Robot-assisted Laparoscopic Prostatectomy: Difference between revisions

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== Videos ==

=== Full videos ===

*Anterior approach

**[https://www.youtube.com/watch?v=YKB3vDHQcuk Anterior approach] (Dr. Jim Hu)

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**[https://www.youtube.com/watch?v=PLp7A6lgr0o Posterior approach] (Asian Institute of Nephrology & Urology)

**[https://www.youtube.com/watch?v=tu6U8-ZvWgQ Posterior approach] (Asian Institute of Nephrology & Urology)

**

=== Segments ===

* [https://www.youtube.com/watch?v=DiDn_5SXFU8& Bladder drop and incision of endopelvic fascia (Dr. Dries Develtere)]

* [https://www.youtube.com/watch?v=cmz6nC86Ko0 Bladder neck dissection (posterior approach) (Dr. Dries Develtere)]

* [https://www.youtube.com/watch?v=nnmXnYIu-PU Dissection of seminal vesicles (anterior approach) (Dr. Dries Develtere)]

* [https://www.youtube.com/watch?v=MsLoSSXjFdE Posterior dissection, nerve sparing, pedicles (Dr. Dries Develtere)]

* [https://www.youtube.com/watch?v=lYw8_UaXqfA Anastomosis, urethral stump, and DVC (Dr. Dries Develtere)]

== Contraindications ==

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*Right hand: monopolar scissors

*4th arm: Prograsp fenestrated graspers

*16F foley at intraoperative catheter

*16F foley as intraoperative catheter

*18F coude catheter as final catheter

*Floseal x2

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**Endo Catch™ Gold device 10 mm

***Volume 220mL

*Jackson-Pratt drain

== Steps of procedure ==

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*** 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: 5 cm right lateral of Robotic 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/]

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**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.

*'''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) and assistant (12mm) ports. 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). Make sure assistant has good access to field from assistant port.

*'''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.

* '''Achieve pneumoperitoneum.''' Connect the needle to high flow CO2 insufflation. There is no need to begin at low flow, because the size of the Veress needle limits flow to 1.5 to 2L/min.[https://www.auanet.org/meetings-and-education/education-products-and-resources/blus-handbook-of-laparoscopic-and-robotic-fundamentals] Opening pressure (initial pressure) should be <10 mm. If pressure >10 mm, withdraw needle slightly. If pressure decreases <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. As the pressure slowly rises to 20, the remaining port sites are marked.

* '''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.

*'''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 ~~in shape of arc,~~ at least 6cm (approx. 3 fingerbreadths) 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 ~~20mm~~ Hg, make an incision overlying camera port. Use hemostat to dissect down through fat. Twist port into abdomen; twisting is more important ~~that~~ 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.

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* Take down any adhesions that may interfere with surgery.

*'''Posterior Dissection'''

**'''Incise ~~and develop~~ rectovesical pouch.''' 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). ~~Can also use~~ vas deferens ~~as a guide and follow~~ from lateral to medial ~~since goal is~~ to get to SV/vas deferens junction. Be careful of ureteric injury if too lateral. Make incision in rectovesical pouch. Dissect along inferior peritoneal incision towards seminal vesicle. If seminal vesicle not easily identified, identify vas deferens and use the vas deferens to guide you towards the seminal vesicle.

**'''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.

**'''Dissect seminal vesicles.''' Once SV identified, dissect it posteriorly from medial to lateral~~. Do not dissect in between the vas and seminal vesicles. Stick right on vas/SV, okay to burn vas or SV~~. 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 vas deferens can be identified, it can be followed from lateral to medial to get to the SV/vas deferens junction.

**'''Ligate and divide vas deferens.''' Once at the tip of the ~~SVs~~, develop space between vas and SV. Use Maryland to coagulate the vas and then divide vas laterally at tip of SV.

***Be careful of ureteric injury if too lateral.

**'''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. ~~Laterally, try to avoid using monopolar as the neurovascular bundles are lateral to the seminal vesicles.~~ 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.

