V02-05: A possible way to solve outlet bladder obstruction and maintain a normal sexual function in large prostate adenomas: Robot-Assisted “Pure” Adenomectomy
The expansion of the indications of robotic technology let robot-assisted simple prostatectomy enter in the scenario of the surgical treatment of large benign prostatic hyperplasia (BPH). Thanks to the precise robotic dissection, the interest in “urethral sparing” technique with the aim of preserving the ejaculation has renewed. Robotic-Assisted “urethral-sparing” pure adenomectomy is presented in the video.
Since August 2017 all patients with large BPH (prostate volume >80 mL) were enrolled. Patients found with significant 3rd prostatic lobe at trans-rectal ultrasonography were excluded. Transperitoneal approach is chosen. A transversal, anterolateral incision is made between the dorsal venous complex and the bladder neck. The cleavage plane between the surgical capsule and the adenoma is identified anteriorly and gently dissected at the level of the prostate apex, bilaterally. Prostate capsule is barbed sutured and suspended to facilitate the adenoma enucleation. This step is performed following the avascular plane of the surgical capsule starting from the left lobe. Dissection proceeds from the prostate apex to the lateral face of the adenoma till the bladder neck. Then the posterior aspect of the surgical capsule is reached with a caudal-to-cranial dissection. Once the left lobe is mobilized, a longitudinal incision is made at the level of the anterior commissure. Urethra is medialized and gently dissected from the left lobe of the adenoma. At the end of the step the left lobe is removed. The procedure is repeated on the right. Finally, the whole adenoma is removed with urethra spared inside the prostatic lodge. “Pure” adenomectomy is completed. Hydro-distension test is performed to verify the urethral integrity. Prostatic capsule is then barbed sutured.
12 patients were treated. Mean operative time was 95 min; blood losses were 200 mL. No intraoperative complications occurred. Bladder irrigation was stopped 24 hours after surgery in all the cases. Catheterization time and hospital stay were 3 and 4 days. No complications at catheter removal. Mean specimen weight was 80 grams. No prostate cancers were found at final pathology. All the patients who were sexually active before the intervention (8) resumed their activity within 2 weeks after surgery with maintained ejaculation.
The presented technique for robot-assisted urethral sparing “pure” adenomectomy seems to be safe and effective in the treatment of large BPH. Moreover this technique seems to maintain the patient’s sexual functions.