Radical Prostatectomy

Radical prostatectomy removes the entire prostate and seminal vesicles with a vesicourethral anastomosis, and is a curative option for localized prostate cancer. It can be performed open (retropubic or perineal), laparoscopically, or robot-assisted (now the most common); functional and oncologic outcomes are broadly comparable across approaches, so the benefit of a robotic approach is chiefly its minimally invasive nature.

Surgical Anatomy

• Dorsal venous complex (DVC): the retropubic approach lies outside the endopelvic/anterior pelvic fascia, so the DVC (Santorini plexus) must be ligated and the lateral pelvic fascia divided; the perineal approach stays beneath these fasciae and does not divide the DVC.
• Neurovascular bundles (NVB): the cavernous nerves join the capsular vessels ~20–30 mm distal to the bladder–prostate junction, lying between the prostatic fascia and the endopelvic/levator fascia. Correct nerve-sparing is an interfascial dissection that leaves the prostatic fascia on the prostate. Divide the lateral pedicles near the bladder to avoid nerve injury.
• Accessory pudendal arteries (often from the obturator) run along the anteromedial prostate and may be the dominant corporal supply — preserve when possible.
• Striated sphincter: horseshoe-shaped fatigue-resistant slow-twitch fibers at the apex, innervated by the pudendal nerve, responsible for passive urinary control. The pelvic plexus lies on the lateral surface of the seminal vesicles.

Approaches

Approach	Notes
Open retropubic	Allows pelvic lymph node dissection; the standard open route
Open perineal	Less blood loss and shorter operative time (DVC not divided), but no access for lymphadenectomy, higher rectal-injury risk, and ~2% lower-extremity sensory neurapraxia from positioning. Good for prior renal transplant or morbid obesity; contraindicated with hip/spine ankylosis
Laparoscopic / robot-assisted	Robot-assisted is now most common; comparable functional/oncologic outcomes (Coughlin 2018 RCT)

Preoperative Preparation

Defer surgery 6–8 weeks after needle biopsy and 12 weeks after TURP. Hold anticoagulation (aspirin 7 days, clopidogrel 5 days, apixaban 2 days). Antibiotic prophylaxis: a single dose of cefazolin or TMP-SMX (2019 AUA). Use VTE prophylaxis (stockings + heparin) and encourage preoperative Kegel exercises.

Open Radical Retropubic Prostatectomy

Through an extraperitoneal lower-midline incision, with relative hypotension and limited crystalloid until the prostate is out:

1. Pelvic lymph node dissection first — limits: inferiorly the femoral canal/circumflex vein, superiorly the ureter/common iliac bifurcation, medially the bladder, laterally the pelvic sidewall, posteriorly the obturator nerve. The internal iliac (hypogastric) nodes have the highest positive rate; preserve the lymphatics over the external iliac artery to avoid lymphocele/leg edema.
2. Incise the endopelvic fascia laterally (a medial incision risks the Santorini plexus); divide the puboprostatic ligaments, sparing the pubourethral component to preserve anterior sphincter fixation.
3. Ligate and divide the DVC. The apical dissection is the most important step — the apex is the most common site of positive margins.
4. Divide the urethra and place ~6 anastomotic sutures (1, 3, 5, 7, 9, 11 o'clock) incorporating mucosa/submucosa.
5. Nerve-sparing (when appropriate): release the NVB off the posterolateral prostate without upward traction (roll the prostate side-to-side), controlling vessels with clips — never thermal energy. The final decision to preserve or widely excise can be deferred until the prostate is removed.
6. Divide the lateral pedicles near the bladder, the bladder neck, and dissect the seminal vesicles (the pelvic plexus lies on their lateral surface). Bladder-neck and seminal-vesicle sparing have not been shown to improve continence, potency, or margins.
7. Vesicourethral anastomosis (± tennis-racquet bladder-neck reconstruction).

Robot-Assisted Laparoscopic Prostatectomy

Setup: supine (or lithotomy) with steep (25–28°) Trendelenburg on a non-slip/egg-crate surface (test the tilt before docking so the patient does not slide); the da Vinci system provides 3-D magnification and easy suturing. Antibiotics, VTE prophylaxis, and equipment (monopolar scissors, bipolar Maryland, ProGrasp 4th arm) as above.

