Minimally Invasive Surgery for Benign Prostate Disease: Laparoscopic and Robotic Techniques

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Minimally Invasive Surgery for Benign Prostate Disease: Laparoscopic and Robotic Techniques

Mark Ferretti, Amul Bhalodi, & John Phillips

New York Medical College, Department of Urology, Valhalla, NY, USA

Introduction

Benign prostatic hyperplasia (BPH) is one of the most common diagnoses in a majority of urologic practices. Although the treatment options for symptomatic bladder outlet obstruction have expanded dramatically over the past several decades, the simple prostatectomy remains the gold standard for complicated bladder outlet obstruction associated with a large prostate volume, generally greater than 80 g. Transurethral resection of the prostate (TURP) is a feasible option for the treatment of very large prostates, but this can lead to suboptimal results, and, especially for monopolar TURP, may predispose patients to post‐transurethral resection syndrome [1]. It is also known that 12–15.5% of patients receiving TURP required further surgery, while only 1.8–4.5% of those treated with open surgery underwent reoperation within 8 years [2].

Simple prostatectomy is neither simple in technique nor indication and may have short‐ and long‐term complications which are similar to and in some cases more clinically significant than those from radical prostatectomy. Simple prostatectomy is indicated for prostate glands of a volume that may far exceed those of the average prostate gland undergoing prostatectomy for prostate specific antigen (PSA)‐identified prostate cancer. Men who undergo simple prostatectomy are on average older and carry more comorbidities than men undergoing radical prostatectomy. The advent of modern medical therapy for prostatic enlargement markedly changed the use of surgery for prostatic hypertrophy, including transurethral and open techniques. When open prostatectomy occurs in today’s era, therefore, the patient has often had years of unsuccessful medical therapy, may have endured chronic urinary retention, along with the long‐term effects of chronic bladder outlet obstruction. Open surgery in such men was classically associated with blood loss and a transfusion rate exceeding 25%, a prolonged hospital stay, wound healing, and incontinence [3]. Despite the success of the open prostatectomy, there are significant disadvantages, namely the need for an extraperitoneal incision, bleeding requiring transfusion, sphincteric, neurovascular bundle, or rectal injury, prolonged hospital stays, and increased catheterization time [4].

The modern era of minimally invasive surgery for BPH began several years and several hundred cases after the laparoscopic approach to prostate cancer was established. By 2005, groups with experience in robot‐assisted laparoscopic prostatectomy (RALP) began adopting the approach to benign prostatic diseases, such as BPH [5]. The technique for BPH using laparoscopy and robotics is different enough from the approach for prostate cancer to warrant this chapter specifically devoted to the development, controversies, and potential future role of minimally invasive surgery in the management of benign prostatic disease.

Historical context

Open prostatectomy was first performed via cystotomy in 1894 by Eugene Fuller and then popularized by Peter Freyer in 1900 and Robert Proust in the early 1910s. Hugh Hampton Young of Baltimore and Terrence Millin of Dublin, Ireland recognized that cystotomy may add undue morbidity to the procedure and often precluded visualization of the distal adenoma and sphincter [6]. Young proposed a perineal prostatectomy in 1904 to avoid cystotomy. Millin proposed a purely retropubic approach for more control over the prostatic apex during enucleation to avoid traction injury to the urethral sphincter, and more adequate prostatic exposure at the expense of bladder accessibility [2, 7]. The transvesical approach allows the urologist to treat concomitant bladder pathology via direct access to the bladder at the time of adenomectomy and may, therefore, be preferred over the retropubic approach when bladder calculi, large median prostatic lobes, or bladder diverticula are present [8]. Indications for prostatectomy include catheter‐dependent urinary retention, bothersome lower urinary tract symptoms that is refractory to medical therapy, frequent urinary tract infections secondary to retention, severe hematuria secondary to prostatic bleeding, bladder calculi, and chronic kidney disease secondary to prostatic enlargement. Open simple prostatectomy may be preferred over TURP with prostates larger than 80 g because TURP was historically associated with morbidity and mortality rates of 55% and 6%, respectively, while the open prostatectomy had mortality rates of 3.3% [8, 9]. Additional indications for open surgery include concomitant surgically amenable bladder conditions, planned concomitant hernia repair, and patients in whom ankylotic or degenerative joint disease of the hip prevents the lithotomy position [2]. Today, mortality rates from both procedures approach 0%, an effect of medical optimization and clearance of most active urinary tract infections prior to elective surgery [2, 8, 10]. Furthermore, modern techniques, such as holmium laser enucleation of the prostate (HoLEP) and potassium titanyl phosphate crystal laser (KTP) have produced favorable results in large prostates and have further decreased the prevalence of open prostatectomy [11–13]. However, drawbacks to laser surgery for prostates >80 g include cost, steep learning curve, specialized equipment, prolonged urethral instrumentation with associated urethral complications (e.g. bladder neck contracture), and the need to morcellate laser‐resected tissue free‐floating in the bladder. Disadvantages of the open prostatectomy include need for extraperitoneal incision, bleeding requiring transfusion, sphincteric, neurovascular bundle, or rectal injury, prolonged hospital stays, and increased catheterization time [14].

