Introduction:

SAGE-Journals-Accessible-Video-Player 10.1089/vid.2015.0032.M1 sj-vid-1-vid-10.1089_vid.2015.0032

Introduction:

There are various therapeutic options for the treatment of benign prostatic hyperplasia (BPH), including both medical and surgical alternatives. However, the options for BPH in large glands (>70 g) are somewhat limited. The traditional open simple prostatectomy is associated with relatively lengthy hospital stays as well as significant blood loss and risk for transfusion. We present a novel technique of robot-assisted, laparoscopic simple prostatectomy (RALSP) that we believe is safe, effective, and easily reproducible.

Materials and Methods:

From May 2013 through April 2015, a single surgeon (Daniel D. Eun) performed RALSP on 31 patients with large gland BPH using our posterior approach technique. All the patients underwent preoperative and postoperative postvoid residual (PVR) testing, AUA Symptom Score (AUA-SS) and Sexual Health Inventory for Men (SHIM) evaluation, and preoperative transrectal ultrasonography. Novel aspects of this technique include a posterior cystotomy, lateral retraction of the bladder through extracorporeal sutures, and anastomotic exclusion of the prostatic fossa. The posterior cystotomy offers easy visualization of the enlarged gland without mobilization of the bladder. Closure of the prostatic fossa is achieved with a complete vesicourethral anastomosis, often eliminating the need for postoperative bladder irrigation.

Results:

The mean patient age was 67.4 years (60–85 years) and the mean PVR was 305.3. The mean preoperative AUA-SS and SHIM score were 19.5 (7–28) and 11.6 (1–24), respectively. The average console time was 158 minutes (71–307 minutes) and the mean estimated blood loss was 239.6 mL (50–1000 mL; median 200 mL). The mean weight of removed adenoma was 81.1 g (32–185 g; median 80 g). The average length of stay was 1.1 days (1–3 days; median 1 day). There were no intraoperative complications, and pathology confirmed BPH in all cases except two patients with incidental pT1a prostate cancer. Patients with the diagnosis of prostate cancer were offered standard treatment options; one patient underwent radical prostatectomy and one is currently on active surveillance. Continuous bladder irrigation was not utilized, and no transfusions were necessary. Postoperatively, AUA-SSs were significantly improved (mean 4.8, p < 0.001) as was PVR (mean 27.8 mL, range 0–117 mL, p = 0.001). There was no significant difference in the postoperative SHIM score (mean 12.1, p = 0.35).

Conclusions:

We believe that the posterior approach to RALSP is safe, effective, and easily reproducible. Advantages of this approach include the exclusion of the prostatic fossa from the urinary tract with vesicourethral anastomosis, the avoidance of continuous bladder irrigation, and the effective retroperitonealization of the prostatic fossa with bladder closure. Since the bladder is not mobilized and the space of Rhetzius not entered, after bladder closure, the peritoneum is again intact, thus retroperitonealizing any small anastomotic leaks. It should be clarified that this approach is distinct from the posterior approach to radical prostatectomy and should not be confused. This approach is an important option when considering surgical approaches for the treatment of large gland BPH.

No competing financial interests exist.

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Posterior Approach to Robotic Simple Prostatectomy