Robotic-Assisted Laparoscopic Prostatectomy for High-Risk Prostate Cancer: Technical Considerations and Review of the Literature

Table 1

Technical considerations for RALP with extended pelvic lymph node dissection in high-risk patients.

Division of lateral physiologic adhesions of rectum and sigmoid to left pelvic side wall, facilitating elevation of bowel out of pelvis.
Posterior approach begins with perneotomy and dissection of seminal vesicles under direct vision.
Incise Denonvillier’s fascia under elevated seminal vesicles and establish safe plane between prostate and rectum.
Mobilize bladder and incise peritoneum to level of vas deferens bilaterally to facilitate extended pelvic lymph node dissection.
Consider extrafascial or modified nerve sparing with medial endopelvic fascia incision to balance oncologic control with quality of life outcomes.
Err towards bladder while opening anterior bladder neck.
Meticulous circumferential dissection of the prostate apex is necessary to avoid positive surgical margins.
Identify ureter crossing over common iliac artery and incise peritoneum to begin extended pelvic lymph node dissection.
Consider placement of metal clips at prostate pedicles and during lymphadenectomy to facilitate targeting of postoperative radiotherapy.