Robot-assisted Laparoscopic Prostatectomy: Difference between revisions

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 ** 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 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.
 *'''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.
 *'''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 oversewn, decrease pneumoperitoneum to 15 mm Hg.
-*'''Incise anterior bladder neck.''' Exchange for robotic scissors and bipolar.
+*'''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 anterior bladder neck.''' Exchange for robotic scissors and bipolar.
 **Identify the approximate location of the bladder neck by (3):[https://pubmed.ncbi.nlm.nih.gov/23859125/]
 ***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.
 **Complete lateral dissection of the anterior bladder neck.
 * '''Inspect interior of the bladder.'''