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pelvic plexus, which is in close proximity to the SVs as above, the predominant neurovascular bundle
(PNVB) in the groove between posterolateral prostate and rectum, and the accessory nerve pathways
(ANPs) on the lateral surface of the prostate in the lateral prostatic fascia [10,11] . During surgical dissection,
injury caused by direct trauma or cautery, inflammation, or ischaemia to any of the nerve fibres is
potentially reversible, but cell body injuries are not. The pudendal nerve, with somatic cell fibres from
Onuf’s nucleus in the anterior horn of S2-4, supplies the pelvic floor muscles and external sphincter. In the
context of male NS RARC, this is relevant to neobladder operations, where injury to its nerve branches
[10]
when dissecting and ligating the dorsal vein complex, may compromise post-operative continence . A
detailed knowledge of the neuroanatomy will provide the operating surgeon with direction when dissecting
around the SVs, base of prostate and distally towards the prostatic apex, in order to achieve the most
effective NS whilst proceeding through the steps of RARC described below.

Patient preparation and selection
Patient selection is crucial to surgical planning, especially for the NS approach, with some basic
contraindications when considering the RARC part as well as more specific criteria for NS. Moreover, the
decision to proceed with NS may be made in conjunction with consideration for orthotopic neobladder,
which will also require specific criteria for patient selection. Generally, depending on the surgeon’s
experience, relative contraindications to RARC would include BMI > 35, severe vasculopathy with a history
of surgery, severe cardiorespiratory illness, prior pelvic trauma, surgery or radiation, and locally advanced
[12]
disease . For male NS, preoperative potency is a basic requirement, with a desire for ongoing sexual
activity postoperatively. Some studies have suggested an age cut off of 65 years, based on poorer recovery in
[13]
older age groups , but if patients have reasonable preoperative potency, and otherwise are suitable for
selection, age should not be a factor in the decision-making process. Positive surgical margin rates have
been noted to rise with increasing tumour stage , and clinical tumour stage should be T2 or less. Some
[14]
groups also suggest clinical evidence of prostate cancer should be a contraindication , but if this has been
[15]
proven as localized or low volume intermediate risk prostate cancer by preoperative prostate biopsy and
multiparametric Magnetic Resonance Imaging prostate, NS may still be undertaken. If orthotopic
neobladder is also being considered, patients require unimpaired renal and liver function, no history of
urethral sphincter injury, the necessary motivation and cognitive function to undertake the postoperative
[16]
neobladder training protocols as well as the dexterity to perform intermittent self-catheterization .
Preoperative preparation for patients in modern robotic centres will include application of enhanced
recovery after surgery (ERAS) protocols, as well as advice regarding preoperative lifestyle changes and
physical activity in what is now termed “prehabilitation”, which aims to maximise postoperative recovery.
This is discussed in more detail in the section below. For ERAS protocols, which most robotic centres will
have in place, patients are educated and counselled regarding the procedure and recovery, medically
optimized, and encouraged to change their diet preoperatively to include carbohydrate loading. Pre-
operative low residue diet for 24 h with 6 h fasting for solids and 2 h for fluids is also recommended.

Surgical technique for male RARC
Applying a modular approach to the technique of male RARC has a number of advantages. It provides a
methodical step by step perspective to the procedure that facilitates learning, allows smooth progress
through what is a lengthy procedure, allows the operating surgeon be aware of specific steps that may have
[12]
complications which can be avoided, and ultimately may reduce operating time as experience is gained .
Male RARC include the steps of ureteric dissection, dissection of the anterior rectal space, dissection of the
lateral rectal space, mobilization of the bladder and urethral transection, extended lymph node dissection
(ELND), specimen removal, and urinary diversion. These sections will be discussed individually, before
discussing specific techniques for NS (see Figures 1-16).