Despite widespread use of medical therapy for benign prostatic hyperplasia, a need remains for robust surgical therapy in select patients. Robotic-assisted simple prostatectomy (RASP) is an efficacious and safe therapy for patients with bladder outlet obstruction owing to large volume prostates. Data from 13 published cohorts suggest functional outcomes equivalent to open simple prostatectomy with substantially decreased length of hospital stay and risk of transfusion. However, there are few longer term data.
Key points
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Simple prostatectomy performed by any approach declined in the last 15 years.
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In 2012, 5% of all simple prostatectomies were performed laparoscopically in the US.
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Few large series limited to robotic prostatectomies have been published, with limited data on retreatment rates.
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However, existing data suggest that robotic prostatectomy is associated with equivalent functional outcomes, a significant reduction in transfusion rates, decreased hospital length of stay, and no difference in hospital charges compare to the open approach.
Introduction
Despite widespread use of medical therapy, the global incidence and prevalence of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms have increased in the past 2 decades. At least 6.5 million men in the Unites States and 1.1 billion men globally suffer from BPH.
Factors likely driving these trends include an aging population and an increased prevalence of metabolic disorders such as diabetes, obesity, and the metabolic syndrome, all of which are associated with increased risks of BPH and lower urinary tract symptoms. As a result, the incidence of BPH-associated adverse medical events has persisted and, in the case of urinary retention, possibly increased.
Indications for BPH surgical therapy focus primarily on adverse medical events and include urinary retention, renal failure secondary to BPH, urinary infections, bladder calculi, hematuria, and failure of—or inability to tolerate—medications. Thus, even in an era of BPH medical therapy, the need for BPH surgery persists.
In patients requiring surgery, EAU and AUA Guidelines recommend consideration of open simple prostatectomy (OSP) for the surgical treatment of patients with large volume (>80 mL) glands ( www.EAU.org , www.AUA.org ). Refined from transcapsular and transvesical techniques described by Freyer and Millin, OSP substantially improves International Prostate Symptoms Score, urinary flow rate, quality of life, and postvoid residual volumes.
However, OSP has also been associated with relatively high rates of perioperative transfusion, prolonged hospital duration of stay, reoperation, and urinary infections. An analysis of the US Nationwide Inpatient Sample (NIS), for example, observed a transfusion prevalence of 21% among more than 6000 OSP procedures performed in the United States from 2008 to 2010. In multiple single institution series, perioperative transfusion rates ranged from 3.3% to 36.8%, and perioperative mortality was as high as 2.1%. Other adverse events include clot retention, bladder neck contracture, wound infection, and myocardial infarction.
Robotic-assisted laparoscopic simple prostatectomy (RASP), first described by Sotelo and colleagues in 2008, potentially improves perioperative outcomes for simple prostatectomy, and its use has been increasing. Two recent studies of the NIS examined trends in the use of simple prostatectomy. From 1998 to 2012, there was an overall decrease in the number of simple prostatectomies performed, but a modest increase in the proportion of minimally invasive simple prostatectomies (up to 5% of all surgeries by 2012), although neither study could differentiate laparoscopic from robotic techniques.
Herein, we describe a technique for transvesical robotic-assisted prostatectomy and review published evidence of RASP outcomes.
Introduction
Despite widespread use of medical therapy, the global incidence and prevalence of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms have increased in the past 2 decades. At least 6.5 million men in the Unites States and 1.1 billion men globally suffer from BPH.
Factors likely driving these trends include an aging population and an increased prevalence of metabolic disorders such as diabetes, obesity, and the metabolic syndrome, all of which are associated with increased risks of BPH and lower urinary tract symptoms. As a result, the incidence of BPH-associated adverse medical events has persisted and, in the case of urinary retention, possibly increased.
Indications for BPH surgical therapy focus primarily on adverse medical events and include urinary retention, renal failure secondary to BPH, urinary infections, bladder calculi, hematuria, and failure of—or inability to tolerate—medications. Thus, even in an era of BPH medical therapy, the need for BPH surgery persists.
In patients requiring surgery, EAU and AUA Guidelines recommend consideration of open simple prostatectomy (OSP) for the surgical treatment of patients with large volume (>80 mL) glands ( www.EAU.org , www.AUA.org ). Refined from transcapsular and transvesical techniques described by Freyer and Millin, OSP substantially improves International Prostate Symptoms Score, urinary flow rate, quality of life, and postvoid residual volumes.
However, OSP has also been associated with relatively high rates of perioperative transfusion, prolonged hospital duration of stay, reoperation, and urinary infections. An analysis of the US Nationwide Inpatient Sample (NIS), for example, observed a transfusion prevalence of 21% among more than 6000 OSP procedures performed in the United States from 2008 to 2010. In multiple single institution series, perioperative transfusion rates ranged from 3.3% to 36.8%, and perioperative mortality was as high as 2.1%. Other adverse events include clot retention, bladder neck contracture, wound infection, and myocardial infarction.
Robotic-assisted laparoscopic simple prostatectomy (RASP), first described by Sotelo and colleagues in 2008, potentially improves perioperative outcomes for simple prostatectomy, and its use has been increasing. Two recent studies of the NIS examined trends in the use of simple prostatectomy. From 1998 to 2012, there was an overall decrease in the number of simple prostatectomies performed, but a modest increase in the proportion of minimally invasive simple prostatectomies (up to 5% of all surgeries by 2012), although neither study could differentiate laparoscopic from robotic techniques.
Herein, we describe a technique for transvesical robotic-assisted prostatectomy and review published evidence of RASP outcomes.
