Less is known about the feasibility of combining renal surgery with robot-assisted simple prostatectomy (RASP) for patients with concurrent renal cell carcinoma (RCC) and symptomatic lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH).
In our case series, we describe two patients who underwent combined nephrectomy and RASP during a single operative session. The first patient underwent off-clamp robot-assisted partial nephrectomy followed by RASP for biopsy-confirmed clear cell RCC and severe LUTS due to a 136 mL prostate. The second patient presented with papillary RCC in the setting of polycystic kidney disease and advanced chronic kidney disease, as well as LUTS due to a 153 mL prostate, and underwent laparoscopic radical nephrectomy followed by RASP. Despite comorbidities in both patients, the procedures were completed with minimal blood loss, no perioperative complications, and excellent postoperative recovery, leading to discharge from the hospital on postoperative days 1 and 3, respectively.
Combined surgery requires deliberate consideration of operative sequence, patient positioning and repositioning, port placement, and coordination between surgery and anesthesia teams. In both cases, the renal portion was performed first to prioritize the oncologic component of the operation. The patient was then repositioned for RASP, and several trocar sites were reused between the renal and prostatic portions of the procedure. This port-sharing strategy reduced the number of total incisions, improving cosmesis while preserving access for each segment of the case.
These cases also highlight the efficacy of RASP and its place in the landscape of surgical management options for BPH. RASP remains an effective option for large and very large glands, even with the rising popularity of holmium laser enucleation of the prostate (HoLEP).3 Compared to HoLEP, the potential advantage of RASP is the more forgiving learning curve (i.e., 5-10 cases required for proficiency in RASP versus 50 cases for HoLEP).4,5 Compared to the traditional open simple prostatectomy (OSP), RASP is also associated with lower perioperative morbidity and decreased length of stay.6 Furthermore, robotic surgery platforms are widely available and already in use for many oncologic procedures, which defrays the substantial fixed overhead cost related to the procedure.7 For experienced robotic surgeons, RASP is feasible and can be implemented with perioperative and functional outcomes that compare favorably to HoLEP.
Our experience suggests that combined RASP with robotic or laparoscopic renal surgery is feasible in select patients and may offer a safer approach to managing synchronous upper and lower urinary tract disease. As robotic experience continues to grow, the emphasis should remain on individualized surgical planning that reduces treatment burden without compromising oncologic safety, functional outcomes, or perioperative risk.
Written by: Johnny Wang, BS, University of California Irvine, Department of Urology, Orange, CA, USA
References:
- Boncher N, Vricella G, Greene G, Madi R. Concurrent robotic renal and prostatic surgery: initial case series and safety data of a new surgical technique. J Endourol. 2010;24(10):1625-1629. doi:10.1089/end.2010.0151
- Eun D, Bhandari A, Boris R, Rogers C, Bhandari M, Menon M. Concurrent upper and lower urinary tract robotic surgery: strategies for success. BJU Int. 2007;100(5):1121-1125. doi:10.1111/j.1464-410X.2007.07105.x
- Benzouak T, Addar A, Prudencio-Brunello MA, et al. Comparative Analysis of Holmium Laser Enucleation of the Prostate and Robotic-Assisted Simple Prostatectomy in Benign Prostatic Hyperplasia Management: A Systematic Review and Meta-Analysis. J Urol. 2025;213(2):150-161. doi:10.1097/JU.0000000000004297
- Sosnowski R, Borkowski T, Chłosta P, et al. Endoscopic simple prostatectomy. Cent Eur J Urol. 2014;67(4):377-384. doi:10.5173/ceju.2014.04.art12
- Michalak J, Tzou D, Funk J. HoLEP: the gold standard for the surgical management of BPH in the 21(st) Century. Am J Clin Exp Urol. 2015;3(1):36-42.
- Pandolfo SD, Del Giudice F, Chung BI, et al. Robotic assisted simple prostatectomy versus other treatment modalities for large benign prostatic hyperplasia: a systematic review and meta-analysis of over 6500 cases. Prostate Cancer Prostatic Dis. 2023;26(3):495-510. doi:10.1038/s41391-022-00616-4
- Turchetti G, Palla I, Pierotti F, Cuschieri A. Economic evaluation of da Vinci-assisted robotic surgery: a systematic review. Surg Endosc. 2012;26(3):598-606. doi:10.1007/s00464-011-1936-2