Port Placement (transperitoneal)

A 12-mm supra-umbilical incision with an open Hasson entry (or a Veress needle + drop test — opening pressure < 7–8 mm Hg), then insufflate to 12–15 mm Hg, insert the camera, and inspect for vascular/bowel injury before going steep Trendelenburg. Mark a reference point ~15 cm above the symphysis (usually just below the umbilicus): two 8-mm robotic trocars on the left (arms 2 and 3, each ~7–8 cm apart), one 8-mm robotic on the right (arm 1), a 12-mm assistant on the right (3–4 cm superomedial to the iliac crest), and a 5-mm assistant between them — all robotic ports placed under vision, avoiding the inferior epigastric artery. Bowel-injury mitigation: the Hasson entry, full steep Trendelenburg before the working ports (mobile bowel falls away), and briefly raising the pressure to 20 mm Hg for initial access.

Exposure and DVC Control

1. Drop the bladder — incise the peritoneum above the symphysis, divide the medial umbilical ligaments and urachus, and develop the space of Retzius, carrying the incision laterally to the vas at the internal inguinal ring. Stay lateral to the medial umbilical ligament (the ureter runs medial/deep) but not so lateral (epigastric vessels) or posterior (ureter) as to cause injury. The 4th arm gives cephalad bladder traction; watch for an accessory pudendal artery running to the DVC. A bladder-retraction suture (through the urachal stump, out the 5-mm port) helps in high-BMI or large-capacity bladders.
2. Defat the anterior prostate and send the fat for pathology (~15% contain nodes; in 2–3% the only metastatic site); coagulate the superficial dorsal vein. The endopelvic fascia may be opened now, or the prostate dissected beneath it (leaving the "Veil of Aphrodite") — preserving the puboprostatic ligaments/arcus tendineus may aid continence.
3. Control the DVC — two options: (a) early suture ligation — a no. 0 PDS or Vicryl on a CT-1 needle placed in the anatomic notch between the complex and the anterior urethra (slip-knot, ± a second proximal stitch), suspended to the pubic symphysis, with division deferred to later; or (b) "cold-cut" without prior ligation after full mobilization (raise the pressure to 20 mm Hg, incise with scissors while retracting the prostate cranially, then oversew with 3-0 Vicryl or a barbed suture) — this may lower positive margins/improve early continence but bleeds more.

Bladder-Neck Dissection

Grasp the proximal bladder with the 4th arm/ProGrasp; the perivesical fat ends at the prostatovesical junction, and gentle Foley traction (the balloon) defines the neck — lateral catheter deviation suggests a median lobe. "Pinch" the bladder between the right and left arms to read the prostate contour, then enter proximal to the prostatovesical junction (prostate tissue is thicker, more vascular, and exudes a bubbly white secretion if entered). Deflate and withdraw the Foley, switch to a 30° down lens to expose the trigone, and identify both ureteric orifices. Carry the incision through the posterior bladder neck keeping its wall thickness normal — too close risks ureteric injury or buttonholing; too far enters the prostate base. Bladder-neck sparing may improve early continence but risks a positive margin; a large median lobe is suspended with a stitch or the 4th arm to protect the orifices.

Seminal Vesicles and Posterior Plane

Develop the avascular plane anterior to the seminal vesicles; divide the vas (control its artery) and clip the SV-tip artery, minimizing cautery near the tip (the NVB runs posteriorly nearby — the athermal technique retracts the vasa posterolaterally, dissects medial to them, and divides the tip pedicle between clips). An alternative is the rectovesical (Retzius-sparing) approach — enter the peritoneum over the pouch of Douglas, free the vasa/SVs first, and mobilize the prostate posteriorly without dropping the bladder at all. Then incise Denonvilliers' fascia, choosing the plane by depth:

Plane	Posterior dissection	Use
Intrafascial	Between the prostate and Denonvilliers' fascia (no fascia left on the prostate)	Maximal nerve-sparing
Interfascial	Between prostate and Denonvilliers; laterally between prostatic and lateral pelvic fascia	Standard nerve-sparing
Extrafascial	Posterior to Denonvilliers along perirectal fat, taking all lateral pelvic/levator fascia	Advanced/high-grade tumour

The peri-Denonvilliers plane is avascular — bleeding means the dissection is too far anterior (into the base) — and the rectum lies just behind, so avoid cautery.

Nerve-Sparing, Pedicle, Apex, and Urethra

Preserve the NVB athermally and without stretch. In ~70% of men an anterolateral prostatic artery runs beneath the prostatic fascia — dissect medial to it for full preservation — and incise the lateral pelvic fascia along the anterolateral prostate to the apex. Control the pedicle with locking Hem-O-Lok clips (most common; bulldog clamps, a stapler, or suture ligation are alternatives — avoid thermal spread to the nerves), then release the posterolateral NVB attachments sharply, without cautery. Divide the DVC sharply just proximal to the hemostatic sutures to keep apical length (release Myer's muscle to protect the apex/NVB/urethra; replace a lost stitch with 2-0 Vicryl on an SH needle), then divide the urethra sharply at the apex, withdraw the catheter, divide the posterior urethra and rectourethralis (rectal-injury caution), and bag the specimen.

