EP approach

A 3-cm subumbilical incision was made. The abdominal fascia was exposed and incised, and digital development of the space of Retzius was performed. “Air docking” was performed by placing a GelPOINT Mini into the EP space with the SP trocar (Fig. 1A). Before docking the SP robot, the patient was placed in <10° of Trendelenburg position. An 8-mm AirSeal^® (CONMED, Utica, NY) assistant port was placed under direct vision, taking care to avoid the epigastric vessels. Once docked, the space of Retzius was developed followed by opening of the endopelvic fasciae.

Intraoperative images of the single-port EP approach. (A) Initial view of the retropubic space after digital development and “air docking.” (B) Electrocautery dissection of the dorsal venous complex. (C) Anterior dissection of the vasa deferentia and seminal vesicles bilaterally. (D) Vesicourethral anastomosis. EP = extraperitoneal. Color images are available online.

The dorsal venous complex and puboprostatic ligaments were divided with electrocautery (Fig. 1B), and the anterior bladder neck was opened. The Foley catheter was grasped and brought midline, followed by posterior bladder neck dissection. The vasa deferentia and seminal vesicles were approached anteriorly and dissected bilaterally (Fig. 1C). The Foley catheter was retrieved and placed on tension. The posterior bladder neck was divided, and the prior seminal vesicle and vas dissections were reached. These structures were anteriorly lifted, and Denonvilliers' fascia was dissected from the posterior prostate.

Prostatic pedicles were controlled with either electrocautery or clips. Neurovascular bundles were dissected in an antegrade manner, and the urethra was transected at the apex of the prostate. Running 3-0 V-Loc suture (Medtronic, Minneapolis, MN) was utilized to accomplish vesicourethral anastomosis, taking full-thickness bites of the urethral stump and bladder neck (Fig. 1D). Cooper's ligament, the obturator nerve, and the external iliac vein were utilized as boundaries of dissection for bilateral pelvic lymph nodes. All specimens were extracted using an entrapment sac at the SP trocar site.