Lymphadenectomy is likely the most difficult portion of RARC for most practitioners to master. While the importance of an extended pelvic lymphadenectomy is debatable for patients with prostate cancer, its importance for patients with invasive urothelial carcinoma is well established. Numerous studies have now demonstrated improved survival with extended lymphadenectomy and adequate nodal dissection templates are vital. Indeed, lymph node yield is perhaps the most commonly utilized marker of surgical quality. Therefore, it is critical for surgeons embarking upon RARC to perform an adequate lymphadenectomy and also demonstrate comfort with the extent and degree of lymphadenectomy necessary for patients with invasive bladder cancer.

As high-volume RARP providers, we found it helpful to extend the boundaries of lymphadenectomy during RARP for patients with intermediate- and high-risk prostate cancer. This allowed more familiarity with handling the pelvic vessels and allowed us to develop safe and efficient techniques for dealing with bleeding situations. Over time, we expanded our RARP practice to routinely include lymph node packets in the obturator, internal iliac, and external iliac regions. We found it useful to begin this dissection posteriorly to the iliac vessels between the lymph node packet and the pelvic side wall. This experience was important in developing and maintaining a program in RARC due to the huge volume discrepancies that exist between RARP and RARC.

Dissection of the seminal vesicles and developing a plane between the prostate and the rectum are essential components of RARP as well as RARC. While we have typically performed the seminal vesicle dissection during RARP from an anterior approach, familiarity with the transperitoneal posterior-based approach to RARP would facilitate the conversion to RARC. Posterior-based approaches to RARP enable surgeons to more accurately identify the vascular pedicles at the time of RARC as well as to perform selective neurovascular bundle preservation during RARC when clinically appropriate. We found it helpful after performing the ureteral dissection and lymphadenectomy with the 30° lens that switching to the 0° lens enabled more caudal dissection between the prostate and the rectum during RARC where it was almost possible to reach the apex of the prostate. This caudal dissection is important during RARC as it decreases the risk of rectal injury and enables easier dissection for the remainder of the procedure. Furthermore, the sheer bulk of a cystoprostatectomy specimen is much more challenging to manage after the bladder has been dropped off the anterior abdomenal wall (we would recommend this as one of the last steps in RARC) than the smaller specimen obtained at the time of prostatectomy. This bulk makes the cystoprostatectomy specimen more difficult to maneuver particularly for residual posterior and rectal attachments.

Developing the space of Retzius and dissection of the apex of the prostate are routine procedures during both RARC and RARP. Surgeons comfortable with RARP should be able to transition these skills easily to RARC. Differences do exist, in part due to location of the tumor and the possibility of extravesical disease that make comfort with this portion of the procedure important. Specifically, surgeons must be comfortable with subtle modifications of the anterior dissection to ensure a negative surgical margin, even in patients with anterior-based T3 tumors. Furthermore, apical dissection remains important (particularly in the setting of orthotopic urinary diversion), though surgeons comfortable with control of the dorsal venous complex and apical prostate dissection should be able to transfer this to their expertise expeditiously. Unlike in prostatectomy it is important to prevent urine spillage. For this we recommend that after the prostate apex has been carefully dissected that the urethra be identified so that a large Hemo-o-lok^® polymer clip (Teleflex, Limerick, PA) or stapler can be used to ensure a hermetic seal and prevent possible tumor or urine leakage after removal of the Foley catheter.

Just as comfort with lymphadenectomy from a robotic approach is important when starting RARC, familiarity open pelvic lymphadenectomy is important. This experience is critical to define and replicate the landmarks and limits of dissection. Cystectomy surgeons have for years defined the role of extended lymphadenectomy and it is critical not to lose any progress that may influence the outcome from the disease and intervention. Accordingly, lymphadenectomy at a minimum should include the obturator, internal iliac, external iliac, and distal 1/3 of the common iliac. We recommend that extended pelvic lymphadenectomy be performed as the new standard to include all lymphatic tissue including the common iliacs, proximally to the aortic bifurcation and pre-sacral tissue as well [11]. An important landmark that we use to limit the cranial aspect of the dissection is the take off of the inferior mesenteric artery (IMA).