DESCRIPTION OF OPERATION: The patient was given preoperative antibiotics and sequential TEDs and heparin and brought to the operative suite. He was given anesthesia. The patient was positioned in the dorsal lithotomy position after anesthesia. Sterile prep and drape was performed. The patient had an incision made above the umbilicus approximately 1.5 cm. This was taken down to the fascia. The fascia was tagged and Veress needle was used to create a pneumoperitoneum. The patient then had a 12 mm port placed and under direct vision had 8 mm ports placed 8 cm from the umbilicus, on each side, and in the right lower quadrant. A 12 mm port was placed lateral to the umbilicus on the left side and a 5 mm more lateral assistant port was also placed. The patient had the DaVinci robot docked. The patient had the retroperitoneal space entered by taking down the medial umbilical ligaments and urachus remnants with activated scissors and bipolar cautery. This was taken to the level of the vas deferens bilaterally. The patient had fat overlying the prostate, which was freed. The endopelvic fascia was opened, and using cold scissors, the endopelvic fascia was opened and the levators were swept off laterally. The dorsal venous complex was isolated and ligated with a 0 Vicryl suture. The patient had a midprostate traction stitch. The dorsal venous complex was then divided. Care was taken to not cauterize laterally due to the neurovascular bundle. The lateral prostatic fascia was incised at the apex on both sides. Using the hook electrode, the patient then had transection of the anterior bladder neck from the prostate base. Once Foley catheter was exposed this was retracted and held up with the fourth arm. Of note, the patient did have fossa navicularis stenosis and had some difficulty in passing the 22-French Foley catheter. The fossa navicularis was gently dilated with a hemostat. The 22-French catheter was then advanced into the bladder. There was no trauma, no bleeding. The patient had the lateral bladder neck left intact and the periurethral tissue was then divided posteriorly. The retrovesical space was entered and the seminal vesicles and the ampullae of the vas deferens were identified. These were freed and the vas deferens were divided. The patient had a large vas deferens on the right side. The vas deferens was divided and all pedicles to the seminal vesicles were controlled. These were used to retract the prostate. Denonvilliers was opened in the midline using scissors. The perirectal fat was identified, and using blunt dissection, it was swept off. The bladder neck was isolated, controlled with Weck clips and divided with cold scissors. The pedicles were controlled in a similar fashion and the lateral prostatic fascia was incised and taken lengthwise. The neurovascular bundle was swept off the prostate on both sides. Prostate was then dissected and freed to the level of the urethra. Using the cold scissors, the remaining dorsal venous complex above fascia was taken down and urethra was completely repaired. Circumferential dissection was performed. The urethra was then transected with cold scissors and the specimen was completely freed. The specimen was placed in a bag and later removed through the midline port. A standard bladder neck anastomosis was performed using a 3-0 Monocryl suture x2 tied together and started at the 6 o'clock position outside the bladder neck. This was taken to the urethra and run up circumferentially. Care was taken to assure that the posterior plate was approximated to the urethra. A final 20-French Foley catheter was inserted under direct vision prior to the last stitch being tied down. The patient then had bladder neck to the dorsal venous complex reapproximation stitched with Monocryl suture. The patient had a JP drain placed through the right lower quadrant port and it was secured to the skin. The specimen was delivered through the midline.
