Description of procedure RP 3/20/2018

FINDINGS AND TECHNIQUE:The patient was taken to the operating room where he was placed under general anesthesia in the supine position. He was then placed in low lithotomy position,prepped and draped in the usual manner for a robotically-assisted radicalprostatectomy. The abdomen was entered through a periumbilical incision and adouble balloon 12 mm port was placed here. The abdomen was insufflated. The other five port sites were marked off and placed under direct laparoscopic vision. The robot was docked and the procedure was begun from the console.We began the procedure by releasing large bowel adhesions on the left side of the abdomen. This was done with cold sharp dissection. The space of Retzius was then developed by dividing the median umbilical ligaments bilaterally as well as the urachus. Both vas were divided as they entered through the internal ring. Once the space of Retzius was fully developed, the endopelvic fascia was opened close to the prostate. The dorsal vein complex was suture ligated with 0 Vicryl over the baseof the gland and then divided with the bipolar cautery over the bladder neck.A bilateral pelvic lymph node dissection was then done (obturator and hypogastric)including deep pelvic nodes on the left side. All longitudinal lymphatics were clipped or sealed.Bladder neck was dissected out anatomically and divided. We went wide anteriorly and obtained a negative frozen section here.Seminal vesicles and vas deferens were then identified, mobilized, dissected up and elevated. Denonvilliers fascia was then opened posteriorly and I dissected between the layers of Denonvilliers fascia all the way to the apex. The vascular pedicles to the prostate were taken with the ENSEAL device and large clips as we got close tthe neurovascular bundles. The bundles were well preserved bilaterally. Small metal clips were used as we worked under the posterior aspect of the prostate. An element of high lateral release was done, but I was not aggressive about getting too close to this capsule. I specifically went wide at the left apex to avoid capsularincision. As I dissected along to the apex I noted excellent neurovascular bundle sparing bilaterally.The dorsal vein complex was then isolated and taken with the ENSEAL device. The DVC was oversewn with a V-lock suture. The urethra was divided with cold sharp dissection. The prostate was put into a specimen bag.The anastomosis was then done in a two layer fashion using a Rocco suture toapproximate the urethra posteriorly. This was a single horizontal mattress.Continuous 3-0 Monocryl was then used employing a Quill suture to achieve awatertight anastomosis. The bladder neck was tapered with 2-0 Vicryl. Theanastomosis was sealed with Eviseal and stented with an 18-French Foley catheter. A Blake drain was placed in the abdomen through the fourth arm port. This was secured with silk.Marcaine was used to block all port sites.The right-sided 15 mm port was closed at the fascial level with 2-0 Vicryl. The prostate was removed in its bag through the umbilical port. The umbilical port sitwas closed with continuous #1 PDS in the fascia. All skin incisions were closed with Monocryl and Dermabond. The patient was awakened and taken to the recovery room in good condition. Estimated blood loss for the case was 100 mL. Sponge and needle counts were correct x 2.