Bladder neck dissection during a robot-assisted radical prostatectomy

Surgical decision making and error avoidance cues

Case specifics:

  • Robot-assisted radical prostatectomy—focus on the bladder neck dissection
  • Completed in 2020, Ottawa, ON, Canada at the The Ottawa Hospital.
  • Equipment: Da Vinci, Xi
  • Disease: pT1c, Gleason 4+3 prostate cancer.


Learning objectives:

  1. Conceptualize the steps of the bladder neck dissection
  2. Describe 3 visual cues that could indicate incision into prostatic tissue
  3. Describe 3 maneuvers that can help visualization during the bladder neck dissection
  4. List 2 visual cues that describe the retrotrigonal fascia

 Legend for video:

  • Blue circle/arrow = visual cues and landmarks
  • Purple arrow = maneuver


Steps of the bladder neck dissection:

  1. 00:05. Incise fat lateral to the DVC.
  2. 00:41. Incise the detrusor apron in the midline.
  3. 02:16. Incise the anterior prostatovesical junction.
  4. 03:25. Open the anterior urethra.
  5. 03:28. Drop the anterior bladder lateral to the urethra.
  6. 06:34. Incise the posterior urethra.
  7. 06:41. Incise the posterior prostatovesical junction.
  8. 06:51 + 07:55. Incise the retrotrigonal fascia.
  9. 07:28 + 09:39 + 10:02. Perform hemostasis to the lateral vascular bladder attachments.


Surgical decision making and error avoidance cues:

Cognitive task analysis was performed to identify patterns and cues that expert surgeons use to inform their surgical decision-making and avoid errors.



Lusty, A., Alexanian, J., Kitto, S., Wood, T., Lavallée, L. T., Morash, C., Cagiannos, I., Breau, R. H., & Raîche, I. (2024). How Surgeons Think to Avoid Error: A Case Study of the Neurovascular Bundle Sparing During a Robotic Prostatectomy. Journal of surgical education81(4), 570–577.


Ethical approval:

This project was approved by the University of Ottawa Research Ethics Board.


This project received fundings from:

AO Foundation in the context of the AOEI Fellowship in Medical Education research.