Under general anesthesia, the patient is placed in supine position with abducted legs in the appropriate securely fashioned leggings (Fig. 28.1A). All pressure points are meticulously padded and the patient is secured to the surgical table. Sequential compression stockings are applied prior to induction. The patient is prepared from the nipples down to the midthighs, including the genitalia. A warming blanket covers the upper chest and shoulders. After sterile preparation and draping of the patient, a 20Fr Foley urethral catheter is inserted.

A 15 mm Hg pneumoperitoneum is created with a 2-mm MiniPort and is maintained at this pressure, even during active suction, by a high-flow insufflator. Six transperitoneal ports (four ports of 8 mm for the robot) are placed more cephalad than the port position commonly used for robotic prostatectomy, with the camera port placed in the midline, 5 to 10 cm above the umbilicus (Fig. 28.1B). A 15-mm port is placed in the left iliac fossa and a 12-mm port is placed in the upper left quadrant; the positioning of these two ports is important for allowing a favorable angle for the staplers during small bowel transection and reconstruction, as well as for the removal of lymph nodes in packets, according to node templates dissection. This configuration allows for the dissection of the urachus, extended or superextended lymphadenectomy (if necessary), and adequate intestinal mobilization. With the patient placed in steep Trendelenburg, the robotic platform da Vinci Si Surgical System is then positioned between the patient’s legs and the robot is docked. The first assistant stands on the left side of the patient.

Upon initial inspection, the surgeon must identify five important landmarks:

Identification of these landmarks is essential because it allows for precise orientation throughout the procedure and expeditious dissection.

The ureters are identified at the level where they cross the iliac vessels and the posterior peritoneum is incised. The ureters, along with their surrounding fat, are dissected distally until their insertion into the bladder. It is important to maintain an adequate cover of periureteric fatty tissue. Close to the vesicoureteric junction, the superior vesical artery and the vas deferens are visualized crossing the ureter. These are mobilized away from the ureteric surface to obtain maximum ureteric length. The ureters are then divided just before they enter the bladder (prior to the ureteral orifice) between Hem-O-Lok clips and a sample of each proximal portion is sent for pathologic assessment. The Hem-O-Lok clips on the bladder side of the transected ureter serve as critical landmarks during the subsequent dissection, as they provide a readily identifiable visual clue during transection of the lateral pedicles. The ureters remain clipped throughout the procedure to create proximal ureteral hydrodistention, which facilitates later ureteroenteric anastomosis.

With the robotic arm retracting the bladder anteriorly, the lateral peritoneotomies of the rectovesical pouch that were previously performed are now joined across the midline. It is
important that the peritoneotomy across the cul-de-sac be created distally, such that it is only 1 to 2 cm anterior to the surface of the rectum. Often, there is a subtle transverse peritoneal fold at this location (we refer to it as the “second peritoneal fold”). This plane is now developed between the vasa and seminal vesicles anteriorly and the anterior surface of the rectum posteriorly. The vessels supplying the seminal vesicles are controlled, and bilateral vasa and vesicles are maintained en bloc with the bladder. Continued dissection brings the posterior layer of Denonvilliers fascia into view, which is incised with cold Shears (monopolar curved scissors) to reveal the yellow prerectal fat posterior to the prostate. This is an important landmark guiding the posterior dissection; the plane must remain between the prostate anteriorly and the prerectal fat posteriorly toward to the prostate apex, thus minimizing chance of rectal injury (Fig. 28.2).

The parietal peritoneum lateral to the medial umbilical ligaments is incised from the vas deferens as it crosses the pelvic brim toward the peritoneotomy across the rectovesical cul-de-sac. The vasa are clipped and divided at the pelvic brim. The space between the bladder and the lateral pelvic wall is now developed bluntly, retracting the bladder medially away from the iliac vessels and the obturator nerve. As the bladder is still anteriorly attached to the abdominal wall, this allows the lateral pedicles to be clearly identified bilaterally. The lateral pedicles are now divided with 60-mm laparoscopic vascular staplers (Fig. 28.3). Once again, the
two clips on the bladder end of the transected juxtavesical ureters serve as critical landmarks for the anteromedial limit of resection; the laparoscopic stapler is deployed just posterolateral to these clips. Usually, two or three stapler cartridge firings are necessary on each side to control the entire width of the lateral pedicles down to the endopelvic fascia on either side.

