Education / Lap & Robotics / Surgical Innovations
Introduction & Objective :
Retzius-sparing robot-assisted simple prostatectomy (RS-RASP) in the treatment of benign prostatic hyperplasia (BPH) and lower urinary tract symptoms (LUTS) has been described in the literature. As this robotic procedure is relatively new, several techniques have been described with the ideal approach having yet to be defined. After experimenting with several approaches, we have refined our technique and herein present our surgical modifications in the largest single-surgeon series of RS-RASPs to date.
We retrospectively reviewed 105 men who underwent our modified RS-RASP by a single surgeon (DDE) between 2014 – 2017. Notable technical modifications include: 1) The bladder is not dropped thus the Space of Retzius is not entered. 2) A vertical midline transvesical incision is utilized. 3) After adenoma enucleation, a 360-degree urethro-vesical anastomosis is undertaken, bypassing the prostatic fossa. 4) An 18 french 2-way catheter is left without need for continuous bladder irrigation (CBI). Primary outcomes were the American Urological Association Symptom Score (AUA-SS) with associated bother, the Sexual Health Inventory for Men (SHIM), and post-void residual (PVR) at 6 weeks postoperatively. The preoperative and postoperative outcomes were compared using paired t-tests.
All patients presented with LUTS, with 84 of 105 (80%) in urinary retention pre-operatively. The average estimated prostate size vs. pathological volume of prostate resected was 120cc and 80cc, respectively. When comparing patients pre and post-operatively, a statistically significant difference was noted in AUA-SS (19 vs 6, p < 0.001), Bother (5 vs 1, p < 0.001), and PVR (160 vs 12cc, p < 0.001). There was no statistically significant change in SHIM score (13 vs 12, p = 0.416). Transfusion rate was 2% and 91% of patients were discharged on post-operative day 1. Only 1 patient (0.9%) required catheter assistance post-operatively performing clean intermittent catheterization.
Our modified RS-RASP represents a feasible, reproducible technique to avoid CBI and large catheters while maintaining surgical efficacy; we minimize hematuria by utilizing the 360-degree anastomosis to exclude the prostatic fossa and maintain native bladder support by sparing the Space of Retzius. Our modifications to RS-RASP demonstrate an effective technique in the surgical management of BPH/LUTS by improving functional outcomes without compromising sexual function.