Procedure Robot-assisted laparoscopic radical prostatectomy in the Asian population: Modified port configuration and ultradissection Wooju Jeong, 1 Motoo Araki, 1,2 Sung Yul Park, 3 Young Hoon Lee, 1 Hiromi Kumon, 2 Sung Joon Hong 1 and Koon Ho Rha 1 1 Departments of Urology and Urological Science Institute,Yonsei University College of Medicine, Seoul, Korea, 2 Department of Urology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan and 3 Hangyang University College of Medicine, Seoul, Korea Abstract: We have carried out over 360 cases of robot-assisted laparoscopic radical prostatectomy (RARP) to date. In the present study, we detail our current technique at Yonsei University College of Medicine. The six-port transperitoneal approach is utilized. The most lateral two ports were placed medially and caudally in patients with a small pelvis to avoid interference between the ports and the pelvis (modified port configuration). Lymph node dissection is carried out in the external iliac, obturator and infraobturator area. The dissection on the lateral border of the bladder neck is carried out until it reaches the seminal vesicle (ultradissection). After transection of the bladder neck, vasa seminal vesicles are dissected further. Neurovascular bundles are preserved in selected patients. The dorsal venous complex (DVC) and the urethra are transected without suturing. Urethrovesical anastomosis is carried out with 3-0 monocryl running suture, incorporating with the edge of DVC. The puboprostatic collar and bladder are incorporated by 3-0 monocryl running suture (puboperi- neoplasty). Between November 2007 and September 2008, RARP was carried out using this technique in 182 patients. Median height, weight, body mass index and prostate-specific antigen (PSA) were 168 cm, 68 kg, 24 kg/M 2 and 7.1 ng/mL, respectively. Mean operative time was 192 min and average blood loss was 250 mL. Median catheterization time was 8days. Positive surgical margin rates for pT2, pT3 and pT4 disease was 12.7, 48 and 100%, respectively. Intraoperative complication rate was 2.7%. Fifty-five patients completed a minimum of 10 months follow up. Their continence rate was 91%. RARP is a safe and feasible surgical modality for prostate cancer among Asian patients with a small pelvis. Our technique achieves a precise bladder neck dissection. Key words: Asia, port configuration, robot-assisted laparoscopic radical prostatectomy, ultradissection. Introduction Since July 2005, we have carried out over 360 cases of robot-assisted laparoscopic radical prostatectomy (RARP). 1–3 It is the largest series by a single surgeon (KHR) at a single institution (Yonsei University College of Medi- cine) in the Asian population. A small pelvis in the Asian population provides a technical challenge for carrying out RARP despite the advantages of the da Vinci system. In the present report, we detail our refined current technique. We also detail our port configuration, which is feasible for patients with a smaller body. Technique Patient position and port placement After induction of anesthesia, the patient is placed in a modified lithotomy position. Port configuration is shown in Figure 1a (six ports). A Veress needle is inserted through a 12 mm supraumbilical incision for the entry of the first port (A, camera port) for the transperitoneal approach. After a drop test, pneumoperitoneum is obtained at 20 mmHg. For a small pelvis, this port configuration is adjusted (Fig. 1b) to avoid interference with the anterior superior iliac spine (ASIS; modified port configuration). After port placement, pneumoperitoneum is decreased to 15 mmHg and maintained throughout the procedure. The patient is tilted in a 30° Trendelenburg position and the robot (da Vinci S; Intuitive Surgical, Sunnyvale, CA, USA) is docked in place. Surgical technique of RARP Exposure of extraperitoneal space and lymph node dissection Dissection is started with the peritoneum medial to the vas deferens with a 0° lens and monopolar scissors (surgeon’s right hand). Lymph node dissection is carried out bilaterally in the external iliac, obturator and infraobturator area. Correspondence: Motoo Araki MD PhD, 2-5-1 Shikata-cho, Kita-ku, Okayama-shi, Okayama-ken 700-8558, Japan. Email: motoosh@aol.com Received 28 July 2009; accepted 4 January 2010. International Journal of Urology (2010) 17, 297–300 doi: 10.1111/j.1442-2042.2010.02480.x © 2010 The Japanese Urological Association 297