Robotic Simple Prostatectomy Rene Sotelo,*,† Rafael Clavijo, Oswaldo Carmona, Alejandro Garcia, Eduardo Banda, Marcelo Miranda and Randy Fagin‡ From the La Floresta Medical Institute, Caracas, Venezuela
Purpose: Minimally invasive approaches for large, symptomatic benign prostatic hyperplasia are replacing the gold standard open surgical approach, duplicating its results with lower morbidity. We describe our initial experience with robotic simple prostatectomy. Materials and Methods: Since January 2007, robotic simple prostatectomy was performed via a transperitoneal approach in 7 patients with symptomatic significant prostatomegaly on transrectal ultrasound (mean 77.66 gm). Demographic, perioperative and outcome data were recorded and all procedures were performed by the same surgeon. Results: Average patient age was 63.2 years (range 56 to 72) and estimated blood loss was 298 ml (range 60 to 800). Average operative time was 205 minutes (range 120 to 300). Average hospital stay was 1.4 days (range 1 to 2), average Foley catheter duration was 7 days (range 6 to 9) and drains were removed after an average of 3.75 days (range 3 to 4). Mean specimen weight on pathological examination was 50.48 gm (range 40 to 64.5). Transfusion was necessary in 1 patient. No complications were documented. Considerable improvement from baseline was noted in International Prostate Symptom Score (preoperative vs postoperative 22 vs 7.25) and maximum urine flow (preoperative vs postoperative 17.75 vs 55.5 ml per minute). Four patients were in acute urinary retention preoperatively. Conclusions: Robotic simple prostatectomy is a feasible, reproducible procedure. Further publications are expected with larger series and larger prostatic adenomas. Key Words: prostate, prostatic hyperplasia, prostatectomy, robotics, laparoscopy
naires, uroflowmetry and transrectal ultrasound with prostate volume measurement. One month following surgery I-PSS, QOL questionnaires and uroflowmetry were done (table 1).
n the last century open simple prostatectomy using a retropubic, suprapubic or perineal approach has traditionally been the treatment of choice for benign, symptomatic, large prostatomegaly. In 2002 Mariano et al first described a technique for laparoscopic simple prostatectomy.1 As surgeons continue to expand the use of minimally invasive surgery in urology, groups at many centers have explored different techniques and measured outcomes using a laparoscopic approach. With the emergence of robotic surgery and its added benefits over laparoscopy of enhanced ergonomics and more dexterous instruments the group at our center developed a technique for robotic simple prostatectomy. We describe our initial experience.
Surgical Technique With the patient under general anesthesia the patient was prepared and positioned in the steep Trendelenburg position, as one would for robotic radical prostatectomy. Using the 4-arm da Vinci® Surgical System a 6 port transperitoneal approach was used with a port configuration identical to that commonly used for da Vinci radical prostatectomy (fig. 1). After mobilizing the bladder the space of Retzius was entered and the anterior surface of the prostate capsule was cleared of overlying fatty tissue. A horizontal cystotomy incision was made proximal to the junction of the bladder and prostate. The bulging lateral lobes of the prostate with or without a median lobe were then visualized. A horizontal incision was made on the vesical mucosa overlying the prostate lobes at the level of the bladder neck. This incision was deepened until the prostate adenoma was identified. The adenoma was freed from the prostate capsule by dissecting in the subcapsular plane outside the prostatic adenoma using a combination of electrocautery and blunt dissection (fig. 2). Stitches placed in the lateral lobes were often used to help create traction on them during the dissection. When a median lobe was present, it was completely mobilized and transected at its junction to the lateral lobes. Any perforating blood vessels were controlled with a bipolar or SonoSurg™ scalpel. Specific care was taken at the apex of the prostate at the point of its transection from the urethra to avoid injury to the external sphincter.
MATERIALS AND METHODS Since January 2007, robotic simple prostatectomy was performed in 7 patients. All patients had symptomatic benign prostatic hyperplasia and 4 were in acute urinary retention, requiring catheterization. Preoperative evaluation included history and physical, routine laboratory assessment with prostate specific antigen measurement, I-PSS and QOL questionSubmitted for publication June 19, 2007. * Correspondence: Cirugia Minimamente Invasiva, Unidad de Urologia, Instituto Medico La Floresta, Planta Baja Consultorio 707, Caracas, DF 1080, Venezuela (telephone: 582122096240; FAX: 582122843812; e-mail: firstname.lastname@example.org). † Financial interest and/or other relationship with Olympus. ‡ Financial interest and/or other relationship with Intuitive Surgical.
For another article on a related topic see pages 748 and 779.
0022-5347/08/1792-0513/0 THE JOURNAL OF UROLOGY® Copyright © 2008 by AMERICAN UROLOGICAL ASSOCIATION
Vol. 179, 513-515, February 2008 Printed in U.S.A. DOI:10.1016/j.juro.2007.09.065
ROBOTIC SIMPLE PROSTATECTOMY TABLE 1. Demographic data and results
Age Operative time (mins) Blood loss (ml) Catheterization (days) Drainage (days) Hospitalization (days) Prostate specific antigen (ng/ml)
64.66 195 381.66 7.5 3.5 1.33 12.51
56–72 120–300 60–800 6–10 3–4 1–2 4.22–20.02
5.35 84.32 337.18 1.64 0.54 0.51 8.02
The incised edge of the bladder neck mucosa was then suture approximated to the posterior edge of the urethra or to the prostatic fossa floor and a 24 Fr Foley catheter was inserted. Enucleation of the lateral prostatic lobes was performed in 1 patient, who did not have a median lobe, with preservation of the prostatic urethra necessitating only suture repair of the longitudinal capsular incision. The horizontal cystotomy incision was closed in a watertight manner and the bladder was irrigated to assess repair integrity. A drain was inserted. The large volume prostate adenoma was divided into 2 specimens (right and left lobes) and extracted using an EndoCatch™ bag. RESULTS We performed 7 robotic simple prostatectomies with this transperitoneal approach without any open conversions. Average ⫾ SD patient age was 63.2 ⫾ 4.43 years (range 56 to 72), estimated blood loss was 298 ⫾ 239.36 ml (range 60 to 800 ml) with transfusion of 2 U blood necessary in 1 patient secondary to epigastric artery injury, operative time was 205 ⫾ 85.73 minutes (range 120 to 300), hospital stay was 1.4 ⫾ 0.54 days (range 1 to 2) and Foley catheter duration was 7 ⫾ 1.41 days (range 6 to 9). Drain removal was done at an average of 3.75 ⫾ 0.5 days (range 3 to 4) (table 2).
