Stepwise Description and Outcomes of Bladder Neck Sparing Robot-Assisted Simple Prostatectomy

Introduction: In this article, we described our novel technique of bladder neck sparing robot-assisted simple prostatectomy (BNS)-RASP, which aims to develop a reproducible procedure with a short learning curve, low incidence of short- and long-term complications rate, as well as offering durably improved functional outcomes.

We used the extravesical approach to access the adenoma, due to the similarity with robot-assisted radical prostatectomy (RARP) technique which provides a capacious working space for the surgeon and the assistant. Also, this technique allows us to completely preserve the puboprostatic ligament as well as dorsal venous complex (DVC) complex, and selectively ligate the dorsal vein run off at the base of puboprostatic ligaments to decrease intraoperative blood loss and preserve the fibrovascular support to the urethra which has shown to have improved continence rate. Finally, sparing the bladder neck is crucial to improve immediate continence and antegrade ejaculation.

Perioperative Outcomes: A total of 30 patients underwent RASP for severe lower urinary tract symptoms (LUTS). The mean operative time was 107.5 minutes, and the mean estimated blood loss was 132.4 ml. All cases were completed robotically without intra-operative complications or conversion to an open technique. