V1028: Robotic Suprapubic Prostatectomy for Severe Benign Prostatic Hyperplasia

Video

Introduction and Objectives
Conventional treatment of BPH includes α-1 adrenergic antagonists, 5 α reductase inhibitors, and minimally invasive procedures including TUMT and TUNA. Men with urinary retention, recurrent UTIs, prostate hemorrhage, bladder calculi, renal insufficiency, and/or symptoms unresponsive to medical therapy may be appropriate candidates for TURP or open prostatectomy. Compared to TURP, open prostatectomy offers a lower retreatment rate, more complete removal of the prostatic adenoma under direct vision, and avoids the potential for TURP syndrome. However, open prostatectomy is associated with an increased risk of perioperative hemorrhage and the need for a longer hospitalization and convalescence. Many of the aforementioned disadvantages with open prostatectomy were likewise common with radical retropubic prostatectomy before the advent of robotics. We present our experience with robotic suprapubic prostatectomy for the treatment of severe BPH.

Methods
A 66 year old male presented with BPH refractory to medical therapy. Preoperative AUA symptom score was 26 and postvoid residual volume was 375cc. Maximum voiding flow rate preoperatively was 7.2mL/sec. The patient underwent transrectal ultrasound with a calculated volume of 175g. Treatment options were discussed with the patient in detail. Following informed consent, robotic suprapubic prostatectomy was performed. With the patient in the lithotomy position, a conventional 5 port configuration was employed. The bladder was dropped and the space of Retzius developed. The bladder was filled and a cystotomy created. The adenoma was circumferentially enucleated using blunt and sharp dissection. The enucleation bed was rendered hemostatic with pinpoint cautery. The incised mucosa of the posterior bladder neck was tacked to the prostate capsule using a running 3-0 Vicryl suture. The cystotomy was closed in multiple layers using absorbable suture.

Results
Operative time was 123 minutes. Estimated blood loss was 50cc. There were no acute intraoperative or postoperative complications. Postoperative postvoid residual volume was 23cc. Postoperative AUA symptom score was 3.

Conclusions
Based on our experience, robotic simple prostatectomy is safe, effective, and minimizes many of the disadvantages traditionally associated with the open approach. The decision to approach the prostate through a suprapubic or retropubic approach is predicated on patient factors and the discretion of the operating surgeon. Further study is needed to determine the appropriate patient selection, efficacy and/or superiority as compared to TURP.

Funding: None