Robot-Assisted Laparoscopic Simple Prostatectomy with Retropubic Approach in Benign Prostatic Hyperplasia: Single Center Experience and Video Demonstration

Abstract

Introduction: Robot-assisted laparoscopic simple prostatectomy was first reported in 20081 and minimally invasive simple prostatectomy demonstrated to be feasible in men with prostate size >80 cc needing surgical treatment under EAU guidelines.2 From 2006 to 2016, more than 1000 robotic surgeries were carried out in our medical center.3 In this study, we will introduce our single medical center experience of robot-assisted laparoscopic simple prostatectomy. Materials and Methods: A total of 30 patients who underwent robot-assisted laparoscopic simple prostatectomy were included in the study. All of them had symptomatic benign prostatic obstruction with prostate volume >80 cc. Transrectal biopsy was also performed in all of the patients and reveal nodular hyperplasia without evidence of malignancy. Preoperative assessments include PSA, International Prostate Symptom Score (IPSS), uroflowmetry, and postvoid residual urine. Operation was performed with a four-arm da Vinci surgical system with six ports that adapted the transperitoneal approach.4 Bladder was mobilized and Retzius' space was reached. Two rows of hemostatic sutures for control of the Santorini plexus were used. Dissection of the adenoma from the prostatic capsule was performed by the Millin's retropubic method.5 The bladder neck mucosa was approximated to the prostate apex to achieve retrigonization and anterior prostatic capsule was closed. Foley's tube was inserted and kept for about 7 to 14 days. In our clinical experience, cystogram was not performed routinely and it may be used in case for evaluation of anastomosis leakage. Parameters such as bladder neck-to-pubic symphysis ratio6 or posterior vesicourethral angle7 would be used as predictor for postoperative continence. Results: Totally 30 patients underwent the whole procedure without major complication. Mean patient age was 65.7 (55–79) years and mean estimated prostate volume was about 105.43 cc (75.0–173.0 cc). Mean operation time measured was 140 minutes (105–190) and mean blood loss was estimated about 141.3 mL (30–850). Patient stay was about 4.5 days and mean catheterization days were about 8.83 days. There was significant improvement in postoperative outcome based on uroflowmetry and International Prostate Symptoms Score. For uroflowmetry, there was also significant improvement in mean and maximum flow rate, which increased from 3.25 to 10.54 mL/s (p < 0.001) and from 8.36 to 21.25 mL/s (p < 0.001), respectively. Postvoiding residual urine volume also showed significant decrease from 98.36 to 11.00 mL (p < 0.001). Concerning patient's self-administered parameter, International Prostate Symptoms Score also showed significant improvement from 23.47 to 3.47. The patient was 69 years old and healthy with benign prostatic obstruction, and prostate measured about 85 g. We performed retropubic simple prostatectomy by the transperitoneal approach as already mentioned. Direct anastomosis was performed at bladder neck and urethra without trigonization. Cystography was performed at the seventh day after operation and showed the bladder neck in good shape. Good continence was also noted immediately after the catheter was removed and the patient was voiding well during follow-up. Conclusion: Robotic simple prostatectomy may be a feasible alternative option for patients with benign prostate hyperplasia and greatly enlarged prostate gland in consideration of acceptable complications and postoperative continence. Human Ethical Statement: Certification of approval with IRB: CE15215B. Music Origination: Bumper-Tag, edit by John Delay, download from YouTube Audio Library. No competing financial interests exist. Runtime of video: 7 mins 56 secs