**'''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.

*'''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. Incise the peritoneum in the avascular area, lateral to the medial umbilical ligament, medial to inguinal ring ('''CAUTION: to avoid inferior epigastric vessels'''), 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 avascular space~~ inferiorly and medially, medial to inguinal ring and lateral to medial umbilical ligament. Goal is to expose and be inside pubis. Repeat on contralateral side.

***If SV not easily identified, identify vas deferens and use the vas deferens to guide you towards the SV.

**'''Always stay lateral to medial umbilical ligament'''

***Do not dissect in between the vas and SV.

*** 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.

***Stick right on vas/SV, okay to burn vas or SV.

*** '''CAUTION: Do not be too lateral or you will encounter external iliac vessels.'''

***If nerve-sparing, try to avoid using monopolar current laterally as the neurovascular bundles are lateral to the seminal vesicles.

*'''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.

**'''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.

*'''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.

**'''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.

**'''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

***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.

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*****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.

**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.

**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.''' 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.

*'''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 ~~notal~~ packet distally, at the node of cloquet.

**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

**#Assessing the proximal midline aspect where the anterior prostatic fat was removed

***Retracting the foley catheter to visualize the distal end of the balloon

**#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

**#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

**#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.

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**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. Denonvilliers ~~is grasped~~ and ~~lifted and incised sharply~~.

* '''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.

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**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.

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**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 ~~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 oversewn, decrease pneumoperitoneum to 15 mm Hg.

* '''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 middle is brought down to figure of 8.

**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 ~~right~~ side.

**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 ~~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.'''

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**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 ~~anastamosis~~ from 4 o'clock towards 1 o'clock.

**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 ~~anastamosis~~ from 7 o'clock to 1 o'clock. Cinch along the way.

**7 o'clock to 10 o'clock: Run the anastomosis from 7 o'clock to 1 o'clock. Cinch along the way.

**Complete the ~~anastamosis~~ from 4 o'clock to 1 o'clock. Start on bladder outside-in at 4-430 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

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**[https://www.youtube.com/watch?v=yCwlA1CAFvs Management of Median Lobe during RALP (Dr. Edward Schaeffer)]

**[https://www.youtube.com/watch?v=EOsSnKbhYmQ Management of Median Lobe during RALP (Dr. Ali Moinzadeh)]

**[https://www.youtube.com/watch?v=44DTaknEGzw Management of Median Lobe during RALP (Dr. Dries Develtere)]

=== Bladder Neck Reconstruction ===

* May be needed if a large defect is present, to narrow the diameter of the bladder neck opening to match the urethral diameter

* Technique[https://pubmed.ncbi.nlm.nih.gov/20858064/ §][https://pubmed.ncbi.nlm.nih.gov/18455623/ §]

* Technique[https://pubmed.ncbi.nlm.nih.gov/20858064/ §][https://pubmed.ncbi.nlm.nih.gov/18455623/ §][https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25 §]

**Equipment: 2-0 Vicryl suture on SH needle, cut to 15-20cm

**Method 1: Figure-of-eight stitches inferiorly in the bladder neck (ie, tennis racquet closure). [https://pubmed.ncbi.nlm.nih.gov/20858064/ §]

**Method 1 (anterior tennis racket closure)[https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25 §]

***This inverting approach moves the UOs away from the anastomosis, thus avoiding a leak or inadvertent injury.

***Proceed with the anastomosis as is usually performed, knowing that there will still be a substantial anterior bladder defect. Once the anastomotic sutures circumferentially complete the anastomosis, these sutures are tied together.

** Method 2: Interrupted sutures ~~from~~ the 2-o’clock to the 4-o’clock position and the 8-o’clock to the 10-o’clock position on the bladder neck, closing it in a ‘‘fish mouth’’ configuration or in a ‘‘reverse tennis racket’’ approach.[https://pubmed.ncbi.nlm.nih.gov/18455623/ §]

***The anterior bladder neck defect is then closed in a side-to-side manner using 2-0 or 3-0 polyglactin sutures similar to bladder closures for other surgical procedures when the bladder has to be opened. This closure mimics a tennis racket and hence the name.

