa
* '''Defat anterior prostate.''' Use heat to dissect the anterior prostatic fat from the anterior prostatic capsule from the apex to the bladder neck to help visualize the border between the prostate and bladder neck.. Skeletonize the puboprostatic ligaments for optimal visualization of the apex.
** Anterior prostatic fat is sent for a pathologic examination in case the pathologist reports a positive surgical margin. If a positive surgical margin is seen anteriorly, the fat can be evaluated for residual cancer.
** About 15% of men will have lymph nodes in the anterior prostatic fat and that in 2% to 3% of men, this will be the only site of metastasis.
* '''Coagulate superficial branches of DVC, if present'''
* At this point, visible landmarks include:
** Anterior aspect of the bladder and prostate
** Puboprostatic ligaments
** Endopelvic fascia
** Pubis/superior pubic ramus
* '''Lymph node dissection, if applicable.''' Identify appropriate landmarks (external iliac artery and vein, ureter, obturator nerve, node of cloquet) and dissect out lymph nodes.
*'''Incise endopelvic fascia.''' Retract the prostate medially and use scissors to make an incision in the endopelvic fascia, laterally closer to muscle than the nerve. This location fully exposes the neurovascular bundles (NVBs), which facilitates visualization and reduce traction injury. At the apex, release Myer’s muscle completely to visualize and protect the apex, neurovascular bundles, and urethra when transecting the dorsal venous complex (DVC) and remaining apical structures.
* '''Incise anterior bladder neck.''' Retract the foley catheter to visualize the distal end of the balloon to identify the approximate location of the bladder neck. Once location identified, advance foley completely, use bipolar to coagulate in midline then use scissors to make a transverse incision in this area. Transection of the bladder from the prostate is facilitated with retraction of the left hand with continuous sufficient force to maximize visualization. Continue dissecting in midline towards the catheter. The anterior bladder neck incision should not be carried too far laterally because branches of the bladder pedicle are often encountered, resulting in unwanted bleeding. Once the catheter has been identified, deflate the balloon and suspend the prostate with Prograsp focep grapers. Complete lateral dissection of the anterior bladder neck.
* '''Inspect interior of the bladder.''' Evaluate for median lobe of prostate. Identify locations of ureteric orifices, to avoid injury during repair. In patients with prior TURP, the ureteric orifice may be much closer to the bladder neck.
* '''Incise posterior bladder neck.''' Continue dissection to enter the muscular/ vascular space behind the detrusor (or the posterior bladder neck). Immediately behind the posterior bladder are the longitudinal muscle and multiple vessels that need cauterization. This muscular/ vascular layer is later incorporated into the Rocco stitch. The bladder neck incision is completed and the prostate is now free at the base. The Foley catheter is withdrawn so only the tip is visible.
* '''Posterior dissection (seminal vesicle and rectum).''' Identify and dissect out the vas deferens. Use Prograsp forcep grapsers to retract the vas superiorly and continue dissect distally towards the ejaculatory ducts. The seminal vesicles are found immediately lateral to the distal portion of the vasa. The seminal vesicles are dissected from the surrounding vas medially and laterally from the neurovascular bundle. The seminal vesicles should be mobilized with minimal traction to the surrounding hypogastric nerves, which are important for the sensation of orgasm. Minimize use of monopolar given proximity to neurovascular bundle. After one side complete, dissect out contralateral vas and seminal vesicles.
*'''Dissect prostate from rectum.''' Suspend the seminal vesicles with Prograsp forcep grapsers. Denonvilliers is grasped and lifted and incised sharply. The incision is above the fascia for aggressive nerve-sparing, and below the fascia until perirectal fat is seen for aggressive cancer. Dissection of the plane between the prostate and rectum is facilitated by the surgeon’s left hand elevating the prostate as the assistant retracts gently but firmly on the rectum with the sucker as needed. The dissection is carried distally to the apex.
* '''Pedicles.''' Create windows in the pedicles, apply clips, and gradually divide posterolateral pedicles
*'''Nerve sparing.''' The periprostatic vasculature within the interfascial space has been used as a macroscopic landmark and visual surrogate for identifying and preserving the cavernous nerves. the interfascial plane is between capsular artery and fascia. Critical to nerve preservation is holding the prostate with Prograsp forcep grapsers, sharply releasing the nerve from the prostate without traction.
* '''Divide DVC'''. Consider using 30 degree lens. Increase pneumoperitoneum to 20 mm Hg. Use left hand to retract prostate superiorly and cut straight through DVC with cold scissors. When DVC gives, change angle of scissors and follow curve of prostate.
* '''Urethral transection.''' Cut through urethra, will eventually identify catheter. Remove catheter so only the tip is visible and continue to transect urethra and down to rectourethralis muscle with scissors perpendicular to the urethra.
* '''Deliver specimen'''. A laparoscopic entrapment sac is introduced by the assistant through the 12 mm assistant trocar; the specimen is placed in the sac and the string brought out through the midline incision.
* '''Oversew DVC.''' Exchange for robotic needle drivers. Use a 1-0 Vicryl or 4-0 V-lock running suture to oversew the DVC in all cases to prevent late or delayed venous bleeding. After DVC has been overswen, decrease pneumoperitoneum to 15 mm Hg.
* '''Obtain hemostasis.''' Arterial bleeding along the nerves sutured with 4-0 vicryl. The prostatic pedicles are oversewn with a 3-0 V-lock suture for arterial but more importantly venous hemostatic security.
* '''Rocco stitch (optional).''' A 3-0 V-lock begins at the bladder incorporating the cut edge of Denonvilliers and then the posterior bladder detrusor. The next suture is intended to incorporate as much of the muscular structural support behind the urethra as possible. We stress that only the bladder is pulled toward the urethra to avoid pulling and tearing out from the urethral side.
* '''Vesicourethral anastomosis.''' Reduce bladder neck, if needed with 1-0 vicryl. Use 3-0 V lock stitch for running vesicourethral anastamosis. Take an outside-in bite at the 6 o’clock position on the bladder neck. Run the needle through hole of V-lock stitch. Then take an inside-out bite at same position on urethra. Repeat another outside-in bite on the bladder to the right of this and a corresponding inside-out bite on the urethra. Bring in another 3-0 V-lock stitch. Take an outside-in bite on the bladder to left of the pervious 6 o’clock bite. Run the needle through hole of V-lock stitch. Then take a corresponding inside-out bite on the urethra. Repeat another bite to the left of this. Catheter is advanced into bladder. Cinch down both V-locks that are on the bladder neck. Continue running sutures around the clock. As anastomosis completed, insert final catheter. Sutures are cinched.
** [https://www.youtube.com/watch?v=mEWm2wCqLe8 Video (Dr. Ketan Bedani)]
** [https://www.youtube.com/watch?v=UtxeCIsfeLA Video (Dr. Edward Shaeffer)]
** [https://www.youtube.com/watch?v=s6dL8ZgHtYs Video (Dr. Kevin Zorn)]
** [https://www.youtube.com/watch?v=oXgWGvZQrOM Video (Dr. Alexandre Mottrie)]
** [https://www.youtube.com/watch?v=DIInGEl9lac Video (Dr. Jim Hu)]
** [https://pubmed.ncbi.nlm.nih.gov/29792882/ Guided written instructions with video] (USC Robotic vesicourethral anastomosis tutorial - see Supplemental Data)
* '''Closure'''. Catheter is irrigated. If satisfied with irrigation, inflate balloon is inflated with 20cc NS. All needles are removed from the patient. Ensure hemostasis.