The following maneuvers help to maximize the vision in operative field: Increasing Trendelenburg position. This should be done with all precautions during positioning to prevent sliding of the patient by usage of the gel pads with bean bag and fixing the patient. The usual angle of the table is around 25°, and it may be extended to 30°. After establishing a pneumoperitoneum in overweight patients, the instrument’s path may be obstructed by the pubic symphysis and the pelvic brim due to a more vertical angle. Depressing the robotic arms to prevent the instruments from hitting the pelvic brim can help avoid this. If it is difficult to visualize the bladder neck and posterior sphincter complex, the scope is switched from 30° to 0°. Two instruments are used to retract the fat and the bladder and to prevent fat from falling into the operative field. High flow insufflator (Airseal^® technology) [9] has been a useful new addition to the armamentarium for laparoscopic procedures, reducing the number of episodes of pressure loss <8 mmHg. This helps in maintaining already compromised working space in these populations. Barbed suture has shown to decrease the anastomotic time but did not affect the urinary extravasation or long-term continence rates.

It is not uncommon for a radical prostatectomy patient to have had prior abdominal or inguinal surgery. A large RALP series reported prior history of abdominal or inguinal surgery in 27% of patients [10]. Appendectomy was the most common previous surgery identified (11%); but patients with a previous history of colectomy had the highest incidence of adhesiolysis. They have reported five bowel injuries in a cohort of 3950 patients; of these three patients had a history of prior abdominal surgery [10].

Patients with prior midline laparotomies have unpredictable amounts of adhesions. With prior abdominal surgery, consideration must be given not only to the location of the incision, but also to the procedure that was performed. Anticipating area of likely adhesions in the parietal wall, position of each trocar should be marked. A favorable initial access position that corresponds to an intended trocar site should be determined. The spleen and the left lobe of the liver are almost always above the costal margin. Therefore, in the case of a prior midline incision where there are no other compelling factors to dictate the location of initial peritoneal access, the left upper quadrant is the ideal position for initial access. Patient positioning can be used to take advantage of gravity to shift peritoneal contents away from the region of the initial trocar insertion. In our institute, initial insufflation is done with Veress needle. Then, the first trocar is placed in the right or left upper quadrant by the direct visualization entry method using a transparent port. Very careful attention should be paid to the flow of CO₂ when insufflation is initiated. Once the initial trocar has been placed, all other trocar placement must be under direct visualization, taking care of adhesions. Laparoscopic adhesiolysis is performed to create clear entry points for all trocars. Once the robot is docked, adhesions in the lower abdomen and pelvis can be released robotically (Fig. 20.3).

Prior inguinal hernia repair either open or laparoscopic distorts the operative anatomy during RALP. Despite this, RALP can be performed safely and effectively in these patients [11]. The key is early identification of anatomical landmarks to provide spatial orientation prior to dissecting in the area of hernia repair and scarring. The mesh is often readily apparent during the initial laparoscopy. We begin by dividing the urachus and medial umbilical ligaments. The retropubic space is entered in the midline and the posterior aspect of the pubic symphysis is identified. Dissection deep in the true pelvis is usually unaltered by hernia repairs. The superior pubic rami can be exposed and the dissection continues below this level within the pelvis to expose the endopelvic fascia bilaterally. Hence prior to approaching the region of hernia repair/mesh, several valuable anatomical landmarks have been identified and can be used to maintain correct spatial orientation as the dissection proceeds laterally. The peritoneal incisions are then extended laterally to the medial border of the vas deferens. In this method, prior mesh in place is not disturbed. If the mesh is seen, it is essential to keep the plane of dissection deep to the mesh at all times. In patients with prior laparoscopic preperitoneal hernia repairs, the scarring is typically more extensive. Again the same principles are followed. The midline dissection is usually less affected and the retropubic space and pelvic dissection can be approached in the midline with little difficulty. Again early exposure of anatomical landmarks in the pelvis will provide the necessary spatial orientation prior to dissecting further laterally beneath the mesh (Fig. 20.4a, b).

Several authors have reported various degrees of difficulties both in extraperitoneal and transperitoneal robotic prostatectomy in patients with a narrow pelvis. Two technical issues in patients with a narrow pelvis are decreased intrapelvic working space and clashing of robotic instruments externally. Clashing between the third and fourth arm is common in patients with a smaller BMI and narrow pelvis. A minimum distance of 8 cm will negate the instrument clashing externally. Additional maneuvers of depressing the fourth arm, elevating the third arm, and medially rotating the third arm help to prevent clashing. Further intraoperative clashing can be avoided with experience (Figs. 20.5 and 20.6).

The enlarged prostate offers technical challenges that make radical prostatectomy more difficult regardless of surgical technique. For initial cases, selecting a prostate size of 30–40 g is generally recommended, as a large prostate often occupies much of the pelvis, making maneuverability and exposure of the prostate difficult during dissection. Moreover, there is a tendency for the presence of a coexistent median lobe and increased vascularity with a wide vascular pedicle, further increasing the difficulty and possibly operative time and blood loss. A large prostate also displaces the neurovascular bundle posteriorly, thereby obscuring it from view. These drawbacks can result in significant differences in intra- and postoperative outcomes. Identification of the BN in patients with a large prostate is perhaps the most challenging aspect of the procedure, as the large prostate requires a technically precise dissection in the correct plane to avoid leaving prostate tissue in the bladder. However, defining the BN by traction of an inflated Foley catheter may be misleading in cases of a concomitant median lobe. In this circumstance, the fat insertion line can be reliably utilized for defining the BN, as the bladder fat stops at the prostatovesical junction. The contour of the lateral prostate also provides an additional clue for identifying the BN. By employing gentle compression on the lateral aspect of the prostate with both robotic arms, the prostatovesical junction is revealed as a dimpling point due to the consistency of the prostate. The published results on large prostates are promising, and authors have commonly reported no clinical differences in terms of operative and pathologic outcomes in the robotic era, even though there were trends toward higher blood loss and longer operative time in patients with larger prostates (Fig. 20.7) [12, 13]