We routinely perform PLND as the very first step of RARC as it allows the identification and preparation of the principal anatomical landmarks (ureters, vas deferens, hypogastric and vesical vessels) and sets-up the cystectomy part of the procedure. By lifting up umbilical ligament, bladder can be easily translated ensuring better exposure of iliac and obturator areas.

An extended or super-extended template is adopted (Fig. 68.2). From an oncological point of view we are keen to remove all lymph nodes with an en-block fashion trying to avoid any nodal incision and manipulation in order to avoid disease spread during the procedure.

Ureters are bilaterally identified at their crossing on the iliac vessels and carefully dissected towards the bladder. It is mandatory to handle ureters with care and to prevent the excessive skeletonization in order to preserve vascular integrity and therefore avoiding the dreaded risk of ureteral stenosis at follow-up. For oncological reasons the section of the ureters should always performed through 2 hem-o-lok clips (Weck Surgical Instruments, Teleflex Medical, Durham, NC, USA) and the most cranial clip has a pre-placed tie, which will facilitate subsequent handling of the ureters. Intraoperative frozen section of distal ureteric-margin is always performed.

Prior to the bladder “take down” (Retzius space opening), the posterior space dissection allows the preparation of vesico-prostatic pedicles and the development of the recto-prostatic space. A transverse peritoneal incision at level of Douglas will lead to seminal vesicle and prostatic base dissection reaching the recto-urethralis muscle. Vesico-prostatic pedicles are commonly transected by the assistant using vessel-sealer devices (Fig. 68.3a, b). In case of nerve-sparing procedure an antegrade, energy- and traction-free approach is performed as commonly adopted during radical prostatectomy.

In female patients, a transvaginal-retractor facilitates the dissection of the recto-vaginal plane. A transvaginal extraction of the specimen (Fig. 68.3c) is performed in case of ICUD. In case of a sexual-sparing approach the ovaries, fallopian tubes, uterus, and cervix, and most of the vaginal wall may be completely spared (Fig. 68.3d).

Once the cystectomy part has been completed, the robot is undocked and the Trendelenburg position is minimized. Bowel manipulation should be performed with caution, avoiding direct grasping with robotic instruments. Pro-grasp forceps and needle driver can exert extremely high-force leading to direct or delayed intestinal lesion or mesentery bleeding. A coordinated work with the assistant is necessary, in order to reduce tensions through the synchronous use of two atraumatic Johan Grasping and Cadier robotic forceps. The left ureter is generally passed below the sigmoid. A 20 cm long ileal segment is isolated (Endo-GIA 60) and ileo-ileal side-to-side anastomosis (Fig. 68.4a) is obtained (Endo-GIA 60 + 45). Some author described near infrared fluorescence after injection of indocyanine green [8] or lighting from urethra with cystoscope [4] in order to obtain a better visualization of the mesenteric vascular arcade. Ureters are spatulated for 1.5–2 cm and catheterized with Single-J inserted percutaneously. An “head-to-head” (Wallace I) uretero-ileal anastomosis (Fig. 68.4b) is performed after extraction of single-J through the isolated bowel tract. Ileocutaneous-stoma is performed only after the final decompression of pneumoperitoneum (Fig. 68.4c).