FIG. 2. Hand simulated joint of Endowrist instruments inside capsular plane provides meticulous and hemostatic dissection, and prevents capsular avulsion.
Histopathology confirmed benign glandular-stromal hyperplasia in all 7 patients. Average prostate volume on preoperative transrectal ultrasound was 77.66 ⫾ 22.98 gm (range 40 to 106). Average specimen weight on pathological examination was 50.48 ⫾ 11.47 gm (range 40 to 64.5). Therefore, average weight of the excised prostate specimen was equal to 65% of the gland weight estimated on preoperative transrectal ultrasound. The average postoperative maximum urine flow rate was 55.5 ml per second. DISCUSSION The benefits of laparoscopic surgery in urology, including lower morbidity, limited pain, a shorter hospital stay and earlier return to normal activities, have been largely proved. As it relates to the outcomes of simple prostatectomy, the results of our series and those of others are promising. Numerous groups have reported various techniques for this operation. Mariano et al first reported applying a laparoscopic approach for retropubic simple prostatectomy using a longitudinal vesicocapsular incision.1,2 Baumert3 and van Velthoven4 et al also re-
TABLE 2. Preoperative and postoperative data
(USTR) prostate vol (gm) Prostate wt (gm) I-PSS: Preop Postop QOL: Preop Postop Max urine flow (ml/sec): Preop* Postop
FIG. 1. Trocar placement in robotic simple prostatectomy
* Acute urinary retention in 66.66% of patients.
ROBOTIC SIMPLE PROSTATECTOMY ported their experience with van Velthoven et al using a slightly different technique. Their technique included hemostatic control of lateral venous vesicoprostatic pedicles, transverse anterior incision of the prostate capsule, adenoma enucleation using the harmonic scalpel, and reconstruction of the posterior bladder neck and prostate capsule. Advantages of the technique proposed by van Velthoven et al are its preperitoneal approach, the relatively short operative time (2.4 hours), and limited blood loss (192 ml). Recently we described our initial experience with an extraperitoneal technique for laparoscopic simple prostatectomy in 71 patients with the average specimen weight of the excised prostate in this series equal to 84.86% of the gland weight estimated on preoperative transrectal ultrasound.5 In that technique a transverse cystotomy was made just proximal to the prostatic-vesical junction and enucleation was assisted by a prostatotome device. As described, the reported benefit of the technique is a decreased potential of hemorrhage, which is most likely to occur from the capsulotomy incision or the prostatic fossa.6 Porpiglia et al reported a comparative study evaluating the open and laparoscopic extraperitoneal approach for simple prostatectomy using the Millin technique and found no improvement in catheterization time.7 Compared to open surgery all techniques have limitations, including a steep learning curve and the requirement of significant laparoscopic expertise. In addition, despite the outcomes reported in prior series Barret et al evaluated the morbidity of laparoscopic vs open simple prostatectomy and found that there was no significant difference between the 2 groups in terms of estimated blood loss, transfusion rate, perioperative complications and the duration of postoperative catheter irrigation.8 In reported series in the literature there is a cumulative experience of more than 800 patients using a laparoscopic technique for simple prostatectomy.1–17 In our hands the laparoscopic technique proved to be feasible, safe and reproducible. However, the future is in robotics. We have performed 7 laparoscopic simple prostatectomies using a robot assisted transperitoneal approach and to our knowledge this approach has not yet been described in the literature. Using this technique we are able to preserve the prostatic urethra, necessitating only suture repair of the longitudinal capsular incision when there is no median prostatic lobe. This initial experience will lead the way for us to perform this procedure for larger prostatic adenomas. We believe that robotics will allow the surgeon greater precision and vision for laparoscopic simple prostatectomy, permitting the popularization of this useful resource. Furthermore, cost is not really a great problem. At our institution the average cost of the last 5 laparoscopic simple prostatectomies performed this year was $10,465.11 and the average cost of the robotic cases in the current series was $12,093.02. CONCLUSIONS The contribution of robotics to urological surgery has allowed reproducible surgical outcomes that equal and in some series exceed the outcomes of open surgery with the advantages of a minimally invasive approach. As it relates to robotic simple prostatectomy, robotics allows the enucleation of adenoma without the need for special devices due to the advantages provided by the EndoWrist® of the robotic instrument. It also facilitates hemostatic figure-of-8 sutures to control the main
prostatic vessels, resulting in less intraoperative blood loss. Robotic simple prostatectomy is a feasible and reproducible procedure in our hands. Further publications are expected with larger series and larger prostatic adenomas.
Abbreviations and Acronyms I-PSS ⫽ International Prostate Symptom Score QOL ⫽ quality of life REFERENCES 1.
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