The open surgical approach remained the gold standard for 100 years, the majority of subjects undergoing suprapubic approaches, followed by retropubic, and, least popular, the perineal prostatectomy, first performed by Young in October 1902. A major change came with the advent of laparoscopic radical prostatectomy, first performed by Schuessler in 1991, refined by Bertrand Guillonneau, Guy Vallencien, and Claude Abbou throughout the late 1990s. Mirandolino Mariano is generally regarded as the first surgeon to intentionally course along the retro‐adenomatous plane to deliver obstructing adenomas and achieve a pure laparoscopic simple prostatectomy (LSP) of a 173 g prostate [15–17]. Reported advantages over the open approach included improved visualization of the adenoma and venous tamponade due to pneumoperitoneum during dissection and the avoidance of a major lower abdominal incision. Disadvantages were the mechanical challenge in laparoscopic manipulation of very large adenomas, steep learning curve, and complex suturing required in capsule plication and advancement of the bladder neck [4, 18]. Additional disadvantages were the lack of articulation of traditional laparoscopic instruments and the small working space for plicating, anastomotic, and hemostatic suture placement. LSP did, however, improve upon blood loss and length of stay compared to similar series of open prostatectomy and may be performed safely and effectively for the treatment of bladder outlet obstruction secondary to BPH. The advent of robotic surgery has largely supplanted straight laparoscopic techniques for benign disease as robotics has done for radical surgery as well [19].

The first radical robotic prostatectomy was performed by Binder et al. in Hanover in a collaborative effort that pioneered the use of the da Vinci® platform in 2000. This revolutionized an approach that is now performed three times more commonly than open surgery for prostatic cancer. Robotic prostatectomy greatly alleviated the burdens of laparoscopic techniques for cancer surgery and made the procedure more accessible. As applicability of robotics to cancer surgery grew, robotics was also considered for benign surgery. Sotelo et al. are regarded as the first group to have performed a simple prostatectomy robotically in 2008, after years of laparoscopic experience [5]. Robotic surgery offers the theoretical advantage over laparoscopy of a faster learning curve, especially regarding suture techniques, with the presumably shared benefits of laparoscopy, including less perioperative morbidity, improved visibility and precision, faster recovery, and ability to demonstrate technique and disseminate skills via the sharing of surgical videos on the internet and social media platforms. Disadvantages of the robotic approach include cost of the device, longer operative times, incomplete resections, and, when performed, the transperitoneal invasiveness of procedure [20].

Technique

The technique of straight laparoscopic versus robotic simple prostatectomy is essentially the same, although there are minor differences in port placement, modifications that have occurred in the robotic era, and specific characteristics of robotics owing to its instrumentation. These are described in the text below.

Port placement

Traditional multiple‐ and single‐access laparoscopic techniques must all ensure an angle and depth of visualization and access to the surgical target, including the distal adenoma and pelvic floor. There are essentially no significant differences, therefore, in port placement for simple or radical laparoscopic prostatectomy. Traditional multiport access prostatectomy begins with placement of five trocars either extra‐ or transperitoneally [16, 21].