*** ~~While~~ feasible, this approach often involves placing sutures very close to the UOs.

****See [https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25#Fig6 Figure]

**Method 2 (posterior tennis racket closure)

***Figure-of-eight stitches inferiorly in the bladder neck (ie, tennis racquet closure).[https://pubmed.ncbi.nlm.nih.gov/20858064/ §]

***'''This inverting approach moves the UOs away from the anastomosis, thus avoiding a leak or inadvertent injury.'''

***See [https://www.urotoday.com/conference-highlights/eau-robotic-urology-section/erus-2018/106782-erus-2018-how-to-manage-complications-during-prostate-surgery.html Figure]

**Method 3 (fish-mouth closure)

***Interrupted sutures

****From the 2-o’clock to the 4-o’clock position and the 8-o’clock to the 10-o’clock position on the bladder neck, closing it in a ‘‘fish mouth’’ configuration or in a ‘‘reverse tennis racket’’ approach.[https://pubmed.ncbi.nlm.nih.gov/18455623/ §]

****At 3 and 9 o’clock on the bladder neck and run medially until the bladder neck is of a sufficient size[https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25][https://pubmed.ncbi.nlm.nih.gov/18455623/ §]

***** '''Caution: while feasible, this approach often involves placing sutures very close to the UOs.'''

*****See [https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25#Fig5 Figure]

***Once this has been accomplished, the remainder of the anastomosis is continued in a usual manner.

**Additional sutures placed medially may be needed to narrow the diameter of the bladder neck opening to match the urethral diameter

* Once the bladder neck is complete, a standard running vesicourethral anastomosis is performed.

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** Cancer characteristics

** Prostate size

*** Generally, a smaller prostate is associated with fewer surgical complications but a higher likelihood of positive surgical margins.[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8656835/]

*** Larger prostate size associated with worse rates of urinary continence and recovery of sexual function[https://pubmed.ncbi.nlm.nih.gov/38290859/]

