Editing Robot-assisted Laparoscopic Prostatectomy (section)

=== 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.