Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptoms (LUTS) and bladder outlet obstruction (BOO) in men. The prevalence of this pathology increases with male aging. In the fourth decade of life, BPH is demonstrable in 30% to 40% of men, and its prevalence increases almost linearly to 70% to 80% in those older than 80 years.
Despite recent advances in the endourological management of BPH, the treatment of LUTS caused by large prostatic adenoma (>80 mL) remains a challenge. Currently, open simple prostatectomy (OSP) remains one of the standard treatments in this situation, , providing not only long-term improvement of LUTS, urinary flow, quality of life (QOL), International Prostate Symptom Score (IPSS), but also decreasing post-void residual (PVR) bladder volumes and offering lower reoperation rates when compared with some endoscopic treatments. Surgical techniques commonly used are the Freyer (transvesical approach) or Millin procedures (trans-capsular approach), both with acceptable results. However, OSP has also been associated with high rates of urosepsis, reoperation, prolonged catheterization time, perioperative transfusion, and prolonged length of hospital stay.
In 2002, Mariano et al. described the laparoscopic simple prostatectomy (LSP) technique, combining the benefits of OSP with the potential advantages of a minimally invasive approach. Years later, Sotelo et al. published the first series of robotic-assisted simple prostatectomy (RASP), describing seven patients undergoing suprapubic transperitoneal transvesical approach with interesting outcomes.
Initially, the RASP was classified as an experimental procedure in the 2010 American Urological Association (AUA) guidelines, considering that there were insufficient data to support RASP as a standard treatment option. , However, in this last edition of the AUA guidelines, RASP was deemed as a feasible and safe procedure when performed by experienced robotic surgeons, based on the current literature available. Similarly, in the current European Association of Urology (EAU) guidelines, minimally invasive simple prostatectomy (MISP) was considered feasible and effective in men with prostate sizes greater than 80 mL; however, in order to demonstrate superiority over OSP and other endoscopic methods, randomized clinical trials are necessary.
Current indications of RASP are similar to traditional indications for OSP: ,
Large prostates (prostate volume over 80 to 100 mL) with LUTS refractory to medical treatment;
Refractory urinary retention secondary to BPH;
Recurrent bladder stones, infections, or gross hematuria due to BPH;
BOO refractory to medical therapy;
Symptomatic BOO with diverticulum; and
Renal insufficiency secondary to BPH.
Access, pneumoperitoneum, port placement, and docking
Cystotomy on the bladder dome
Fix/suspend each bladder wall to the lateral peritoneum
Identify the trigonal area and bladder mucosa, incision around the prostate
Circumferential and apical adenoma dissection
Apical urethral transection and adenoma removal
Urethrovesical closure and 18 Fr two-way Foley catheter is placed into the bladder
Adenoma placed in retrieval bag, ports removed and closure
Fenestrated bipolar forceps
Large needle holders × 2
Urethrovesical Anastomosis: 2-0 Quill suture (Monoderm—RB-1 17 mm 1/2 circle—16-cm × 16 cm)
Bladder closure: 2-0 polyglactin suture (SH 20 mm 1/2 circle—20 cm)
10 mm Hem-O-lok
Hem-O-lok clip appliers
Evolution of our surgical technique
The benefits of robotic surgery for simple prostatectomy have been emphasized in multiple recent series, and multiple surgical techniques have been described. , Our personal technique has evolved along the last decade; we have tested different surgical approaches until we established our current standard, the transvesical RASP with urethrovesical anastomosis (UVA). In this chapter, we describe our surgical technique, different approaches, and the benefits and drawbacks of each.
Below, we will start by describing the main stages of our transperitoneal RASP technique, and, after this, we will present the evolution of this approach based on our personal experience. Recently, we recorded a video with three different ways to perform this surgery.
Patient position and ports placement
Under general anesthesia, the patient is placed in lithotomy position at a steep Trendelenburg angle with padding of pressure points, similar to an RARP procedure. We use a bean bag for adequate patient positioning to the surgical table ( Fig. 17.1 ).
