Introduction and Objectives
Open simple prostatectomy is less commonly performed given the widespread adoption of endoscopic techniques for the treatment of benign prostatic hyperplasia. However, there remains a role for enucleation of large adenomas and minimally invasive techniques may offer the advantage of lower blood loss, less morbidity and faster recovery. Simple prostatectomy may be performed via a transperitoneal or extraperitoneal approach; through the bladder (transvesical) or via a Millin technique. With the utilization of robotic assistance and the added dexterity and degrees of freedom it offers, surgeons are better equipped to effectively and safely perform simple prostatectomy for large glands.

In this video we describe our technique of transvesical robotic simple prostatectomy in two patients. The technique involves port placement as for a transperitoneal radical prostatectomy. The adenoma is approached from the dome of the bladder following a large vertical cystotomy. After enucleation of the prostate, ‘trigonization’ is performed, by anastomosing the mucosal free edge of the trigone down to the urethra and posterior capsule.

The two patients in our video are 68 and 82 years of age, one presenting with urinary retention, and the other with symptoms of bladder outlet obstruction and large bladder stones. Both patients had grossly enlarged prostates on TRUS measurement (148ml and 250 ml). Both patients underwent successful robotic-assisted transvesical simple prostatectomy with a mean operative time of 308 minutes and mean estimated blood loss of 225 ml. There were no intra-operative or post-operative complications and no transfusions were required. The mean prostate specimen weight was 143.5 gm. The histology was benign in one case, and in the second case a small focus of gleason 7 cancer was identified, with negative margins.

The transvesical approach to robotic-assisted simple prostatectomy is feasible, safe, and offers excellent visualization of the lateral lobes and apex of the adenoma during enucleation. In addition, the trigone and ureteric orifices are well seen throughout the case and permits a safe dissection and facilitates trigonization after the adenoma has been enucleated. The dexterity and 3D magnification afforded by the robot makes it ideal for simple prostatectomy in appropriately selected patients.

Funding: none