Editing Robot-assisted Laparoscopic Prostatectomy (section)

=== 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.