Robot-Assisted Simple Prostatectomy with Bladder Neck-Sparing Technique

Abstract

Introduction: Benign prostatic hyperplasia (BPH) is the most common benign tumor in men in the United States and one of the most common causes of lower urinary tract symptoms.1 Several modalities are utilized to manage BPH surgically including vaporization, laser enucleation of the prostate (LEP), and open, laparoscopic, and robotic-assisted simple prostatectomy (RASP). RASP is endorsed by American Urological Association (AUA) guidelines for patients with large (>100 mL) and very large prostates (>150 mL) as it has favorable outcomes including low perioperative morbidity rates, blood loss, transfusion rates, and short recovery time.2–4 The learning curve is significantly shorter with RASP compared to LEP.4,5 RASP can also be utilized with same-day discharge pathway reducing the cost of care and healthcare burden. Here we describe our bladder-neck sparing technique for RASP with emphasis on intraoperative technical aspects to hasten the recovery and avoid the use of continuous bladder irrigation. Methods: Data were prospectively recorded from 24 patients who underwent outpatient RASP from September 2021 to March 2023 following the IRB approval. Patient demographics, preoperative, perioperative, and postoperative outcomes were collected. All patients followed an enhanced recovery after surgery protocol. Results: The mean age was 71.5 ± 7.8 years, mean body mass index was 28.8 ± 4.5 kg/m2, median preoperative Prostate Specific Antigen (PSA) was 5.9 (3.1–11) ng/mL, median preoperative AUA score was 20 (13.5–28.25), and 9 patients (37.5%) were in retention, median prostate size was 135 (101.5–158) mL, mean operative time was 138.3 ± 39.8 minutes, mean console time was 78 ± 20.1 minutes, estimated blood loss was 100 (50–100) mL, median weight of the removed specimen was 72.4 (47.1–95.1) mL, median hospital stay was 157 (116.5–180) minutes, median length of catheterization was 7-days. There were no perioperative complications, blood transfusions, conversions to open, or need for continuous bladder irrigation. Twenty-one (87.5%) patients were discharged home on the day of surgery. The median pain score at discharge time reported by 15 patients was 3 (0–5). Only 3 (25%) of 12 patients reporting on pain management needed to use opioids. All patients were able to urinate after the catheter removal. One patient was readmitted for blood clot retention due to strenuous exercise at 3-weeks postoperatively (Clavien Dindo class II). Incidental cancer (Gleason Score 3+3) was found in one patient (4.2%) who is now managed by monitoring the PSA levels every 3 months. The median postoperative 3-month PSA was 0.8 (0.48–1.65) ng/mL. Twenty patients reported their postoperative 3-month urinary continence status, and all of them were continent. The median postoperative 3-month AUA score reported by 15 patients was 5 (3–11). Only one patient needed reintervention postoperatively due to slowing of the urinary stream as he had a urethral mucosal flap from preoperative catheter injury. Conclusions: Outpatient RASP is safe with the described technique and is an excellent option for men with enlarged prostates while also eliminating routine hospital stays. No competing financial interests exist. Patient Consent Statement: Author(s) have received and archived patient consent for video recording/publication in advance of the video recording of the procedure. Runtime of video: 8 mins 15 secs