The posterior pedicles are now visualized coursing from just lateral to the rectum toward the urinary bladder. These are controlled with the stapler or divided between sequentially applied Hem-O-Lok clips. Usually, only the cephalad part of the posterior pedicles can be controlled at this stage; the caudal aspect is addressed after releasing the bladder from the anterior abdominal wall and completing the anterior dissection. At this point, the dissection is within proximity to the anterolateral surface of the rectum.

A liberal inverted U incision is made with the hot Shears electrocautery, starting lateral to each medial umbilical ligament, with the limbs of the U joined anteriorly across the midline at the umbilicus. The urachus and medial umbilical ligaments are divided just caudal to the umbilicus. The bladder is dynamically pulled posteriorly, an avascular plane between the muscles aponeurosis and prevesical fat is dissected caudally toward the pubic bone and endopelvic fascia. The bladder is then released from the anterior abdominal wall; care is taken to protect the inferior epigastric vessels as they course up from the external iliac vessels to enter the posterior rectus sheath.

The space of Retzius is developed behind the pubic bone. Areolar tissue is dissected away to expose the anterior surface of the prostate and the endopelvic fascia on each side. The endopelvic fascia is incised down to the region of the dorsal venous complex. The superficial dorsal vein is coagulated and the fat overlying the anterior surface of the prostate is cleared off with the bipolar forceps. The puboprostatic ligaments are divided with cold Shears.

The dorsal vein complex (DVC) is now ligated, using a 0-Vicryl on a CT-1 needle and carefully transected with cold scissors toward the anterior surface of the urethra. The remaining posterior pedicles are then clipped and divided. If an orthotopic neobladder reconstruction is planned, a long urethral stump is required. Thus, a meticulous dissection with small cuts surrounding the urethra is performed, releasing the urethra from the prostate apex. An anterior urethrotomy is performed, and the Foley catheter is then divided between Hem-O-Lok clips to avoid local spillage of urine. The urethra is now transected just proximal to the verumontanum and biopsies of the proximal and distal urethra are sent for frozen section evaluation. The free specimen is entrapped in an Endo Catch bag (II Endo Catch bag 15 mm) and parked in one side within the abdomen for later retrieval.

For cystectomy in women, the procedure begins with the dissection of the ureters as previously described. The uterus is pulled proximally by the fourth robotic arm and Endo GIA staplers transect the infundibulopelvic ligaments and the uterine arteries. An incision is made in the posterior peritoneum near the uterine cervix. A stick sponge previously inserted into the vagina facilitates visualization of the vaginal fornix (Fig. 28.4). The remaining posterior dissection and the vaginal incision are made after preparing the DVC. The lateral pedicles are transected with laparoscopic staplers and the bladder is dropped in the usual fashion as described earlier. The DVC is suture-ligated with a 2-0 polyglactin suture on a CT-1 needle.

Attention is now returned to the posterior dissection. With the uterus anteverted, a transverse incision of the posterior vaginal fornix is completed at the previously scored site. The vaginal incision is extended distally on either side of the urethra, excising a narrow central strip of vagina en bloc with the bladder specimen. Using a perineal approach, the external meatus and distal urethra are circumferentially cored out using electrocautery. The urethra is then resected along with the bladder, the anterior two-third portion of the vagina, the uterus, and the ovaries. The specimen is entrapped in an Endo Catch bag and extracted through the vulva (Fig. 28.5). A minipad is placed in the vulva to minimize the loss of CO2 and the pneumoperitoneum is maintained by a high-flow insufflator. These allow for vaginal reconstruction using 2-0 V-Loc sutures on a CT-1 needle via robotic technique before proceeding with urinary diversion.

