Purpose: Nerve-sparing robot-assisted radical prostatectomy is technically challenging in patients with large prostates due to distorted anatomy and limited working space. Through a surgical video demonstration, we describe our step-by-step application of a retrograde nerve-sparing technique in a patient with a large prostate. Surgical
Surgical Methods: A 68-year-old man with clinical T1c prostate cancer and a 124 cc prostate underwent conventional robot-assisted radical prostatectomy using a six-port transperitoneal approach. Retrograde nerve sparing was performed bilaterally. After incising the Denonvilliers’ fascia, an avascular plane was developed posteriorly to release the posterior neurovascular bundle from 5 to 1 and 7 to 11 o’clock positions on the right and left sides, respectively. During posterior dissection, the camera was toggled between 30° down and 30° up to obtain a clear visualization of the narrow posterior plane. Subsequently, the endopelvic fascia was incised at the base of the prostate until the posterior neurovascular plane was reached. The bilateral pedicles were then secured using Hem-o-lok clips.
Results: The total operative time was 80 minutes, with an estimated blood loss of 100 mL. The patient was discharged the following morning without any perioperative complications. The Foley catheter was removed on postoperative day 5 following the confirmation of no leakage at the anastomosis site.
Conclusions: Retrograde nerve-sparing approach with the toggling technique facilitates early neurovascular bundle release and can reduce the risk of traction and thermal injury, even in a restricted workspace. This approach allows for precise dissection and can contribute to improved functional outcomes while maintaining oncologic safety in anatomically challenging cases.