** Preoperative lower urinary tract symptoms

** Preoperative erectile dysfunction

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 == Videos ==
+=== Full videos ===
 *Anterior approach
 **[https://www.youtube.com/watch?v=YKB3vDHQcuk Anterior approach] (Dr. Jim Hu)
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 **[https://www.youtube.com/watch?v=PLp7A6lgr0o Posterior approach] (Asian Institute of Nephrology & Urology)
 **[https://www.youtube.com/watch?v=tu6U8-ZvWgQ Posterior approach] (Asian Institute of Nephrology & Urology)
-**
+=== Segments ===
+* [https://www.youtube.com/watch?v=DiDn_5SXFU8& Bladder drop and incision of endopelvic fascia (Dr. Dries Develtere)]
+* [https://www.youtube.com/watch?v=cmz6nC86Ko0 Bladder neck dissection (posterior approach) (Dr. Dries Develtere)]
+* [https://www.youtube.com/watch?v=nnmXnYIu-PU Dissection of seminal vesicles (anterior approach) (Dr. Dries Develtere)]
+* [https://www.youtube.com/watch?v=MsLoSSXjFdE Posterior dissection, nerve sparing, pedicles (Dr. Dries Develtere)]
+* [https://www.youtube.com/watch?v=lYw8_UaXqfA Anastomosis, urethral stump, and DVC (Dr. Dries Develtere)]
 == Contraindications ==
@@ Line 57: / Line 65: @@
 *Right hand: monopolar scissors
 *4th arm: Prograsp fenestrated graspers
-*16F foley at intraoperative catheter
+*16F foley as intraoperative catheter
 *18F coude catheter as final catheter
 *Floseal x2
@@ Line 76: / Line 84: @@
 **Endo Catch™ Gold device 10 mm
 ***Volume 220mL
+*Jackson-Pratt drain
 == Steps of procedure ==
@@ Line 98: / Line 107: @@
 *** 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: 5 cm right lateral of Robotic 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/]
@@ Line 124: / Line 133: @@
 **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.
+*'''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) and assistant (12mm) ports. 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). Make sure assistant has good access to field from assistant port.
+*'''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.
-* '''Achieve pneumoperitoneum.''' Connect the needle to high flow CO2 insufflation. There is no need to begin at low flow, because the size of the Veress needle limits flow to 1.5 to 2L/min.[https://www.auanet.org/meetings-and-education/education-products-and-resources/blus-handbook-of-laparoscopic-and-robotic-fundamentals] Opening pressure (initial pressure) should be <10 mm. If pressure >10 mm, withdraw needle slightly. If pressure decreases <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. As the pressure slowly rises to 20, the remaining port sites are marked.
+* '''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.
-*'''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 in shape of arc, at least 6cm (approx. 3 fingerbreadths) 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 20mm Hg, make an incision overlying camera port. Use hemostat to dissect down through fat. Twist port into abdomen; twisting is more important that 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.
@@ Line 139: / Line 146: @@
 * Take down any adhesions that may interfere with surgery.
 *'''Posterior Dissection'''
-**'''Incise and develop rectovesical pouch.''' 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). Can also use vas deferens as a guide and follow from lateral to medial since goal is to get to SV/vas deferens junction. Be careful of ureteric injury if too lateral. Make incision in rectovesical pouch. Dissect along inferior peritoneal incision towards seminal vesicle. If seminal vesicle not easily identified, identify vas deferens and use the vas deferens to guide you towards the seminal vesicle.
+**'''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.
-**'''Dissect seminal vesicles.''' Once SV identified, dissect it posteriorly from medial to lateral. Do not dissect in between the vas and seminal vesicles. Stick right on vas/SV, okay to burn vas or SV. 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 vas deferens can be identified, it can be followed from lateral to medial to get to the SV/vas deferens junction.
-**'''Ligate and divide vas deferens.''' Once at the tip of the SVs, develop space between vas and SV. Use Maryland to coagulate the vas and then divide vas laterally at tip of SV.
+***Be careful of ureteric injury if too lateral.
-**'''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. Laterally, try to avoid using monopolar as the neurovascular bundles are lateral to the seminal vesicles. 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.
+**'''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.
-*'''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. Incise the peritoneum in the avascular area, lateral to the medial umbilical ligament, medial to inguinal ring ('''CAUTION: to avoid inferior epigastric vessels'''), 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 avascular space inferiorly and medially, medial to inguinal ring and lateral to medial umbilical ligament. Goal is to expose and be inside pubis. Repeat on contralateral side.
+***If SV not easily identified, identify vas deferens and use the vas deferens to guide you towards the SV.
-**'''Always stay lateral to medial umbilical ligament'''
+***Do not dissect in between the vas and SV.
-*** 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.
+***Stick right on vas/SV, okay to burn vas or SV.
-*** '''CAUTION: Do not be too lateral or you will encounter external iliac vessels.'''
+***If nerve-sparing, try to avoid using monopolar current laterally as the neurovascular bundles are lateral to the seminal vesicles.
-*'''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.
+**'''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.
-*'''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.
+**'''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.
-**'''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
+***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.
@@ Line 165: / Line 181: @@
 *****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.
-**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.
