The initial step of extraperitoneal robot-assisted laparoscopic radical prostatectomy (RALP) is creation of the extraperitoneal space. A 2.5 cm paraumbilical skin incision is made down to the level of the anterior rectus sheath. A 1 cm incision is made in the latter to expose the rectus muscle. A 0-polyglactin suture is placed through the two apices of this incision and the free ends are secured with a snap (Fig. 19.4). The muscle fibers are pushed laterally using a clamp, exposing the posterior rectus sheath. A balloon dilator (Extra View™ Balloon, OMS-XB 2, Tyco Healthcare, Norwalk, CT) is inserted just above the posterior sheath and advanced down to the pubic symphysis in the midline (Fig. 19.5). A 0° scope is placed in the balloon trocar to allow direct visualization of the space being created. Care should be taken not to overstretch or tear the epigastric or iliac vessels from overinflation. Once the space is created, the balloon dilator is replaced by a 10/12 mm Dilating Tip Ethicon Endopath 512XD (Ethicon Inc. US, LLC., Somerville, NJ) trocar. It is necessary to use a transparent trocar such as this so that the retropubic space can be developed under direct vision. The retroperitoneum is insufflated up to 12–15 mmHg. The beveled tip of the trocar is used to further create the extraperitoneal space laterally, facilitating placement of the assistant trocars as mentioned above. The loose areolar tissue is swept laterally and cephalad, bluntly pushing the peritoneum off the abdominal wall. The epigastric vessels are left attached to the anterior abdominal wall to avoid bleeding from branches entering the rectus muscle (Fig. 19.6). If a da Vinci^® Xi Surgical System is used, the 12 mm paraumbilical Ethicon Endopath 512XD trocar must be replaced with a 12 mm da Vinci^® trocar with a reducer placed on its hub to accommodate an 8 mm, 0° laparoscopic camera. A petroleum jelly-impregnated gauze is wrapped around the trocar at the level of the anterior rectus sheath and the previously placed 0-polyglactin is tied tightly around the trocar to avoid leakage of CO₂. The additional trochars are then placed under direct vision as described above.

A 0° lens is used throughout the entire operation. Monopolar and bipolar electrocautery settings are set to 90 and 30 W, respectively. Accessing the retropubic space by the extraperitoneal approach described above eliminates the bladder “take-down” step required during the transperitoneal approach, and allows rapid visualization and access to the prostate, endopelvic fascia, and puboprostatic ligaments (Fig. 19.7). The fatty tissue overlying the endopelvic fascia is easily swept away exposing the prostate. We routinely incise the endopelvic fascia, freeing the prostate from its lateral attachments. Accessory pudendal vessels, if present, are identified and preserved. We routinely incise the puboprostatic ligaments to allow adequate mobilization of the prostatic apex. Superficial vessels encountered are cauterized.

A 2-0 Covidien V-Loc™ barbed suture is used to ligate the dorsal venous complex (DVC). With medial retraction of the prostatic apex, a groove is visualized between the DVC and the anterior urethra. We routinely pass the needle three times through this plane and suspend the complex to periosteum of the pubic symphysis after the first and third pass. A Hem-o-lok^® clip is applied to the distal end of the suture and used to further cinch it to the pubic symphysis (Fig. 19.8).