The guiding surgical principles of robotic surgery are deeply rooted in the enhanced visual imagery and unique vantage point afforded by the da Vinci^® Surgical System. This advantage allows for performance of an anatomical operation at the macroscopic and subfascial levels. Like conventional radical prostatectomy, the goals of robotic prostatectomy are complete cancer excision while preserving urinary and sexual function. Ideally, these goals are achieved by precise identification of key anatomic landmarks and minimizing injury to vital structures.

The robotic prostatectomy technique currently performed at the Urology Center of Florida embodies several important technological innovations, many of which were pioneered and or refined at our institution, including:

• Extraperitoneal Approach. When feasible an extraperitoneal technique with balloon dissection of the retroperitoneal space is used to access the surgical site, otherwise a conventional transperitoneal approach is employed. This technical modification shortens operative time, maintains natural compartmentalization of peritoneal cavity, alleviates need for bowel retraction, improves exposure and minimizes bowel related complications.
• Pubovesical Complex “Bunching”. The pubovesical complex, composed of the pubovesical ligaments and underlying ventral vascular complex, is managed using a “bunching” technique. Once the endopelvic fascia has been opened several millimeters lateral to each fascial tendinous arch, the pubovesical complex appears as a swath of tissue over the anterior surface of the prostate and forms the basis for surgical bunching or bundling of the pubovesical ligaments and underlying vessels into the midline to improve prostate exposure and facilitate hemostasis. This step greatly facilitates identification of the prostatovesical junction and preservation of the bladder neck and proximal prostatic urethra as well as release and preservation of the neurovascular bundles.
• Dorsal Venous Complex. Facilitated by pubovesical bunching the dorsal venous complex is controlled with a single figure of eight horizontal mattress suture placed just distal to the pubovesical ligaments and prostate apex. Placement of the suture distal to the pubovesical ligaments perfects compression of the ventral vascular plexus and improves hemostasis while minimizing manipulation and distortion of the striated urethral sphincter complex.
• Bladder Neck and Proximal Urethra Preservation. Aided by the pubovesical bunching, the bladder neck dissection is initiated laterally, where the convexity of the posterolateral aspects of the prostate are easily discerned. This convexity is traced cephalad and medial allowing identification of the natural tissue plane between the prostate and bladder. Just distal to this site, the overlying pubovesical fascia is incised sharply and a plane is initiated between the prostate base and bladder. The remaining detrusor muscle fibers are gently separated from the prostate base thereby exposing the proximal urethra. The dissection is continued circumferentially in the subcutaneous tissue plane surrounding the urethra as it funnels into the concavity of the prostate base. To the extent possible, considering prostate size, shape, and configuration, the bladder neck and approximately 1 to 1.5 centimeters of proximal urethra are preserved intact. Preservation of these critical structures alleviates the necessity to reconstruct the bladder neck and significantly shortens the time to urinary continence.
• Neurovascular Bundle Preservation. Articulated robotic scissors are used to divide the lateral pedicles adjacent to the prostatic base and the incise lateral pelvic fascia anterior and parallel to the neurovascular bundles. The plane of dissection is extended from prostatic base to apex releasing the neurovascular bundles from the posterolateral surface of the prostate. The use of articulated scissors and the avoidance of thermal energy minimizes damage to the neurovascular bundles and improves preservation of sexual function.
• Apical Dissection. Precise apical dissection and urethral incision are performed with robotic scissors. The bunched pubovesical complex is incised tangentially on the surface of the prostate just proximal to the prostatourethral junction preserving the anterior fixation of the striated urethral sphincter to the pubis. The distal urethra is gently dissected away from the apex of the prostate, preserving approximately 1 to 1.5 centimeters of circumferentially intact urethra. These two technical modifications enhance complete cancer excision, minimize manipulation of the striated urethral sphincteric complex and facilitate reconstruction.
• Urethrourethral Anastomosis. The urethrourethral anastomosis with mucosa-to-mucosa approximation is accomplished with a running double-armed stitch with one intracorporeal knot. This technical modification decreases the operative time, allows for a “water-tight” closure and facilitates early catheter removal and return of urinary continence.
• Pubovesical Ligaments and Fascia Re-Approximation. The proximal and distal ends of the incised pubovesical ligaments and fascia are re-approximated using a running, laced, double-armed stitch with one intracorporeal knot. This innovation restores the normal anchoring of the urethra and bladder to the pubis, reduces tension on the urethrourethral anastomosis, promotes normal bladder neck (internal urinary sphincter) coaptation and improves the preservation and early return of urinary continence.

These technical modifications along with their consistent application have had a direct impact on complete cancer excision, preservation of sexual function and early return of urinary continence.

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