• Curative treatment option for prostate cancer - removal of prostate and seminal vesicles, followed by urethrovesical anastomosis
• Pelvic lymph node dissection (PLND) based on risk - perform if nomogram shows high risk of involvement > 5-7% (MSKCC; Briganti).
• Robotic/lap vs open:
• similar outcomes in cancer control, continence, and ED
• Less blood loss with robot/lap (< 10% transfusion rate w open, < 1% with lap/robotic)
• Shorter hospital stay with RALP

PLND template borders Anterior: external iliac vein Posterior: obturator nerve/fossa Extended PLND - go deeper to floor of pelvis; better chance of detecting metastases) Proximal: origin of internal iliac artery Extended PLND - go up to where ureter crosses the common iliac Super-extended: up to aortic bifurcation Distal: Cooper's ligament Medial: bladder Lateral: pelvic side wall Super-extended: include pre-sacral lymph nodes

Anatomy

Anatomic landmarks

• Anterior: puboprostatic ligaments - from pubic bone to prostate
• Lateral: endopelvic fascia (inner investing fascia of levator ani fascia)
• Posterior: Denovillier's fascia (rectoprostatic fascia) - invests seminal vesicles, goes over rectum
• Base - bladder neck, vas, SVs
• Apex - Urethra

Stanford attending RALP notes

Surgical Atlas - RALP

Stanford robotic prostatectomy

Complications:

• Erectile dysfunction
• If neurovascular bundle (posterior-lateral to the prostate) not involved, can do nerve sparing to preserve erections.
• Penile rehabilitation (vacuum erection device/VED) - regular erections prevent fibrosis/scarring and preserve tissue
• Daily low dose PDE-5 
• Stress urinary incontinence
• Improves during year after surgery; chronic incontinence uncommon ~ 5%
• 89% continent at 1 year after surgery (1-5% rate of surgical repair at 1 year)
• Continence rates correlate with longer preserved urethral length
• Internal sphincter (involuntary) is removed but external sphincter (voluntary) remains and urinary continence is typically regained after ~12-18 mo.
• Some benefit to starting Kegels before surgery
• Infertility/aspermia (always)
• Bladder neck/anastomotic stricture (5-10%)
• Typically presents about 2 months after surgery
• Responds well to dilation, then DVIU
• Decrease in penile length (~1 cm)
• Lymphocele
• Less common with robotic/intraperitoneal approach - lymph will just drain into the abdomen
• IF extraperitoneal, can treat with peritoneal window
• Rectal injury
• Obturator nerve injury (impairs leg adduction)