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advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) with the SP Cannula to the
Alexis. The abdomen is then insufflated to 15 mmHg, and carefully surveyed to identify any abdominal
adhesions. We then place 2 additional trocars under direct vision, specifically a 12 mm port (to which an
AirSeal is attached) approximately ⅔ of the distance between the umbilicus and left iliac crest and a 5 mm
assistant port halfway between the umbilicus and the 12 port. The SP robot is then side-docked.

General considerations
The SP RARC technique largely follows the standard multiport technique with RARC, with several key
adjustments, notably the positioning of the robotic instruments. We begin with the monopolar scissors at
the 3 o’clock position, Cardiere forceps at the 6 o’clock position, bipolar forceps at the 9 o’clock position,
and the camera at the 12 o’clock position. Instruments are switched periodically to allow for optimal
retraction depending on the specific step of the procedure performed.

Identification of the ureters
We locate the ureters bilaterally by incising the overlying peritoneum just lateral to the medial umbilical
ligament and dissecting down to the level of the common iliac artery. The Cadiere forceps at 6 o’clock are
useful for holding traction on the ureters and pushing the bowel medially during this dissection, which can
be completed without the bedside assistant. Once the ureters are identified, they are placed on vessel loops
and dissected down to the ureteropelvic junction, at which time they are clipped with two Hem-o-lock clips
(Weck Closure Systems, Research Triangle Park, NC, USA) and divided.

Anterior and posterior bladder dissection
The LigaSure device is then used to divide the obliterated umbilical arteries bilaterally and the tissue lateral
to the ureters. The bipolar forceps at 9 o’clock are used to lift the bladder, the Cardiere at 6 o’clock is used to
provide downward traction on the bladder, and the monopolar scissors at 3 o’clock are used to open up the
endopelvic fascia. The posterior peritoneum is then incised over the rectum, connecting the two entry
points into the endopelvic fascia. The seminal vesicles are then identified and elevated, and the posterior
plane between the rectum and bladder is bluntly dissected out. The LigaSure device is used to divide the
superior vesical arteries bilaterally, taking care to stay below the seminal vesicles and ureteral stumps
bilaterally. This dissection plane is taken all the way down to the prostate apex. We then divide the median
and medial umbilical ligaments using the LigaSure device and drop the bladder into the pelvis. After the
apex of the prostate is dissected, we switch our 3 o’clock and 9 o’clock instruments out for robotic needle
drivers and oversew Santorini’s plexus using 2-0 V-Loc suture in a figure-of-eight fashion. We then replace
our monopolar scissors at 3 o’clock and bipolar forceps at 9 o’clock and divide Santorini’s plexus. Next, we
dissect out and free the urethra. The Foley catheter is clipped with a Weck clip to keep the balloon inflated
to avoid spillage of bladder contents. The remaining lateral attachments of the prostate are then divided in a
modified nerve-sparing fashion with bipolar cautery. Once the specimen is completely freed, it is placed in a
15 mm entrapment sac and set aside.

Pelvic lymphadenectomy
We then perform our bilateral pelvic lymphadenectomy, removing the external, obturator, internal, and
common iliac lymph nodes bilaterally using Weck clips and bipolar cautery for lymphostasis. We
periodically switch the positions of the Cadiere and bipolar forceps between the 6 o’clock and 9 o’clock
positions as needed for better retraction of the lymph nodes, as the Cardiere provides a better medial
retraction. The specimens are sent to pathology as right and left pelvic lymph nodes. The presacral space is
then divided to allow for the passage of the left ureter under the mesorectum at the level of the sacral
promontory. This dissection is performed with the Cardiere forceps at the 9 o’clock position to hold