Step 1: Incision of the Peritoneum and Entry into the Space of Retzius

A transverse peritoneal incision is made through the median umbilical ligament and extended on both sides in an inverted U fashion to the level of the vasa deferens laterally. The fourth arm provides countertraction for this step. The peritoneum is dissected down to the pubic tubercle, which is the anatomical landmark used to follow the pubic rami lateral and horizontally so as to not produce inadvertent injury to epigastric vessels above the rami. It is important to dissect the peritoneum all the way up to the base of the vasa for optimum release of the bladder to allow a tension-free vesicourethral anastomosis.

Step 2: Incision of the Endopelvic Fascia (EPF) and Identi cation of the Dorsal Venous Complex (Figs. 54.7 and 54.8)

The important landmarks are bladder neck, base of the prostate, levator ani muscles, and apex of the prostate. After defatting the prostate, the fourth arm is used to retract it contralaterally so as to provide adequate exposure and tension on the EPF. The EPF is opened (with blunt dissection) toward the base of the prostate and then followed toward the apex of the prostate to nally identify the dorsal venous complex (DVC) and the notch where the dorsal ligation and suspension stitch will be placed. This step is performed using cold scissors and taking extra caution in identifying any accessory pudendal arteries that may travel along the EPF. Proceeding from the base to the apex, the bers of the levator ani are dissected off the prostate with the round edge of the scissors until the DVC and urethra are visualized. Use caution when dissecting and cutting the pubo-prosatic ligaments because if carried out too medially it will de nitely lead to injury of the DVC and unnecessary bleeding. Full dissection of the apex is best performed at the end of the procedure.

Step 3: Ligation of the DVC (Figs. 54.9–54.12)

We use Caprosyn 1 on a large CT1 needle. The needle is held two-third back at a 45° angle and placed in the notch between the urethra and DVC. The needle is pushed straight across at 90° and then the wrist is turned to curve around the apex of the prostate. At this point we prefer to use the slip knot to tie as it prevents the suture from loosening as it is tied. A second suture is then placed to suspend the urethra to the pubic bone and secondarily ligate the DVC. The DVC is encircled and then stabilized against the pubic bone along with the urethra (Fig) 22.

Step 4: Anterior Bladder Neck (BN) Dissection (Figs. 54.13 and 54.14)

The scope is changed to a 30° down-facing lens for the BN dissection. Although some authors use 0° scope throughout the case, we believe that this angled lens is optimal to see inferiorly and to visualize the correct planes. Key points here to correctly identify the BN is identifying where the bladder fat ends on the prostate in the form of an inverted “U” (Fig. 14.​4); another trick is to pull on the Foley catheter and visualize the balloon as it reaches the base of the prostate. However, although useful, this can be misleading in patients with prior transurethral resection of the prostate (TURP) or in the presence of median or anterior lobes. The robotic arms also provide a moderate amount of visual feedback to facilitate localization of the boundaries (double-pinch maneuver). This step is begun by cauterizing the superficial veins that are located in the midline with the bipolar forceps. Then the bladder is dissected off the prostate in the midline using a continuous sweeping motion of the monopolar scissors and traction with the bipolar forceps while visualizing the bladder fibers. The key is to stay in the midline to avoid lateral venous sinuses until the anterior bladder neck is opened and the Foley catheter visualized. Once the anterior urethra is divided, the Foley catheter is retracted out of the bladder using the fourth arm, in an upward manner to expose the posterior bladder neck.

Step 5: Posterior Bladder Neck (Figs. 54.15 and 54.16)

The posterior BN dissection is generally considered to be the most challenging step of the operation for the novice robotic surgeon. The difficulty is in appreciating the posterior tissue plane between the bladder and prostate and the direction and depth of dissection necessary to locate the seminal vesicles. After incising of the anterior BN, any remaining peripheral bladder attachments should be divided to atten out the area of the posterior bladder neck and allow precise visualization and dissection of the posterior plane. The full thickness of the posterior bladder neck should be incised at the precise junction between the prostate and the bladder. The lip of the posterior BN is then grasped with the fourth arm and retracted upward. The bipolar forceps is then used for traction thus visualizing the correct plane between prostate and bladder. The dissection is directed posteriorly and slightly cephalad (toward the bladder) to expose the seminal vesicles. It is important to avoid dissecting caudally (toward the prostate) as there is a possibility of entering the prostate and missing the seminal vesicles completely.

Step 6: Seminal Vesicle (SV) Dissection (Fig. 54.17)

Once the posterior BN dissection is complete, the vasa and SVs can be identified. The thin fascial layer over the SVs and vasa should be opened to free the structures for retraction. The fourth arm is used to retract the left vas superiorly and laterally. Dissection continues on the medial side of the vas due to the inexistence of vessels in this area, until the tip of the left SV is venous complex. (e) Second pass through the dorsal venous complex and the periostium on the retropubis. (f) The final stitch is tied. (Reprinted with permission from Patel et al.) reached. When this occurs it is grasped and retracted with the fourth arm elevating it away from the neuro structures that lie beneath (hypogastric plexus). The vas is then clipped with a 10 mm hem-o-lock followed by clipping of the vessels of the tip of the SV. Then the SV is dissected completely to the base. This procedure is carried out similarly on the right side.

Step 7: Denonvilliers’ Fascia and Posterior Dissection (Fig. 54.18)