An 18 Fr Foley catheter is inserted into the bladder and six ports are placed across the abdomen similar to RARP: the camera port just above the umbilical scar, three 8-mm arm ports, a 12-mm assistant port in the right flank, and a 5 mm for suction in the right upper quadrant ( Fig. 17.2 ). These surgical steps are similar in all surgical approaches we have adopted.
Our initial technique: RASP through the retzius space with bladder neck incision or a midline cystotomy
Initially, the anterior peritoneum is incised and the Retzius space is dissected. Periprostatic and perivesical fats are then removed to expose the bladder neck. We no longer open the endopelvic fascia nor ligate the dorsal venous complex (DVC). After surpassing the learning curve, we believe those steps are not necessary and the procedure can be performed with minimal bleeding without DVC ligation. However, during initial procedures, the endopelvic fascia was opened laterally to the reflection of the puboprostatic ligaments bilaterally and the DVC ligated using a 12-inch monofilament polyglytone suture on a CT-1 needle, as described in prior studies. ,
Transverse bladder neck incision
The prostate adenoma may be accessed in different ways. We initially described a 1 to 2.5 cm transverse incision in the anterior vesicoprostatic junction, , similar to the anterior bladder neck dissection performed in a RARP ( Fig. 17.3 ). This approach allows easy identification of ureteral meatus and allows the bladder mucosa to be sectioned in the plane of the adenoma and the prostate capsule. Most robotic surgeons are familiar with this anatomy due to prior experience with RARP. The major disadvantage of this approach is the need of a larger transverse incision for larger adenomas, risking injury of the neurovascular bundle laterally.
Due to this limitation, we have evolved our transvesical access to a proximal midline cystotomy after the Retzius dissection, as also described by other authors. , This approach allows better access to larger adenomas without the risk of neurovascular bundle injury. The decision on which approach to use depends mainly on the surgeon’s personal experience, but these advantages and disadvantages should be taken into consideration ( Fig. 17.4 ).
Dissection of prostate adenoma
The plane between the adenoma and the prostatic capsule is identified and incised over the posterior bladder neck; the adenoma is dissected using a combination of cautery, traction, and blunt dissection. This dissection should start posteriorly, preventing blood spillage from the anterior dissection into the posterior plane. The adenoma is then mobilized from the capsule anteriorly and laterally ( Fig. 17.5 ). Occasionally, a 0-polyglactin stay suture can be used for counter traction of the prostate adenoma during the dissection. Finally, the prostatic urethra is carefully sectioned, avoiding injury to the urinary sphincter, and the adenoma finally is removed. Two 2-0 poliglecaprone sutures are placed at 5 and 7 o’clock positions in the vesicoprostatic junction for additional hemostasis; however, this step is not mandatory if the surgeon has found the correct avascular plane. Hemostasis is revised and bleeding vessels are cauterized or ligated with absorbable sutures.
Reconstruction: Advancement of the bladder neck mucosa or urethrovesical anastomosis
In the classical “trigonization” technique, the mucosa of the posterior bladder neck is then advanced to the distal urethral mucosa using two figure-of-eight 2-0 polyglactin sutures or using a continuous 3-0 poliglecaprone suture. The idea is to reapproximate the mucosa to reconstruct the anatomy of the prostatic fossa and promote hemostasis. We described a modified reconstruction technique which includes three surgical steps: plication of the posterior prostatic capsule, modified van Velthoven continuous UVA, and suture of the anterior prostatic capsule to the anterior bladder wall. In this approach, after the resection of the adenoma, the posterior capsule was plicated using two 12.5 cm 3-0 poliglecaprone sutures (on RB 1 needles) tied together. The proximal edge of the capsule was approximated to the distal capsule using one arm of the continuous suture. The posterior bladder neck was then sutured to the posterior urethra using the other arm of the suture. A continuous modified van Velthoven UVA was then performed. Two 20-cm 3-0 poliglecaprone sutures of different colors (on RB 1 needles) were tied together with 10 knots to provide a bolster for the anastomosis. The posterior part of the UVA was performed with one arm of the suture ( Fig. 17.6 ), in a clockwise direction, from the 5 to 9 o’clock positions. This step was followed by completion of the anterior anastomosis with the second arm of the suture, in counterclockwise fashion. ( Fig. 17.7 A–C shows needle pathway.) This modified technique of RASP has potential advantages: reduced blood loss, lower blood transfusion rates, shorter length of hospital stay, and no need for postoperative continuous bladder irrigation.
