After port placement and docking of the robot, RARP is begun by taking down distal peritoneum, including transection of the umbilical ligaments, and then developing the retropubic space from the vasa deferentia proximally to the pubic symphysis distally and laterally to the iliac vessels and the parietal endopelvic fascia. Dissection to isolate the prostate and seminal vesicles cannot proceed expeditiously without first removing all retropubic adipose tissue, including loose areolar (cotton candy–like) tissue attached to the visceral fascia covering anterolaterally the bladder and the dorsal vein (vascular) complex (DVC) of the penis. Emerging distally from the fascia, the pubovesical/puboprostatic ligaments (PLs) containing cores of pubovesical muscle attach to the distal third of the pubis (Myers 2002). If these ligaments are partially and proximally transected, the prostate apex drops to facilitate delineation of the anterior prostato-urethral junction, with greatest benefit when there is concomitant benign prostatic hyperplasia (BPH). To reapproximate the function of the ligaments to support the urethra distally (Steiner 1994), the ligated DVC can be sutured to the symphysis pubis, a maneuver culminating in some suspension of the underlying urethral stump (Walsh and Partin 2007). However, ultimate impact on urinary continence is not clear. But fixation of the striated sphincter-membranous urethral complex by adjacent subpubic fascia and medial fascia of the levator ani appears to be an important structural mechanism that should be preserved (Burnett and Mostwin 1998).

The surface of visceral endopelvic fascia proximal to the PLs covers longitudinal muscle extension of bladder over prostate, the detrusor apron (Myers 2002), which spreads laterally to each fascial tendinous arch of the pelvis (FTAP) (arcus tendineus fasciae pelvis, Terminologia Anatomica [Federative Committee on Anatomical Terminology 1998]) and, in turn, hides underlying DVC and prostate (Fig. 1.1). In most cases (about 90%) (Myers 1991), a superficial vein emerges from the underlying DVC between the PLs to enter retropubic adipose tissue and, in most cases, joins the vesicovenous plexus. Sometimes the superficial vein emerges to course right or left along the pelvic sidewall.

This then is the initial operative field. The usual full space for RARP working elements extends anteriorly above collapsed bladder to the PLs, laterally to the iliac vessels, deep enough bilaterally to expose the obturator nerves and internal iliac lymph nodes along the internal iliac artery, and, in most cases at the start of the case, proximally to the vasa deferentia descending from each spermatic cord.

Visible impression of the prostate pushing upward against the distal bladder and its anterior detrusor apron becomes increasingly apparent the greater the degree of underlying BPH. BPH contributes directly to the size of the bridge of prostate tissue connecting the halves of the prostate anterior to the urethra, the anterior commissure, the first variable of practical importance to affect the pinch test, which is done by compressing the bladder and its underlying lumen proximal to the prostate with the robotic arms in order to find the optimal point of anterior bladder entry relative to the underlying prostate. Compared with an average prostate with a broader commissure (Fig. 1.2a), the presence of a narrower anterior commissure results in a pinch test showing the bladder lumen to be much closer to the PL takeoff and the prostato-urethral junction (Fig. 1.2b). Conversely, when there is significant protrusion superiorly of BPH, the bladder, like a hood, will encapsulate the prostate. The upwardly protruding BPH (Figs. 1.2c, d) will then make the pinch test less reliable in finding the correct plane of dissection of bladder from prostate without cutting down into the prostate. Furthermore, once the bladder is opened anteriorly, a median lobe of BPH must be recognized when present. Proximity of a median lobe to the interureteric ridge is variable and should be appreciated before incising the posterior bladder wall enroute to the seminal vesicles (SVs).

Also affecting the vesicoprostatic junction is the degree of anterior angulation of the prostatic urethra at the veru, described on average to be 140° (Fig. 1.3b) (McNeal 1972). However, sometimes there is no angle, and at other times the angle may be nearly 90°, a configuration that makes delineation of the vesicoprostatic junction difficult (Fig. 1.2d). The practical point is that the angle affects how BPH projects into the bladder lumen as the prostate elevates the bladder base, including the trigone. If there is no angle and no BPH, the pinch test is very reliable, as opposed to any situation in which there is BPH (Figs. 1.2c, d and 1.3). If bladder entry is made too distal, the anterior prostate may be entered, and if entry is too proximal, the bladder may not reach the urethral stump easily for anastomosis.

With carbon dioxide pressure, control of the DVC is much simpler than in open surgery, and blood loss is potentially less. Thus, in RARP, control of the DVC, as a result of surgeon preference, may be either immediate or delayed toward the end of the procedure, and at times the DVC may be sectioned without any significant back-bleeding. What is important about the DVC is its variability after emerging proximally from the pubic arch. The safest concept to have in mind is to consider the prostate apex embedded in a nest of veins situated anterior, posterior, and lateral to the apex. These veins then become distributed cephalad into three basic subgroups. The major primary mass of veins and venous sinuses passes anterolaterally on the prostate beneath the detrusor apron, and posterolaterally two minor groups of veins run as elements of the neurovascular bundles (NVBs). As these three groups course cephalad, connections between the posterolateral and anterolateral veins are common. They are readily observed beneath the remnant levator ani fascia (LAF) on the lateral surface of the prostate (see below). Variability is such that the sides of the prostate may be bare of or completely covered with veins. When the lateral surfaces of the prostate are covered by veins, both hemostasis and dissection of the NVB from the posterolateral aspect of the prostate are more complicated.