Surgical technique
We describe a technique for suprapubic, transperitoneal RASP which emulates classic anatomic principles of suprapubic OSP. Other investigators have described retropubic and preperitoneal approaches for RASP. There is no evidence in the literature to suggest that any one of these techniques is superior to the others.
Preoperative Evaluation and Preparation
Judicious screening for prostate cancer should be considered per evidence-based recommendations ( www.nccn.org ). Although prostate adenocarcinoma has been reported in up to 10% of series of simple prostatectomy, the clinical significance of this observation in the modern era is unclear.
Per evidence-based guidelines, transrectal ultrasonography, cystoscopy, and urodynamics may be considered, and may be helpful in establishing the need for simple prostatectomy. Documentation of prostate volume, intravesical protrusion of median lobe, diverticuli, and calculi may be noted. Standard considerations for the preoperative evaluation of a patient undergoing laparoscopy may be made. Bowel preparation is unnecessary.
Patient Setup
The patient is placed in the supine Trendelenburg position with the legs spread, identical to the positioning for a robotic-assisted radical prostatectomy, with a Foley catheter in the bladder and 5 or 6 ports placed across the lower abdomen: typically a camera port, three 8-mm arm ports, and a 12-mm assistant port ( Fig. 1 ). The robot is docked in the standard fashion.
Prostate Exposure
In an initial approach identical to robotic-assisted radical prostatectomy, an incision is made in the anterior abdominal wall and the space of Retzius is accessed in the standard transperitoneal fashion. The medial and the median umbilical ligaments are transected and the bladder is released from the anterior abdominal wall. A transverse or vertical incision is made in the anterior bladder 2 to 3 cm proximal to the junction of the prostate and the bladder. The bladder lumen is entered, exposing the prostate adenoma.
Alternatively, the bladder is filled with normal saline to mark its boundaries and incised vertically on the posterior wall to enter the lumen. To provide fixed exposure of the bladder neck and prostate adenoma, the cystotomy incision is secured open with four 2-0 Vicryl sutures, 2 each placed at the anterior and posterior apices of the incision. The anterior and posterior sutures are secured in place to the anterior and lateral abdominal wall, respectively, with hemolock clips. The incision is lengthened as needed to afford additional exposure. Retraction sutures can be placed at the lateral margins of the cystotomy and affixed to the abdominal wall to facilitate exposure.
Development of the Posterior Plane
To provide exposure of the posterior plane, the median lobe is placed on anterior traction by grasping it with the Prograsp forceps attached to the third arm of the robot. To minimize tissue tearing, we recommend placement of a 0 silk suture on a tapered needle through the adenoma in a figure-of-8 configuration, which then may be grasped with the forceps. The suture also facilitates dynamic repositioning of traction as the surgical plane develops circumferentially around the adenoma.
The bladder trigone and ureteral orifices are identified. A transverse, semicircular incision is made in the bladder mucosa along the posterior aspect of the adenoma corresponding with the posterior curve of the adenoma and the plane between the adenoma and capsule is entered. As the posterior plane between the adenoma and the peripheral zone is developed distally toward the prostatic apex, the bladder trigone and ureteral orifices drop posterior and cephalad.
Development of the Lateral and Anterior Planes
The mucosal incision is extended on the left and the right, first laterally, then anteriorly, such that the left and right extensions of the initial posterior incision are made to join anteriorly. Once the circumferential mucosal incision is completed, the plane between the adenoma and the peripheral zone is developed circumferentially in a distal fashion toward the prostate apex. Perforating vessels are cauterized with monopolar or bipolar energy as needed. The traction on the median lobe is repositioned as necessary to provide appropriate exposure; in general, continued cephalad traction will aid dissection.
Transection of the Urethra and Removal of the Adenoma
Once the adenoma is completely mobilized, the urethra is transected sharply at the apex under direct visualization, which allows urethral transection to occur well proximal to the external urinary sphincter. The adenoma is removed from the bladder and placed out of the operative field, for later extraction.
Advancement of the Bladder Neck Mucosa
The bladder neck mucosa is advanced to the distal urethral mucosa using 2 figure-of-eight 2-0 Vicryl sutures or as a continuous 3-0 monocryl V-lock suture.
Bladder Closure
A 22-F or 24-F 3-way Foley catheter is placed under direct visual guidance into the lumen of the bladder. The bladder incision is then closed in multiple layers using a 3-0 Vicryl suture for the urothelium and 2-0 Vicryl for the detrusor muscle, both in a running fashion. If a transverse incision was made proximal to the bladder neck, the bladder incision is closed with a single full thickness 2-0 Monocryl suture in a running fashion. A Jackson-Pratt drain is placed. The Foley catheter is placed on traction, and consideration is given to initiating continuous bladder irrigation at a slow to moderate rate.
Postoperative Care
The catheter should be left to traction as needed for up to 2 hours after surgery, and continuous bladder irrigation should be used. Unless otherwise indicated clinically at an earlier time, hemoglobin and hematocrit are measured on the first postoperative day. If pain is well-controlled, laboratory test values are acceptable, and they are tolerating a diet, patients are discharged to home on postoperative day 1 with Foley catheter removal 1 week after surgery. A cystogram is not routinely obtained before catheter removal.
Related posts:
The Epidemiology of Benign Prostatic Hyperplasia Associated with Lower Urinary Tract Symptoms
Diagnostic Work-Up of Lower Urinary Tract Symptoms
Alpha-blockers for the Treatment of Benign Prostatic Hyperplasia
Convective Water Vapor Energy for Lower Urinary Tract Symptoms/Benign Prostatic Hyperplasia
Bipolar, Monopolar, Photovaporization of the Prostate, or Holmium Laser Enucleation of the Prostate
Sexual Side Effects of Medical and Surgical Benign Prostatic Hyperplasia Treatments
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