Usually, a 18 Fr two-way Foley catheter is placed into the bladder and the balloon is inflated with 20 mL of distilled water. Alternatively, the surgeons who practice the classical “trigonization” technique use a three-way Foley catheter insufflated in the prostatic fossa in order to further promote hemostasis; however, with our technique the prostatic fossa is totally plicated and reconstructed, precluding the need for this maneuver and the use of three-way catheters. After testing the suture with bladder repletion of 120 mL of saline solution and proving no leaking, no drain is required. The midline camera port incision is extended, and the specimen is extracted using an endobag. The aponeurosis is closed using a 0-polyglactin suture, and the skin is closed using a 4-0 poliglecaprone subcuticular suture. We do not use routinely continuous bladder irrigation as the prostatic fossa is “bypassed” by the anastomosis and the patients do not present any grade of hematuria in the early postoperative period.
Our current approach
We have recently changed our approach allowing quicker access to the adenoma without opening the Retzius space. Using the same patient position and port placement, we perform a transperitoneal approach. First, we perform a longitudinal cystotomy on the bladder dome; we then secure each bladder wall to the lateral peritoneum with a Hem-O-Lock ( Fig. 17.8 ), obtaining excellent straight access to the adenoma. After proper identification of the trigonal area, we incise the bladder neck mucosa posteriorly to the adenoma ( Fig. 17.9 ); the plane between adenoma and the prostatic capsule needs to be identified; from this plane, the adenoma is dissected circumferentially and apically using a combination of cautery, traction and blunt dissection ( Fig. 17.10 ). During the apical dissection, we identify and section the urethra, preserving the verumontanum ( Fig. 17.11 ). The adenoma is then removed and we have excellent exposure of the prostatic bed and urethra, allowing us to easily perform the UVA.
After hemostasis, we perform a continuous modified van Velthoven UVA using the 3-0 poliglecaprone sutures ( Fig. 17.12 ), covering the entire prostatic fossa with mucosa. Finally, a 18 Fr two-way Foley catheter is placed into the bladder; we unclip the Hem-O-Lock previously placed and close the longitudinal bladder incision using a continuous suture with a 3-0 polyglactin ( Fig. 17.13 ). Adenoma removal is performed with an endobag and Foley catheter is inflated with 20 mL of distilled water. We do not routinely leave a drain, nor is continuous bladder irrigation necessary, as the anastomosis promotes excellent hemostasis of the prostatic fossa.
This approach differs from transperitoneal RASP in the way of accessing the prostate. The surgeon begins with the creation of the preperitoneal space with digital dissection and balloon inflation.
Carefully, all trocars should be inserted without perforating the peritoneum. After that, a vesico-capsular incision is performed from the anterior wall of the bladder to the bladder neck; the adenoma dissection is similar to the transperitoneal approach, using traction and counter traction.
Disadvantages of this approach include mandatory drainage of the Retzius space and higher risk of injuring the epigastric vessels, compared to the transperitoneal approach. Also, the surgical field is narrower, and to optimize the Retzius dissection a balloon dilator device is usually employed, thereby increasing procedural costs. ,
On the other hand, from the experience of comparative studies between different approaches of RARP, the extraperitoneal approach may prevent inadvertent bowel injuries, reduce postoperative pain and ileus, avoid the need of intraperitoneal adhesiolysis, and, in combination with a single port platform, may reduce the urethral catheter removal to the postoperative day one. , ,
Intrafascial simple prostatectomy
In 2013, Clavijo et al. reported the intrafascial simple prostatectomy. Similar to a radical prostatectomy, neurovascular bundles are preserved early in the intrafascial layer, and the prostate pedicle and deep DVC are divided and secured. In sequence, the urethra is sectioned, the seminal vesicle and vas deferens are cut at the prostate base and then sutured, and finally UVA is performed.
