(UroToday.com) The fifth plenary session of the World Congress of Endourology and Technology 2024 Annual Meeting featured a panel moderated by Dr. Taek-Sang Kim of Yale Medicine entitled “Techniques of Robotic Simple Prostatectomy”, showcasing three different robotic approaches to simple prostatectomy. Panelists for this session included three expert robotic prostate surgeons: Dr. David I. Lee, MD, FACS of the University of California, Irvine, California, Dr. Benjamin Waldorf, MD of the University of Tennessee College of Medicine, Chattanooga, Tennessee, and Dr. Mutahar Ahmed, MD, FACS of Hackensack Meridian Health, New Jersey, USA.
Dr. Lee initiated the session with a discussion entitled, “Robotic Simple Prostatectomy: Transcapsular Approach Multiport”. He briefly reviewed various approaches to the procedure including transabdominal, extraperitoneal, and transvesicle entry; where he opts for a multiport transperitoneal approach. For increased visualization, Dr. Lee will guide the procedure by dropping the bladder, ligating the DVC if necessary, incising and transecting the bladder neck in a similar fashion to radical prostatectomy, resecting the adenoma, transecting at the apex, removing the prostate, and will then perform ureterovesical anastomosis. He proceeded to show a video of a prerecorded case, starting at the transection of the bladder neck. Here, he works to elevate the fat on the lateral aspects of the bladder wall, lifting fat until there is a “drop off” around the sides of the bladder. Once established, he continues to move upward toward the prostatovesical junction. Subsequent steps are chosen based upon the tissue firmness at this point. From a lateral to medial approach, Dr. Lee will join two planes in the center, creating a small bladder neck. Notably, the fourth arm of the robot serves as a retractor, gently tugging upwards on the prostate. The bladder is then spared circumferentially and the prostate is lifted. Once at the adenoma, the capsular fibers are severed, allowing for a cleanly established plane from 6 to 12 o’clock. The adenoma plane is taken to the top, the anterior commissure is divided, and the verumontanum is visualized, which further dictates the amount of apical tissue removed almost entirely; some remains to help prevent transient incontinence. The prostate is removed and 360-degree anastomosis (Figure 1).
Figure 1. Following prostate removal, a 360-degree anastomosis
Following Dr. Lee’s rendition of the transcapsular multiport approach, Dr. Waldorf introduced the transvesical method through three portions: patient selection, dissection, and reconstruction. Ideal patient selection is as follows: rule out prostate adenocarcinoma, prostate size ≥ 100g, intravesical adenoma is present, and there is adequate bladder capacity. He also opts for cystoscopy to define prostate architecture and rule out urothelial carcinoma. Dr. Waldorf has two primary approaches for bladder opening: inverted Boari flap with a large transvesical incision vs midline cystotomy and stay suture through the abdominal and bladder walls on tension. He then proceeds with dissection of the adenoma and incised the mucosa. A hook is his preferred tool for blunt dissection, which is carried distally to the urethra. Notably, he finds that these adenomas are quite adherent in the 2 to 4 o’clock region. The adenoma is eventually removed and followed by hemostasis (Figure 2). Dr. Waldorf will temporarily pack the cavity with surgical and manual pressure. Sutures are eventually placed and a 2-way catheter is inserted.
Figure 2. Removal of adenoma.
Following the two presentations on multiport approaches, Dr. Ahmed then introduced the single port robotic approach entitled “Transvesicle Single Port Robotic System – Simple Prostatectomy, Pneumovesical Approach”. In comparison to the previous approaches, this technique can be completed with the patient supine, with one incision, straightforward closure, and no drainage. After completing 120 cases, Dr. Ahmed believes these to be efficient procedures that will only improve with time. Of note, there have been incidences of air embolism, in which he suggests that insufflation is maintained under 12. Furthermore, it does require a ROSI or flexible suction device, air seal, and SP access port. For Dr. Ahmed, the included patients have large prostates (150g or greater) with urinary retention and other significant comorbidities. With this technique, he has found that maximal removal of the adenoma to relieve retention can be completed regardless of bladder tone. Aside from location, the entry process remains the same. The access sheath is placed and insufflated in the bladder, followed by adenoma removal. He will continue to work anteriorly to limit air absorption. Mucosa to mucosal anastomosis is completed for a 360-degree closure with a water-tight seal (Figure 3).
Figure 3. 360-degree closure with a watertight seal.
Though all approaches differ with respect to approach and intermediate steps, there does exist some overlap for operative outcomes. All can be completed outpatient; wherein same-day discharge is a standard. Furthermore, there is no requirement for continuous bladder irrigation, and the catheter is removed within a week following surgery. In total, all provide intriguing methods for simple prostatectomy.
Moderated by: Taek-Sang Kim, MD, PhD, Yale School of Medicine, New Haven, CT
Panelists:- David I. Lee, MD, FACS – University of California, Irvine, California, USA
- Benjamin Waldorf, MD – University of Tennessee College of Medicine, Chattanooga, Tennessee, USA
- Mutahar Ahmed, MD, FACS – Hackensack Meridian Health, New Jersey, USA
Written by: Mariah Hernandez, Research Specialist, Department of Urology, University of California Irvine, @mariahch00 on Twitter during the 2024 World Congress of Endourology and Uro-Technology: August 12 -16, 2024, Seoul, South Korea