By Jaya Sai Chavali, MD; Juan Garisto, MD; and Jihad Kaouk, MD
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In this video case study, we demonstrate our step-by-step simplified robot-assisted prostatectomy technique to successfully treat benign prostatic hyperplasia (BPH). Of particular note, the robotic approach offers excellent visualization of the surgical field, decreases blood loss and most important, speeds healing, even in cases like this one with a large (100+ cc) prostate. Rapid healing is due to our added ability to advance the mucosa over the excision site to eliminate raw surface at the excision bed.
A 73-year-old man with a history of lower urinary tract symptoms presented to our practice with an International Prostate Symptom Score (IPSS) of 22 and urinary retention. Preoperative assessment included a cystoscopy that demonstrated a bilobar obstructing prostate (estimated prostate volume of 400cc) and normal urothelial lining. His PSA was 2.2. Due to failed medical therapy and the severity of the gentleman’s complaints, we elected to perform robot-assisted simple prostatectomy.
We have refined a simplified robot-assisted prostatectomy technique that provides excellent visualization. Major steps in this robotic procedure:
- Five ports were placed in a fan-shaped configuration for robotic prostate surgery.
- The bladder was incised in the anterior midline. Keith needles were used to assist in retraction of the bladder edges and the Foley catheter for a superior view of the surgical field.
- Trigone and ureteral orifices were identified and mucosa was incised posteriorly due to the large asymmetric median lobe.
- Incision was carried deep into the surgical capsule and a plane was developed bilaterally and posteriorly.
- Due to the large lobe size, the adenoma was split into three smaller portions for easier extraction.
- To avoid injury to the urethral sphincter, the Foley catheter was used as a guide during the dissection of the prostatic apex after removal of lateral lobes.
- Distal mucosal trigone was reapproximated to the distal urethral edge using 2-0 polysorb suture.
- Initial bladder incision was repaired in a watertight fashion with a running 2-0 V-Loc suture.
Total operative time was 186 minutes with an estimated blood loss of 200 ml. Pathology reported BPH with a prostate volume of ±300 cc. There were no intraoperative complications.
The patient was discharged on postoperative day one. A cystogram performed two weeks after surgery showed a dye-filling defect contained in the prostatic capsule area and no extravasation. The vesicourethral junction was intact after the removal of the adenoma.
Our simplified robot-assisted prostatectomy procedure, simple to perform by experienced surgeons, offers distinct advantages particularly for patients with large prostate volumes.
Drs. Chavali and Garisto are clinical fellows at the Glickman Urological & Kidney Institute.