The extraperitoneal approach

The extraperitoneal (EP) approach involves making a 12 mm infra‐umbilical incision and dissecting down to the anterior rectus fascia. This fascia is incised transversely and the bellies of the recti abdomini are separated bluntly in the midline. Finger dissection inferiorly is carried out in the preperitoneal space, taking care to avoid incidental peritoneotomy by applying anterior pressure inferiorly when the posterior rectus fascia disappears below the arcuate line. A 12 mm balloon dissector with 10 mm visual optical channel is inserted and directed inferiorly toward the pubis and into the developed preperitoneal space. The balloon is slowly inflated under direct visualization. In the correct plane, the inferior epigastric vessels remain visible ventrally. The balloon is deflated and the balloon trocar is inserted, a 0° optical lens is inserted, and the space is filled with 10–15 mmHg of CO₂. Four additional trocars are inserted under direct vision with two 5 mm trocars close to the anterior superior iliac spines and two 10 mm trocars lateral to the rectus and 5–10 cm below the umbilicus. The proper space during development appears similar to that encountered in typical transperitoneal access. Joseph found that additional advantages of an extraperitoneal approach was the compartmentalization of any urinoma or hematoma, decreased rates of nonobstructive ileus, and decreased rates of early narcotic‐dependent pain scores in those with ASA scores of 1–3 [22, 23].

The transperitoneal approach

The transperitoneal (TP) approach enters the abdominal cavity directly via a midline or transverse supra‐umbilical 10 mm incision. The rectus fascia is thinned with dissection using a Crile. A Veress needle is used to insufflate the abdomen through the fasciotomy and after pressures have reached 10 mmHg, the Veress is replaced with a 12 mm camera port. Visual inspection identifies the urachus and the medial umbilical ligaments, the pulsation of the iliac vessels and bladder in the midline. Placement of robotic ports occurs one handbreadth or 5–7 cm from the camera port in a line slightly inferior to a transverse perpendicular. Assistant 5 and 10 mm ports are placed in the right upper and right lower quadrant, respectively. Single‐access devices allow for a camera port and two manipulator arm ports, typically through a midline para‐umbilical incision but lateral 5 and 10 mm ports will be required for suction and assistant introduction of needle suture material during the case [24, 25].

Planes of dissection

After successful insufflation of the space of Retzius in an EP approach, or release of the prevesical peritoneum in a TP approach, the arachnoid fibers and areolar tissue of the space are divided to identify the pubic rami. The endopelvic fascia is not punctured and the puboprostatic ligaments are not divided. Apparent in simple prostatectomy is the space in the deep pelvis occupied by the often markedly enlarged prostate not typically encountered in radical prostatectomy. Glands of >300 g may make even dissection to the symphysis pubis challenging and can be deferred. Manual inspection of the transition point between bladder and prostate is replaced by visual landmarks. Deformation of the “shoulders” of the prostate can be appreciated, but may be challenging with large prostates and without interrupting the fibers of the endopelvic fascia. Instead, careful manipulation of the bladder, filled with 200 ml NaCl, may be required to identify the transition to firm prostatic median and lateral lobes from the softer bladder wall. A Foley catheter, when withdrawn to the bladder neck, may not be visible owing to lateral deflection by the obstructing lobes. There is some variation as to the position of the cystotomy. Ideally, the camera will provide a view that is parallel with the planes of dissection and in larger prostates this may require a cystostomy far more cephalad than typically performed for radical prostatectomy.

Leslie et al. employed a “transvesical” approach in which a midline cystotomy is made at the dome of the bladder without development of the space of Retzius at all [26]. Alternatively, an appropriate transverse cystotomy is made that is large enough to expose the adenoma and preferably the ureteral orifices. The prostate must be elevated anteriorly away from the bladder neck and a large adenoma will be difficult to secure with ProGrasp® instruments alone. Instead, a CT‐1 suture is often required through an untied figure of eight, secured with a large Weck clip which is then easier to manipulate with the #4 arm ProGrasp. It is not uncommon for the surgeon to make a cystotomy and be unable to identify the cephalad extent of markedly large median lobes with an intravesical component. The CT‐1 suture technique will be helpful to bring the lobe up into cystotomy wound to better appreciate its extent.

Identification of the ureteral orifices (UOs) is critical but the use of methylene blue or indigo carmine is largely deferred owing to the obfuscation of landmarks by excreted dye. The operator needs to recall that it is not the prostate which one sees upon inspecting the deformed bladder neck but rather the mucosa and the muscularis of the bladder which are being elevated upwards by the hypertrophic adenomata deep to these tissues.

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