Volume 27, Issue 4, Pages 199-207 (December 2016) Standardized procedure of robotic assisted laparoscopic radical prostatectomy from case 1 to case 1200  Sheng-Chun Hung, Yen-Chuan Ou, Chen-Li Cheng, Siu-Wan Hung, Hao-Chung Ho, Kun-Yuan Chiu, Shian-Shiang Wang, Chuan-Shu Chen, Jian-Ri Li, Chun-Kuang Yang  Urological Science  Volume 27, Issue 4, Pages 199-207 (December 2016) DOI: 10.1016/j.urols.2016.11.007 Copyright © 2016 Terms and Conditions

Figure 1 Fig. 1-1 demonstrate Steep Trendelenburg position with a supine position, legs separated and arms tucked to the sides. Fig 1-2 shows the trocar mapping of the transperitoneal approach with six ports. Port 1–4 are for robotic-arms (port 2, 3 and 4 for 8mm robotic arm) and port 5–6 (port 5 for 12mm assistance trocar and port 6 for 5mm assistance trocar) for assistance port. Port 1 is a 12mm camera port and placed at supraumbilicus. Port 2 and 3 were placed 8cm lateral to camera port and port 4 and 5 were placed about 7 cm lateral to port 2 and 3, respectively. Port 2 with robotic instrument: EndoWrist ® Instrument: Hot Shears™ (Monopolar Curved Scissors); Port 3 with robotic instrument: PreCise™ Bipolar Forceps; Port 4 with robotic instrument: ProGrasp™ Forceps. When doing suture for anastomosis, ports 2 and 3 were shifted to robotic instrument: large Needle Driver.15 Urological Science 2016 27, 199-207DOI: (10.1016/j.urols.2016.11.007) Copyright © 2016 Terms and Conditions

Figure 2 Magnetic resonance imaging (MRI) with 3.0-Tesla magnet and a slice thickness < 3.0mm was used for evaluation of tumor status (tumor location, image staging, anatomic structure and lymph node metastasis). Fig. 2-1 revealed a patient with a significant protrusion prostate and left lobe predominant. Fig. 2-2 further informed the significant protruding median lobe. All of these are helpful information when doing bladder neck dissection. Urological Science 2016 27, 199-207DOI: (10.1016/j.urols.2016.11.007) Copyright © 2016 Terms and Conditions

Figure 3 In most of the cases, after entering the rise high of peritoneal reflection which indicated the tip of the seminal vesicle was covered behind, we first do dissection at right seminal vesicle. Fig. 3-1 shows the robotic arm doing traction at the right seminal vesicle, facilitating the countertraction and the arteriole to the seminal vesicle tip as isolated and ligated. Fig. 3-2 after the bilateral seminal vesicles were free, the left side was grasped by the fourth robotic arm and the right side was held by an assistant, where both were outstretched and lifted. Then, a posterior dissection was performed and Denonvillier's fascia is separated posteriorly from the prostatic fascia. Urological Science 2016 27, 199-207DOI: (10.1016/j.urols.2016.11.007) Copyright © 2016 Terms and Conditions

Figure 4 Fig. 4-1 from the right side the prostate was retracted medially by a robotic arm. A sharp incision was made without the thermoelectric source and towards the prostate base, then, turned from the cranial side to the caudal side. The endopelvic fascia was entered and levator ani fascia was separated from the lateral pelvic fascia without damage. Fig. 4-2 shows the left side with emphasis on the well countertraction forced by the robotic arm, which push the prostate medially. With a sharp dissection, the levator ani fascia and lateral pelvic fascia were separated, respectively. Urological Science 2016 27, 199-207DOI: (10.1016/j.urols.2016.11.007) Copyright © 2016 Terms and Conditions

Figure 5 Fig. 5-1 the lens of the scope was switched 30 degrees downward facing the vesicoprostatic junction and bladder neck. Tenderly pinching the muscle of the bladder neck with blunt robotic instruments, the prostate is trapped on both sides and pulled proximally. Under such a condition, the vesicoprostatic junction could be easily identified. Fig. 5-2 after well identification of the bladder neck, an anterior dissection of the bladder neck was meticulously performed until Foley's catheter was well recognized. Fig. 5-3 Foley tip was extracted and tilted, then traction force was put in place. The retrotrigonal muscle layer was identified, an incision made and the seminal vesicle was popped out and lifted. Urological Science 2016 27, 199-207DOI: (10.1016/j.urols.2016.11.007) Copyright © 2016 Terms and Conditions

Figure 6 A bilateral intrafascia dissection for maximum preservation of the neurovascular bundle was done in a low risk patient. Fig. 6-1 at the right side after ligation of the prostate pedicle vessels, an incision between the prostate fascia and prostate capsule anteromedially was made. The prostate was pushed medially to facilitate countertraction and the right plain was entered. Fig. 6-2 at the contralateral side, the prostate was pushed medially and a sharp incision at the same plain was performed. The lateral pelvic fascia and prostate fascia were left intact with the neurovascular bundle preserved. The prostate capsule is shown smoothly and intact. Urological Science 2016 27, 199-207DOI: (10.1016/j.urols.2016.11.007) Copyright © 2016 Terms and Conditions