SIU 2018: BPH Panel: Enucleation Techniques: Robot-assisted Simple Prostatectomy

Seoul, South-Korea ( Thomas Guzzo, MD described the robotic surgical treatment of benign prostatic hyperplasia (BPH). According to both the American Urologic Association (AUA) and European Association of Urology (EAU) guidelines, open prostatectomy is recommended for patients with large prostates, greater than 80-100 cc. However, according to Dr, Guzzo, open prostatectomy is a morbid procedure with a high estimated blood loss, high rates or perioperative complications, and prolonged length of hospital stay. In a nationwide inpatient sample from 1998 to 2010, among all open prostatectomies cases during 2008-2010 (6027 cases), the blood transfusion rate was 21%, and the median length of hospital stay was four days (IQR 3-5).1

Due to this significant morbidity, robotic surgery for BPH was explored. This type of surgery was first reported in 2008, in a publication describing the first 7 cases.2 However, in recent years, this procedure has been implemented more commonly with a growing number of centers that perform this procedure. In indirect comparisons, simple robotic prostatectomy has been shown to have a shorter length of hospital stay, lower morbidity profile, and similar functional outcomes compared to open prostatectomy.3 In a direct comparison, simple robotic prostatectomy was shown to provide similar functional outcomes but offers the advantage of the reduced length of hospital stay and reduced blood loss.4

The rationale for using robotic prostatectomy for large prostates includes several important reasons. The robotic procedure has a good safety profile; it is minimally invasive with a shorter length of hospital stay. It also enables the surgeon the possibility to treat any concomitant bladder disease (such as stones or diverticula), there is no cost to buy additional technology/equipment in centers with an already established robotic program. Furthermore, there is a short learning curve for surgeons who already perform radical robotic prostatectomy. Due to these reasons, the simple robotic prostatectomy will likely continue to increase in the robotic surgical era.

Before completing his presentation, Dr. Guzzo gave some tips and tricks on how he performs the simple robotic prostatectomy. Patient position and port placement are identical to that used in robotic radical prostatectomy, but with only one assistant port. Once the abdomen is entered, the first step is the development of the space of Retzius. Next, a horizontal cystotomy is performed, the adenoma is enucleated, making sure the right plane is entered and that the ureteral orifices are far away from the dissection plane. Lastly, hemostasis is achieved, and the bladder defect is closed.

Dr. Guzzo believes this is a safe and simple procedure to master, with excellent functional outcomes, a short length of hospital stay, and minimal side effects. All these make the robotic simple prostatectomy ideal for large prostates that require surgical treatment.

Presented by: Thomas Guzzo, MD University of Pennsylvania, United States

1. Kellogg Parsons J et al. J. Endourol 2015
2. Sotelo R et al. J Urol 2008
3. Curr Urol Report 2018 July
4. Sorokin I et al. J. Endourol 2017

Written By: Hanan Goldberg, MD, Urologic Oncology Fellow (SUO), University of Toronto, Princess Margaret Cancer Centre  Twitter: @GoldbergHanan at the 38th Congress of the Society of International Urology - October 4- 7, 2018 - Seoul, South Korea