Our lens preference is a 0° lens at the outset. The monopolar scissors (right hand) and bipolar grasper (left hand) are the primary working instruments at this stage. The ProGrasp™ forceps is used with the fourth robotic arm for grasping and retraction of tissues. The electrocautery generator settings used throughout the operation are 35 W for both monopolar and bipolar electrocautery. Once abdominal access is achieved, inspect the peritoneum for bowel adhesions and identify the internal inguinal rings, urachus, and the medial umbilical ligaments. Lyse adhesions as is necessary. We also prefer to mobilize the sigmoid colon so that it is fairly mobile. On occasion, the sigmoid is bunched and adhered to the peritoneum posterior to the bladder. We always mobilize these attachments as the colon in this position may greatly limit the working space in the pelvis once the bladder is dropped.

We prefer the anterior transperitoneal approach and thus drop the bladder to enter the space of Retzius as our initial step of the operation. Incise the peritoneum just lateral to the medial umbilical ligaments and carry the dissection laterally to the level of the vas deferens. We prefer to keep the incision just medial and anterior to the internal inguinal ring. Keep the incisions superficial so as not to injure the epigastric vessels. The assistant can use the suction device to prevent camera fogging by evacuating smoke during this dissection. Bladder irrigation via the urethral catheter can help define the limits of the bladder; however, incisions created lateral to the medial ligaments obviate the likelihood of bladder injury. Carry the incisions medially and anteriorly until they are joined at the midline at the urachus, which is then divided. We prefer to incise as cephalad as possible to avoid redundant tissue obscuring the view of the camera throughout the case. As the bladder flap is created, the whitish fibers of the transversalis fascia come into view. Follow these fibers caudally; once these thin out, follow the contour of the abdominal wall inferiorly until the pubis is seen. Clean the pubis of connective tissue. We thoroughly sweep all periprostatic fat toward the midline. This move also cleans off the endopelvic fascia. The superficial dorsal vein is usually contained within this fat; use bipolar electrocautery to seal this vessel. After the vein is divided, roll the fat away from the apical portion of the prostate toward the base. We excise the large fat bundle and send it for pathologic examination due to the possible presence of lymph nodes that may harbor metastatic disease [3].

Sharply incise the fascia laterally so that the underlying prostate and levator muscles are seen (Fig. 17.4). We prefer cold sharp incision with scissors; this prevents the “jumping” of the pelvic floor muscles that can be seen with electrocautery. Initiate this incision in the region of the prostatovesical junction and then carry it toward the apex of the prostate. This helps avoid bleeding from the vessels that are consistently present at the prostatic apex. We prefer to create a small separation of the levator muscles from the prostate; too much separation at this point is not necessary and may lead to inadvertent injury of the neurovascular bundle (NVB). Inferolateral to apex of the prostate, a band of muscle is often present that usually encases a vein, artery, or both. Using a small amount of bipolar electrocautery to seal these vessels prior to incising this tissue close to the prostate can limit blood loss and as such preserve visibility (Fig. 17.5). To better define the dorsal venous complex (DVC), we coldly incise the puboprostatic ligaments. With the prostate apex clearly in view, thin the fascia overlying the lateral aspect of the DVC in order to better define the junction between the vein and the urethra.

The DVC can be handled by one of several methods; the most common methods are suture ligation or stapling. If suturing is to be performed, a 0-Polyglactin or PDS suture on a CT-1 needle is typically used to place a figure of eight around the DVC. We have used a figure-of-eight suture that is pexed into the pubic periosteum. This helps elevate the urethra after division of the prostatic apex which helps to visualize the urethra during the anastomosis and may be associated with recovery of urinary continence. Often, a back-bleeding suture is also placed toward the prostate base. Once tied, the DVC can be divided at this point, but many surgeons leave this intact temporarily until the urethra is approached later during the case. Alternatively as of late we have on occasion cold cut across the DVC and then used a 3-0 V-lok suture to oversew the bleeding vessels after all vascular structures are divided. Some theorize that this may help limit compression damage that the pre-placement of a suture may create.