Introduction

Simple prostatectomy for benign prostatic hypertrophy (BPH) is indicated for failure of medical management in the context of gland size not manageable with transurethral means and for BPH with concurrent bladder diverticula, stones, median lobe hypertrophy, and retention. Medical treatment remains the treatment of choice for benign prostatic BPH for organ size <80 g.

Surgical intervention with transurethral resection of the prostate (TURP) is indicated with failure of medical management, and for prostate sizes >80 g simple prostatectomy is superior to TURP due to the increased risk of transurethral resection syndrome associated with TURP [1]. Holmium laser enucleation has also been used for BPH and found to be of similar or superior functional outcomes compared with open simple prostatectomy (OSP); it has shorter operative time and hospital stay, and little blood loss, but is technically difficult [2, 3].

With the introduction of laparoscopy, conventional laparoscopic simple prostatectomy (LSP) has also been successfully performed [4]. OSP remains the procedure of choice for symptomatic prostate adenoma due to the steep learning curve associated with LSP. A comparative study showed LSP to be similar in functional outcomes and complications but superior in terms of decreased blood loss and shorter recovery time [5]. However, operative time was increased, ostensibly because of technical difficulty associated with LSP.

Robotic technology has been used successfully in radical prostatectomy for treatment of localized prostate cancer (CaP). To our knowledge, two series exist documenting the feasibility of robotic-assisted laparoscopic simple prostatectomy (RLSP). Sotelo et al. [6] reported their experiences in 7 patients, and John et al. [7] used the preperitoneal approach successfully in 13 patients (3 with finger-assisted enucleation technique). Herein, we report our experience in 15 patients with favorable clinical outcomes and describe further the clinical advantages.

Materials and methods

Retrospective chart review of all patients treated at a single institution by robotic laparoscopic surgery for genitourinary disease from May 2007 to January 2010 was performed with institutional review board (IRB) approval. During this period, 423 patients were treated, of whom 15 men underwent RLSP. The indications for this procedure were persistent lower urinary tract symptoms (LUTS), urinary retention, and refractory gross hematuria related to BPH with/without gland size >80 g, bladder diverticula, bladder stones or median lobe hypertrophy. Demographic and clinical data were collected. Preoperative data recorded included age, history of prior instrumentations, PSA, transrectal ultrasound (TRUS)–estimated prostate volume, International Index for Erectile Function (questions 1–5 and 15, also called IIEF-6), Index of Prostate Symptom Score (IPSS), urinary quality-of-life (UQOL) questionnaires, and urodynamics. UQOL scores were as recorded on the IPSS questionnaires by the patients. Operative and postoperative data including operative times, Foley catheter times, hospital days and complications, IPSS, UQOL, and PVR at 1, 2, and 3 months postoperatively were recorded.

Procedure

All procedures were performed with a da Vinci-S surgical system. Using standard techniques, the patient is prepped and draped in supine position with insufflation and port placement as for any laparoscopic pelvic surgery. The robot is docked. The retropubic space is identified and developed. A transverse incision is made at the bladder neck, opening the bladder to the 3 and 9 o’clock positions with ureteral orifices identified. Traction is placed on the posterior bladder neck and the prostate is approached via an incision into the bladder mucosa. The adenoma is mobilized posteriorly with the dissection involving sweeping laterally and anteriorly, with gentle traction and retraction down to the level of the apex. Traction on the apical adenoma and sharp dissection medially defines the posterior plane, preserving the verumontanum, and joins the posterior plane of dissection previously defined. The mobilized adenoma is then bagged.

Hemostasis is achieved with 2–0 Monocryl at the standard sites and electrocautery, and the trigone is advanced back to the level of the verumontanum. A 22-F two-way Foley catheter with 30-cc balloon is placed, and the bladder neck is closed with running locked suture. Irrigation of the bladder is then performed for any evidence of extravasation and a drain is placed anteriorly if needed. The robot is undocked and the specimen extracted. Port sites are closed in standard fashion.