Anastomosis, Reconstruction, and Closure

• Posterior (Rocco) reconstruction — approximate the cut Denonvilliers'/retrotrigonal layers with a double-ended barbed suture before the anastomosis; continence evidence is mixed but it reduces pelvic haematoma.
• Vesicourethral anastomosis — a modified van Velthoven running anastomosis with 2-0 or 3-0 Monocryl (RB-1/SH needle, two suture colours, 8-inch strands) or a barbed suture; take posterolateral urethral bites (not too deep/lateral — NVB), avoid the ureteric orifice, parachute the larger bladder neck down to the urethra with straight anterior traction, and fill the bladder to confirm no leak (narrow a large bladder neck with a tennis-racquet closure).
• Closure — a non-suction drain via the left-lower-quadrant port is optional; extract the specimen at the umbilical port (enlarge the fascia to prostate size) and close the 12-mm/umbilical fascia with no. 1 Vicryl to prevent a port-site hernia. (A transverse camera-port incision lowers incisional-hernia risk — 0.6% vs 5.3% vertical.)

Extended PLND (intermediate/high-risk) removes the obturator, external iliac, internal iliac, and common iliac nodes (± presacral/para-aortic) with a 30° down lens, protecting the obturator nerve/vessels and the ureter; a more cephalad port configuration extends the template to the aorta if needed.

Special scenarios:

• Median lobe — increases risk of ureteral injury, bladder buttonholing, positive margins, incontinence, and the need for bladder-neck reconstruction; manage with a traction stitch or grasper to elevate the lobe, dissecting in the plane between bladder mucosa and the lobe.
• Bladder-neck reconstruction — for a large defect, use a tennis-racquet (anterior or posterior) or fish-mouth closure; the inverting (posterior tennis-racquet) approach moves the ureteric orifices away from the anastomosis.
• Previous TURP — distorted anatomy and a wide bladder neck usually need reconstruction; plicate at 3 and 9 o'clock (avoid 6 o'clock — highest tension/leak risk).
• Salvage RALP (post-radiotherapy/HIFU) — the hardest steps are opening the (adherent) endopelvic fascia — which can be deferred until after the posterior dissection — the posterior dissection (Denonvilliers' fused to the rectum → sharp dissection only, no blunt or cautery), and the apex; perform a rectal insufflation test after removal. The robotic antegrade dissection off the rectum (base→apex) may make rectal injury less likely than the open retrograde (apex→base) approach.

Postoperative Care

Clear liquids the evening of surgery; early ambulation; robotic patients usually need only a single overnight stay, with the drain out the first morning and transfusion in fewer than 1% (some ileus is common for a few days). The catheter stays ~7 days for robotic (3–21 days open; removal before 7 days carries a 15–20% retention risk), or is removed earlier if a cystogram confirms the anastomosis. Restart Kegels after catheter removal; sexual-function recovery occurs over 1–2 years.

Complications

• Intraoperative: hemorrhage (DVC — best controlled by completely dividing it over the urethra and oversewing; <1% intraoperative transfusion open); obturator-nerve injury during PLND (attempt fine non-absorbable reanastomosis); rectal injury (<0.3% open, more common in salvage; repair with copious irrigation, multilayer closure, and omental interposition to prevent rectourethral fistula; consider a diverting colostomy for a large defect, prior radiation, or chronic steroids); ureteral injury (rare).
• Early: ileus, wound infection, UTI; venous thromboembolism (DVT/PE is a major cause of post-RP mortality, peaking 14–28 days); lymphocele (~3%; can masquerade as worsening incontinence after robotic RP); urine leak (~1.8%); reoperation (~1.6%); rare delayed hemorrhage (explore early for severe hypotension).
• Late: vesicourethral anastomotic stenosis / bladder-neck contracture (1.3–4.8%; less with robotic; up to 22–40% after salvage; manage with dilation or cold-knife incision ± triamcinolone); urinary incontinence; erectile dysfunction; incisional hernia; urethral stricture.
• Continence: ~95% of men <60 and ~85% of men >70 regain pad-free continence; nerve-sparing and posterior reconstruction (Rocco stitch) improve early continence (the long-term rate is less affected).
• Erectile function: recovery predicted by younger age (<65), good baseline potency, and extent of nerve-sparing; erections return as partial erections at 3–6 months and improve up to ~3 years — encourage early penile rehabilitation (PDE5 inhibitors, injections, vacuum devices).