If a urinary orthotopic neobladder reconstruction is planned, the distal urethra must be preserved (Fig. 28.5). Thus, the urethra must be carefully dissected and sectioned allowing for a sufficiently long stump for neobladder-urethral anastomosis. In these cases, it is recommended to pad the remainder of the vagina with the omental patch positioned between the neobladder and the vagina to prevent urinary fistula formation.

Although the extent of lymphadenectomy is debatable, it is noteworthy that not only the lymph node yield but also the quality of resection, including skeletonization of the arteries is important (16).

Also relevant is the ligation of the larger lymphatic vessels to prevent formation of lymphocele or chylous ascites, and care must be taken to avoid cutting into any enlarged lymph nodes to minimize the risk of tumor spillage. We perform lymph node dissection after the robotic cystectomy. The landmarks (template) for superextended lymphadenectomy are distally the lymph nodes of Cloquet, laterally the genitofemoral nerve, medially the perivesical fat, and proximally the inferior mesenteric artery (IMA). Therefore, the anterior surface of the aorta and vena cava up to the IMA, along with the para-aortic, preaortic, interaortocaval, precaval, and pericaval lymphatic fatty tissue/nodes, are excised. The aortic bifurcation and the presacral area are also dissected (17). The technique mimics the “split-and-roll” technique used during ORC. Right lymphadenectomy is performed first. Using the 30-degree camera lens, the lymphadenectomy begins distally with the dissection of the lymph nodes of Cloquet. It then continues proximally toward the bifurcation of the aorta up to the IMA (Fig. 28.6A). To obtain a good dissection of the obturator fossa, lateral dissection is necessary up to the external iliac vessels allowing for direct visualization of the obturator nerve (Fig. 28.6B). The right ureter should be dissected cranially to avoid inadvertent proximal damage. The lymphadenectomy then continues in the left pelvic region, which is initially performed from proximal to distal (aorta to iliac vessels), as opposed to the technique on the right side. The mesosigmoid is retracted laterally to the left allowing lymphadenectomy of the left internal iliac vessels and presacral region. This maneuver facilitates the creation of a “window” below the sigmoid colon for later transposition of the left ureter to right during ureteral bowel anastomosis (Fig. 28.7). The remainder of the left pelvic lymphadenectomy is performed in the same fashion as the right lymphadenectomy. The sigmoid colon is now retracted to the right and the dissection begins distally and continues proximally toward the already skeletonized internal iliac vessels. The removal of the lymph nodes occurs in packets, according to the templates, and the nodes are placed in the appropriate bag at the time that each region is dissected, as this may influence the number of lymph nodes removed (18).

For the urinary ileal conduit (IC), a stoma site is marked prior to RARC for all patients by an enterostomal therapist in a location separate from the patient’s skin folds or bone eminences (21). The technique for the intracorporeal robotic IC replicates the open procedure with a few minor modifications (7). A 15-cm ileal segment 15 cm proximal to the ileocecal valve is isolated using two applications of 60-mm laparoscopic staples; the isolated segment is then dropped posteriorly. Ileoileal continuity is restored with a side-to-side anastomosis using the Endo GIA stapler, as described earlier for the ileal neobladder. The mesenteric window is closed with interrupted suture. The proximal end of the conduit is closed with a 3-0 Vicryl running suture to exclude the staples, avoiding their contact with urine/mucus and preventing stone formation. The distal ends of the ureters are spatulated and two separate anastomoses are performed over 7Fr double-J ileoureteral stents using interrupted sutures as described earlier. The stoma is then fashioned for IC maturation. With Allis forceps, the assistant holds and pulls out the distal part of the IC. The staple line of the distal part of the ileal segment is resected and the IC is matured in the previously marked location on the patient’s skin. The ports are then closed and the drain is placed as previously described for the neobladder.