Results

Table 1 shows the preoperative data recorded. Eleven men (73%) had persistent urinary retention, intravesical lobe hypertrophy was recorded in 93.3%, and 13.3% had bladder diverticula with/without stones. Average prostate size was 70.85 ml (Table 1).

Table 1 Demographic and clinical data
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Average operative time was 128.8 min, calculated from skin incision to closure. No drains were used with the procedures. Mean estimated blood loss (EBL) was 139.3 ml, and no blood transfusion was administered during or after procedures. Adenoma weights were recorded on the final surgical pathology reports. Mean adenoma weight was 46.4 g. All patients were admitted to the surgical floor following the procedures for postoperative care. Average hospital length of stay was 2.5 days. Eight (53%) of the men had their Foley catheters removed before discharge. Average Foley catheter time was 4.6 days, excluding catheter time for one patient admitted to another hospital for an unrelated illness. Including this patient, the average Foley catheter time was 5.7 days. Robotic inguinal hernia repair was performed for incidentally discovered inguinal hernia in two cases. In one of these cases, the repair broke down postoperatively, requiring reoperation for incarcerated hernia (Table 2).

Table 2 Operative data
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Postvoid urine residual (PVR) improved to a 3-month average of 44.19 ml postoperatively, with IPSS also improving to a monthly average of 8.13 (3-month average). UQOL score improved to a 3-month average of 2.2 (Table 3).

Table 3 Outcomes data
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Discussion

For prostatic adenoma greater than 80 g, there are alternatives to open simple prostatectomy. Conventional laparoscopic simple prostatectomy, Holmium laser enucleation (HoLEP), and robotic simple prostatectomy have all been successfully performed. There are several comparative studies that address clinical outcomes between all the techniques (Table 4).

Table 4 Comparative studies for simple prostatectomy
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In a retrospective study of 1,804 patients who underwent OSP, complication rates were reported as 11.6% with severe bleeding, 8.2% with transfusion, 8.6% with sepsis, 3.3% with early postoperative urinary retention, and 3.2% with reoperation; mean hospital time was 6.9 days [8]. In another prospective multicenter study of 902 patients who underwent OSP, the overall complication rate reported was 17.3%, with transfusion in 7.5% and reoperation due to severe bleeding in 3.7%, and mean hospital time of 11.9 days [1]. In contrast, laparoscopic simple prostatectomy series reported mean hospital time of 2 days, transfusion in 29%, and overall complication rate of 19% [4]. Comparing conventional laparoscopic and open simple prostatectomy, there was no significant differences in clinical outcomes. Operative time was longer in the laparoscopic group, but mean hospital time and Foley catheter time were shorter with LSP. Complication rates were similar in both groups, with the most common complication being hemorrhage, occurring in 28.1% in LSP and 29.3% in OSP [9]. Despite these studies, OSP has remained the main option for surgical treatment of large symptomatic prostatic adenoma in the urologic community. The apparent reason for this seems to be the steep learning curve associated with LSP.

With the evolution of robotic surgery in urology, robotic simple prostatectomy has been performed successfully, with favorable outcomes. Generally, the learning curve associated with robotic surgery is less compared with conventional laparoscopy [10, 11]. Advantages proposed include dexterity enhancement due to increased degrees of freedom and tremor filtering, restoration of hand–eye coordination, stereo vision with three-dimensional (3-D) view, and depth perception [12]. The main disadvantage with robotic surgery remains its high cost.

The feasibility of RLSP has been reported in two other series [6, 7]. In this series, we further substantiate it as an alternative minimal invasive procedure with low morbidity and favorable outcomes. Comparative studies may be needed to compare RLSP versus OSP and LSP to determine similarity and differences among the three surgical options for symptomatic prostatic adenoma.

Conclusion

Robotic simple prostatectomy is an alternative minimal invasive approach to open simple prostatectomy for surgical management of symptomatic prostatic adenoma. Further comparative study seems warranted.