As the retropubic space is cleared of adipose tissue, accessory and/or aberrant pudendal arteries should be recognized and saved whenever possible. Cadaveric study suggests that 70% of men have penile arteries that are both infralevator and supralevator, 15% have exclusively infralevator arteries, and 15% have only supralevator arteries (Droupy et al. 1997). Supralevator pudendal artery origin includes branches from obturator, internal, and external iliac arteries (Walz et al. 2010). These arteries usually course along the side of the bladder if internal iliac in origin, arise often from the obturator artery and run laterally along the pelvic sidewall, or sometimes emerge from the levator ani as apical pudendal arteries (Fig. 1.4) (Mulhall et al. 2008; Walz et al. 2010). Rarely, they derive from a branch of the external iliac artery. These arteries usually enter distally anterior to the DVC and are protected if DVC control is posterior and proximal to the point of pudendal artery entry.

Radical prostatectomy is performed in an age range of men with gradually declining erectile function, particularly after age 60 for various reasons, one of them being atherosclerosis affecting penile blood supply with resultant arterial insufficiency. It is easy to appreciate intraoperatively large supralevator pudendal arteries, but also present are small arteries that accompany each NVB and those associated with the DVC, the latter necessarily transected in the course of any retropubic approach. The combined flow of arterial blood through these small arteries may be critical to erectile function in some men undergoing RARP, and their loss precipitates enough arterial compromise to induce arteriogenic impotence (Mulhall et al. 2008). Preservation of as many supralevator arteries as possible is strongly recommended. The intrafascial dissection described below, which may not be oncologically as safe in some cases, may be more preserving of the fine arterial vasculature and the autonomic nerves that accompany each NVB.

Partially beneath where the DVC more proximally forms a rich plexus of veins at the vesicoprostatic junction (proximal runoff) (Fig. 1.5) (Thomson Walker 1905–06; Beneventi and Noback 1949; Reiner and Walsh 1979), the main vascular pedicle enters the base of the prostate, and the NVBs, very thick at this site, converge with the vessels to form a neurovascular triangle (Takenaka et al. 2006). To preserve the neurovascular triangle with its sympathetic and parasympathetic nerves and numerous ganglia, both the venous plexuses of the DVC runoff and the prostate vascular pedicle must be secured and transected anterior to the main course of the NVBs (Walsh et al. 1983). The correct line of dissection should hug athermally the vesicoprostatic junction and not wander proximally to violate the triangle (Fig. 1.6).

The SVs should always be dissected medially away from the laterally adherent distal portion of the pelvic plexus and subsequent neurovascular tissue (Fig. 1.7). The SVs are tightly bound by nerves not just posterolaterally but also laterally and anterolaterally (Durward 1953; van der Zypen 1988; Lunacek et al. 2005; Walz et al. 2010), and they descend backward and downward in a plane aimed at the S2, S3, and S4 sacral foramina (Fig. 1.8). This plane is different from the coronally oriented plane of the prostate as it sits on the rectal surface. A “spray distribution” for nerves of the NVBs has been described occurring just distal to the vascular pedicle (Takenaka et al. 2004), but there is clearly an NVB component adherent to the lateral SV entering the neurovascular triangle, and presumably through numerous ganglia in this region connecting with nerves entering more distal to the pedicle as a presumptive merging point for sympathetic nerves of hypogastric plexus origin and parasympathetic nerves (nervi erigentes).

Of importance, the actual tips of the SVs are encased in tiny fascial pockets and therefore free from pelvic plexus adherence, which occurs along the lateral surface of the SVs, not at their tips. Saving the tips per se does not translate into preservation of erectile function.

Arterial supply to the SVs is variable. Multiple small arteries to the SVs may enter laterally, at the tips, and medially. Between each SV and vas deferens lies a constant, relatively larger vascular pedicle of arteries and veins supplying both SVs and vasa deferentia.

Distally, the NVBs may decussate or cross-communicate in the midline beneath the posterior prostato-urethral junction (Costello et al. 2004; Takenaka et al. 2006), which bears on Rocco stitch placement posteriorly to anchor the bladder to the rectal serosa (Rocco et al. 2006). Decussation also affects nerve-sparing radical perineal prostatectomy (Weldon et al. 1997) if the decussation has to be disrupted in the midline to find the posterior prostato-urethral junction.

The posterior prostate and SVs are covered by a continuous triangular fascia to be entitled herein as the common parlance, eponymic Denonvilliers’ fascia (DF), the posterior prostate fascia/seminal vesicles fascia (Walz et al. 2010) or, easier to say, prostatoseminal vesicular fascia (Myers and Villers 2006). The distal tip of this triangular fascia ends in a multilayered terminal plate posterior to the prostato-urethral junction (Stamey 1994). The plate then becomes continuous with the midline, fibrous tissue raphe of the central tendon of the perineum into which the posterior fibers of the striated urethral sphincter insert.

The junction of SVs and prostate posteriorly is the most frequent site of extraprostatic extension of cancer (Jewett et al. 1972). In the interest of oncologic safety, this junction should not be rendered devoid of fascia, meaning that the point of transverse transection of DF in RARP should be performed proximal to the base of the SVs so that there is sufficient fascia on the specimen to cover the vesicoprostatic junction and the posterior surface of the prostate. The correct plane of dissection must be sought carefully. Direct invasion by cancer of this posterior fascia is not common but is of sufficient incidence, especially in cT3 disease, that resection of the prostate should not exclude it as a posterior cover of the underlying peripheral zone capsule (Villers et al. 1993).

Where DF is cut transversely both proximally and distally weighs on the issue of where and how to place sutures for posterior stabilization of the bladder and urethra before vesicourethral anastomosis (Rocco et al. 2006). Parenthetically, although the SVs are covered posteriorly by DF, a true anterior layer of this same fascia on the SVs is a misconception (Secin et al. 2007).