The extraperitoneal space at this point only needs to be expanded a bit in order to appear identical to the standard open retropubic space that surgeons have grown accustomed to over the last decades. It is worthwhile to spend several minutes dissecting through areolar tissue until the entire pubis and midline symphysis are clearly identified (Fig. 6.6a, b show the area first as it looks on removal of the balloon and subsequent insufflation, then after the areolar tissue has been cleared away). It then helps to defat the area as well until the endopelvic fasciae are visible (Fig. 6.6c). The superficial dorsal vein is usually apparent as fat gets dissected off of the anterior prostate and it should be taken with electrocautery. The fat overlying it generally ramifies along with its proximal branching to the right, left, and center over the prostate toward the bladder, but with bipolar diathermy these branches can easily be taken and the fat and superficial dorsal venous complex removed to better expose the prostate. We have in recent years been sending this fatty tissue for pathologic analysis as a minority of patients (5–15 %) will have periprostatic lymph node(s) contained within.

Flimsy tissues overlying the external iliac vessels and spermatic cords should then be incised to facilitate easy access to the pelvis for the assistant and fourth robotic arm. Any inguinal hernias or herniated fat that are in the way should be reduced. Finally, identification of important landmarks should ensue, the puboprostatic ligaments and endopelvic fasciae for the prostatectomy, and the external iliac veins (EIV) and obturator nerves for men who will be receiving pelvic lymph node dissection (PLND). It is particularly important to make sure to assess the position of the right EIV in comparison to the right assistant port, and ideally to advance that port past the vein such that instruments that are placed through the port do not risk traumatizing it.

We prefer to perform the PLND prior to the prostatectomy, though it certainly can be accomplished subsequent to the mobilization of the prostate. In either case, preparation for PLND involves identifying the EIV and obturator nerves. The former can usually be found, even if there is much fat overlying them, by looking for venous waveforms just above the pelvic brim. Once found, the fascia overlying the EIVs must be incised and the sidewall accessed under the veins. The assistant’s suction device can be placed in this space while the operator dissects the nodes off the EIV and looks for the obturator nerve. If not obviously under the EIV it can often be found by looking for the obturator foramen which often has a fat plug in it. The nerve courses through the foramen and out of the pelvis by hugging the foramen superolaterally; once it is found the nodal packet under the EIV and above the obturator nerve should be clipped distally and handled with the ProGrasp for dissection as proximally as indicated. A standard PLND can certainly be performed in this space, taking all level I and II nodes, as the bifurcation of the iliac vessels is reachable (as in open radical prostatectomy which, as mentioned, is performed in the same space and with the same limitations). With the ProGrasp holding the nodes anteriorly, two arms remain for dissection, cautery, and retraction (Fig. 6.7). In addition, the wrist of the arm on the side of the PLND can be used to hold back pre-peritoneal fat if it gets in the way, while still allowing the instrument to be used as a grasper/dissector. Extended PLND depending on the definition may or may not be able to be performed, as presacral nodes are not reachable without mobilizing the bladder more than can be done extraperitoneally; a 30° lens may be used to facilitate deeper and more medial dissections at the internal iliac artery(ies) and vein(s). In any case, we favor using Hem-o-lok™ clips (Weck, Teleflex, Limerick, PA) to secure lymphatic pedicles, rather than bipolar cautery or suction whenever possible. A harmonic scalpel is also a great tool for PLND and for sealing small lymphatics, but is certainly not necessary. The nodes are typically extracted after the dissection, through the 12 mm assistant port (Fig. 6.8), though they can also be left in their location for later extraction with the prostate specimen. A drain should be placed at the conclusion of the case whenever PLND is performed, particularly when confined to the extraperitoneal space.

The subsequent steps can be performed in much the same manner as a radical prostatectomy would be done in open retropubic fashion or in transperitoneal laparoscopic/robotic fashion. The order of the steps and the tools used may differ, but fundamentally the retropubic potential space, once expanded, allows for a comparable retropubic view of the cancerous prostate. An advantage to remaining extraperitoneal, or preperitoneal, as in open radical retropubic radical prostatectomy, is that steep Trendelenburg is not necessary prior to docking the robot, although some minor Trendelenburg is helpful. The reason is that the bladder and peritoneum form a natural superior and posterior floor to the operation until Denonvilliers’ fascia is reached, preventing small and large bowel and any prior intra-abdominal adhesions from complicating access to the prostate. The critical aspect of the case that differs from most other approaches and that must be mastered in order to perform successful extraperitoneal radical prostatectomy is identification, dissection and taking of the posterior genital structures the vasa deferentia and seminal vesicles. These are taken after bladder neck transection and not accessed transperitoneally nor retrograde as in open retropubic radical prostatectomy. Nerve sparing on the other hand, may be accomplished antegrade, retrograde, or in a combined manner regardless of the approach to the prostate and is performed as per the preferences of the operating surgeon.