V409: Robotic Suprapubic Prostatectomy: An Intravesical Approach.

Video

Introduction and Objectives
Compared to endoscopic transurethral resection of prostate open prostatectomy allows for more complete removal and lower retreatment rates. Proposed disadvantages of the open approach include the need for an abdominal incision, longer hospitalization and recovery. Post-operative hemorrhage is also more likely vs. the endoscopic approach. We believe that mimicking the open suprapubic prostatectomy with minimally invasive robotic technology afford the surgeon the advantages of open prostatectomy without the potential disadvantages. As the first step in testing this notion, we present our surgical technique suprapubic prostatectomy, an intravesical approach.

Methods
Using the daVinci Si robot, with port placement similar to a robotic radical prostatectomy, a suprapubic prostatectomy in preformed and described. The steps needed to achieve enunciation of prostatic adenoma are systematically presented. We present potential advantages of the intravesical approach and results of this case.

Results
The critical steps of the robotic suprapubic prostatectomy are illustrated and described in our video. The surgeon first drops that bladder from the anterior abdominal wall. The bladder neck is then opened in a horizontal fashion. The bladder mucosa is circumscribed at the bladder neck, allowing for the development of a plain between the adenoma, bladder mucosa and prostatic capsule. This is aided by the use of the robotic tenaculum. The enuclation is carried out from the bladder neck to the apex. The prostatic adenoma is removed with little blood loss and excellent visualization though out. Two figure-of-eight sutures are placed achieving excellent hemostatis. A running v-lock suture is used to recreate the trigone. The bladder is then closed using another v-lock suture. The intravesicle approach allows for simultaneous treatment of bladder stones, bladder diverticulum and large intravesicle median lobes. The patient shown is the video was successfully treated using this technique with resolution of his urinary retention and improvement in his LUTS.

Conclusions
This video presents our technique for managing benign prostatic hypertrophy causing lower urinary tract symptoms when traditionally an open approach would have been performed. In our early experience the steps of this technique mimics those of the open approach with improved visualization ease of reconstruction and quicker convalesce than an open approach. Now that we have described our technique we hope to prospectively compile complications data as well as objective and subjective outcomes measures to allow comparison to open approaches.

Funding: None