The authors defend that this technique offers some advantages such as: it eliminates the need for irrigation due to the absence of bleeding, facilitates the detection of prostate cancer and high-grade prostatic intraepithelial neoplasia, and prevents the development of prostate cancer or new prostate enlargement because it completely removes all prostatic tissue.
Although innovative, we believe this technique requires greater expertise from the surgeon and increases the unnecessary risk of erectile dysfunction during the treatment of a benign condition.
The da Vinci Single Port (da Vinci SP) surgical system is an evolution in the miniaturization process of the robotic surgery platform.
Steinberg et al. were the first to report a series using this platform. In this series, a surgeon with extensive experience in RASP performed 10 extraperitoneal and transvesical procedures through the robotic cannula of the da Vinci SP system placed in a median vertical incision of 2.5 cm positioned two fingers below the navel. The results were encouraging, with an average estimated blood loss (EBL) of 141 ± 98 mL; the operative time (OT) was 172 ± 19 minutes, and the mean catheter time was 1.9 ± 1.8 days.
They have demonstrated that this method was safe, feasible, and effective. However, as an initial series, the OT was still longer than conventional multiport RASP (median 95 minutes reported by Autorino et al. ), probably due to the learning curve inherent to the novelty. Maybe, the greatest achievement brought by da Vinci Single Port in RASP is a smaller incision over the bladder resulting in a shorter period of catheter, allowing removal on the first postoperative day for most patients.
Robotic-total prostatectomy for low-risk prostate cancer patients with enlarged glands
Recently Pathak et al. reported 12 consecutive patients submitted to this novel technique developed by them, with similar trocars placement and patient positioning for RASP. They described the procedure through the transperitoneal approach, following bladder drop and with a complete circumferential bladder neck sparing.
Once the posterior bladder neck is identified, an incision is made two-thirds down or one-third above the traditional bladder neck ( Fig. 17.14 ), with the main premise of dissecting above Denonvilliers’ fascia sparing musculofascial plate, seminal vesicle, and ampulla of the vas deferens.
Then the prostate is dissected following the plane at the level of the pseudocapsule, the outer stromal edge of the prostate parenchyma. Thereafter, a complete circumferential anatomic UVA is performed. No continuous bladder irrigation is required. Hospital discharge occurs at the first postoperative day and Foley catheter removal at 1 week.
They included mainly patients with inconclusive but suspicious prostate biopsies (e.g., ASAP, HGPIN, negative biopsy with suspicious resonance). Final pathology demonstrated only one patient with HGPIN and all others had prostate cancer (ISUP 1 in seven patients; ISUP 2 in two and ISUP 3 in two), all with negative surgical margins. The mean postoperative PSA levels at 3 and 15 months (9/12 patients) were .03 (.006 to .07) and .04. No patients required additional treatment for LUTS. Only one patient developed stress urinary incontinence with no pad needed after 6 weeks postoperatively. Urinary continence and pad free status were achieved in all patients at the 3-month postoperative period. The SHIM score reduced, on average, 5.5 points compared to preoperative.
Data comparing outcomes between RASP, LSP, and OSP for the treatment of large prostatic adenoma (>80 mL) are limited. There are some retrospective comparative series of RASP with other treatment modalities. Recently, a randomized clinical trial (RCT, level 1 evidence) comparing RASP, LSP, and Holmium Laser Enucleation of the Prostate (HoLEP) was described. Larger RCTs are desirable. We include herein the largest published series of RASP, with a minimum of 50 patients each. The data were tabulated and weighted means calculated using the number of patients in each study as the weighting factor. Preoperative characteristics ( Table 17.1 ), perioperative outcomes ( Table 17.2 ), and postoperative outcomes ( Table 17.3 ) are reported. Table 17.4 summarizes the largest comparative series including RASP with other techniques with a minimum of 30 patients.