NARUS 2018: Robotic Simple Prostatectomy: Transvesical Retzius-Sparing Approach
Open simple prostatectomy is the gold standard surgical procedure with durable long-term results, however this is associated blood loss, transfusions, and a long length of hospital stay. In the 2010 AUA guidelines, and even in the updated 2014 version, robotic and laparoscopic simple prostatectomy are still considered investigational procedures. National trends of all approaches for simple prostatectomy (2002-2012) assessed 35,171 patients, noting a median length of stay of 4 days, a 28% complication rate, 0.4% mortality rate. By 2012, 5% of simple prostatectomies were via a minimally invasive approach [1].
When answering the question “Why robotic simple prostatectomy”? Dr. Eun makes several important points:
1. There is less intraoperative blood loss secondary to better visualization, focused use of cautery, and pneumoperitoneum
2. Concomitant treatment of bladder problems, specifically diverticulectomy and cystolithotomy
3. Less complications and morbidity
4. Shorter length of stay
In a recently published, multi-institutional study assessing laparoscopic and robotic simple prostatectomy from 2010-2014, 23 institutions contributed 1,330 cases (38% robotic, 64% laparoscopic) [2]. The median prostate weight in this study was 100 grams, median EBL was 200cc, with a 3.5% transfusion rate. There was an overall complication rate of 10% and conversion to open rate of 3%. The median length of stay was 4 days and the incidental prostate cancer rate was 4%. HoLEP has also been recently compared to robotic simple prostatectomy in a single institution analysis (81 patients undergoing robotic simple prostatectomy vs 45 HoLEP) [3]. Comparing the two groups, there was a similar improvement in flow rate, PVR, and IPSS, as well as operative time. However, HoLEP had a shorter catheter time (2 vs 3 days) and short length of stay (2 vs 4 days). Dr. Eun notes that while HoLEP has shown good results, it requires a steep learning curve and appropriate equipment. Most urologists in the US are not adept with the technique and do not have the equipment. Alternatively, many urologists have access to the robot, have already invested significant time and effort towards the robotic learning curve, and are familiar with the anatomical dissection of the adenoma plane.
Dr. Eun notes there are various approaches to robotic simple prostatectomy, including retropubic, suprapubic, urethral sparing and posterior (retzius-sparing) approaches, of which Dr. Eun has favored since 2013 with >100 cases. He notes that the advantages are that the bladder is not dropped, there is a posterior longitudinal cystotomy with transvesical prostate dissection, a 360-degree running anastomosis of the bladder neck to the prostatic urethra, and he can inject Floseal into the prostatic fossa space. Typically, because of less bleeding, he doesn’t place a 3-way catheter but rather a 2-way 18Fr catheter. Patients are usually discharged on post-operative day #1 and the Foley catheter is removed in 5-7 days.
In summary, Dr. Eun notes that robotic simple prostatectomy is associated with a 3% transfusion rate, the anastomosis re-establishes urothelial continuity, a smaller 2-way catheter can be utilized which is removed in 1 week, with a quick recoverable recovery akin to a robotic radical prostatectomy.
References:
1. Pariser JJ, Pearce SM, Patel SG, et al. National trends of simple prostatectomy for benign prostatic hyperplasia with an analysis of risk factors for adverse perioperative outcomes. Urology 2015;86(4):721-725.
2. Autorino R, Zargar H, Mariano MB, et al. Perioperative outcomes of robotic and laparoscopic simple prostatectomy: A European-American multi-institutional analysis. Eur Urol 2015;68(1):86-94.
3. Umari P, Fossati N, Gandaglia G, et al. Robotic assisted simple prostatectomy versus Holmium laser enucleation of the prostate for lower urinary tract symptoms in patients with large volume prostate: A comparative analysis from a high volume center. J Urol 2017;197(4):1108-1114.
Speaker: Daniel Eun, Temple University Hospital, Philadelphia, PA
Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre @zklaassen_md at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV