Having a dedicated team versed in robotic surgery helps to ensure a smooth and efficient surgery. Preoperative briefings allows for the entire team including the surgeon, circulating nurse, scrub technician, and anesthesiologist to identify the patient and planned procedure as well as verbalize any concerns so that these may be addressed and resolved before beginning the surgery. This includes communication with the anesthesiologist, making them aware of surgical expectations and anticipated challenges such as placement of an orogastric tube, intravenous access, fluid administration, and end-tidal carbon-dioxide monitoring especially with the patient placed in the steep Trendelenburg position.

Once in the operating room, the patient is placed in a supine position. After induction of general endotracheal anesthesia, the patient’s arms are tucked to the sides using two draw sheets and egg-crate padding (Fig. 18.2a–d). To secure the patient’s arms, one draw sheet is left below the arm, while the second draw sheet is held taught against the patient’s abdomen. The arm is placed on an egg-crate padding to provide additional cushion (Fig. 18.2a). The first draw sheet is then brought over the arm and tucked below the patient while using the second draw sheet to slightly lift and roll the patient to aid in tucking (Fig. 18.2b). The second draw sheet is then brought down and tucked under the patient while an assistant gently lifts the ipsilateral hip to aid in securing the second draw sheet. Alternatively, arm sleds padded with egg-crate padding may be used. Finally, the hand and wrist are protected using an additional egg-crate padding, keeping the thumb directed upward (Fig. 18.2c). The patient’s legs are abducted and placed in a gently flexed position on a split leg table to allow for access to the rectum and perineum. The patient’s legs are secured to the split leg supports with egg-crate padding and adhesive tape. Alternatively, yellow fin stirrups may be used; however, docking of the fourth arm can at times be compromised by the relatively wide profile of the stirrups as compared to the more narrow split leg supports. Sequential compression stocking devices are placed on both legs and activated. Fixed shoulder pad supports to prevent the patient from cephalad migration in the Trendeleburg position should be avoided as this can result in compression and neuropraxic injury. Instead, the patient is secured to the operating room table above the xyphoid process with egg-crate padding and a band of heavy cloth tape across the chest or in a criss-cross pattern. A gel pad can be placed beneath the patient to minimize slippage during the steep Trendelenburg position. The patient is placed in steep Trendelenburg and is ready for shaving and prepping (Fig. 18.2d). An orogastric tube is inserted to decompress the stomach and a 16 Fr urethral catheter is placed under sterile conditions so that it can be accessed throughout the surgery by the bedside assistant .

The prostate biopsy pathology is again reviewed on the day of surgery to help guide the intraoperative surgical approach. By mapping the approximate site-specific locations of cancer based upon sextant biopsy findings, a surgeon can begin to formulate a tentative plan for bilateral vs. unilateral vs. incremental neurovascular bundle (NVB ) preservation. If high-risk features (i.e., high-grade disease, high percent core involvement, palpable disease) are present, plans for a non-nerve-sparing approach may be prudent. A digital rectal examination can be performed with the patient now under general anesthesia as this is the best opportunity to examine the prostate, while the patient is fully relaxed. This is the only time during the surgery that the surgeon has true tactile feedback to assess the size, shape, and abnormalities of the patient’s prostate, especially along the posterolateral border adjacent to the location of the NVB .

In total, six trocars are placed transabdominally (Fig. 18.3). The first trocar is a 12 mm trocar for the endoscope and camera and is placed 15–17 cm superior to the pubic symphysis and generally just above the umbilicus. Two 8 mm pararectus trocars are placed 8–9 cm lateral and 2–3 cm caudal to camera trocar on the left and right sides. These accommodate the second and third robotic arms. An additional 8 mm trocar is placed 8–9 cm lateral to the left pararectus trocar in the left lumbar region high above the iliac crest and accommodates the fourth arm of the robot, allowing for intraoperative retraction among other uses. For the surgical assistant, a 12 mm trocar is placed 8–9 cm lateral to right pararectus trocar in the right lower quadrant above the anterior iliac spine at the same level as the pararectus trocars. An additional 5 mm assistant trocar is placed in the right upper quadrant at the apex of a triangle made between the assistant trocar and the right pararectus trocar.