+**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.
-**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.''' 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.
+*'''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 notal packet distally, at the node of cloquet.
+**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
+**#Assessing the proximal midline aspect where the anterior prostatic fat was removed
-***Retracting the foley catheter to visualize the distal end of the balloon
+**#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
+**#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
+**#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.
@@ Line 196: / Line 212: @@
 **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. Denonvilliers is grasped and lifted and incised sharply.
+* '''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.
@@ Line 206: / Line 222: @@
 **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.
@@ Line 223: / Line 240: @@
 **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 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 oversewn, decrease pneumoperitoneum to 15 mm Hg.
+* '''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 middle is brought down to figure of 8.
+**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 right side.
+**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 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.'''
@@ Line 239: / Line 256: @@
 **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 anastamosis from 4 o'clock towards 1 o'clock.
+**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 anastamosis from 7 o'clock to 1 o'clock. Cinch along the way.
+**7 o'clock to 10 o'clock: Run the anastomosis from 7 o'clock to 1 o'clock. Cinch along the way.
-**Complete the anastamosis from 4 o'clock to 1 o'clock. Start on bladder outside-in at 4-430 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
@@ Line 338: / Line 355: @@
 **[https://www.youtube.com/watch?v=yCwlA1CAFvs Management of Median Lobe during RALP (Dr. Edward Schaeffer)]
 **[https://www.youtube.com/watch?v=EOsSnKbhYmQ Management of Median Lobe during RALP (Dr. Ali Moinzadeh)]
+**[https://www.youtube.com/watch?v=44DTaknEGzw Management of Median Lobe during RALP (Dr. Dries Develtere)]
 === Bladder Neck Reconstruction ===
 * May be needed if a large defect is present, to narrow the diameter of the bladder neck opening to match the urethral diameter
-* Technique[https://pubmed.ncbi.nlm.nih.gov/20858064/ §][https://pubmed.ncbi.nlm.nih.gov/18455623/ §]
+* Technique[https://pubmed.ncbi.nlm.nih.gov/20858064/ §][https://pubmed.ncbi.nlm.nih.gov/18455623/ §][https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25 §]
 **Equipment: 2-0 Vicryl suture on SH needle, cut to 15-20cm
-**Method 1: Figure-of-eight stitches inferiorly in the bladder neck (ie, tennis racquet closure). [https://pubmed.ncbi.nlm.nih.gov/20858064/ §]
+**Method 1 (anterior tennis racket closure)[https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25 §]
-***This inverting approach moves the UOs away from the anastomosis, thus avoiding a leak or inadvertent injury.
+***Proceed with the anastomosis as is usually performed, knowing that there will still be a substantial anterior bladder defect. Once the anastomotic sutures circumferentially complete the anastomosis, these sutures are tied together.
-** Method 2: Interrupted sutures from the 2-o’clock to the 4-o’clock position and the 8-o’clock to the 10-o’clock position on the bladder neck, closing it in a ‘‘fish mouth’’ configuration or in a ‘‘reverse tennis racket’’ approach.[https://pubmed.ncbi.nlm.nih.gov/18455623/ §]
+***The anterior bladder neck defect is then closed in a side-to-side manner using 2-0 or 3-0 polyglactin sutures similar to bladder closures for other surgical procedures when the bladder has to be opened. This closure mimics a tennis racket and hence the name.
-*** While feasible, this approach often involves placing sutures very close to the UOs.
+****See [https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25#Fig6 Figure]
+**Method 2 (posterior tennis racket closure)
+***Figure-of-eight stitches inferiorly in the bladder neck (ie, tennis racquet closure).[https://pubmed.ncbi.nlm.nih.gov/20858064/ §]
+***'''This inverting approach moves the UOs away from the anastomosis, thus avoiding a leak or inadvertent injury.'''
+***See [https://www.urotoday.com/conference-highlights/eau-robotic-urology-section/erus-2018/106782-erus-2018-how-to-manage-complications-during-prostate-surgery.html Figure]
+**Method 3 (fish-mouth closure)
+***Interrupted sutures
+****From the 2-o’clock to the 4-o’clock position and the 8-o’clock to the 10-o’clock position on the bladder neck, closing it in a ‘‘fish mouth’’ configuration or in a ‘‘reverse tennis racket’’ approach.[https://pubmed.ncbi.nlm.nih.gov/18455623/ §]
+****At 3 and 9 o’clock on the bladder neck and run medially until the bladder neck is of a sufficient size[https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25][https://pubmed.ncbi.nlm.nih.gov/18455623/ §]
+***** '''Caution: while feasible, this approach often involves placing sutures very close to the UOs.'''
+*****See [https://link.springer.com/chapter/10.1007/978-3-319-20645-5_25#Fig5 Figure]
+***Once this has been accomplished, the remainder of the anastomosis is continued in a usual manner.
 **Additional sutures placed medially may be needed to narrow the diameter of the bladder neck opening to match the urethral diameter
 * Once the bladder neck is complete, a standard running vesicourethral anastomosis is performed.
@@ Line 381: / Line 410: @@
 ** Cancer characteristics
 ** Prostate size
+*** Generally, a smaller prostate is associated with fewer surgical complications but a higher likelihood of positive surgical margins.[https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8656835/]
+*** Larger prostate size associated with worse rates of urinary continence and recovery of sexual function[https://pubmed.ncbi.nlm.nih.gov/38290859/]
 ** Preoperative lower urinary tract symptoms
 ** Preoperative erectile dysfunction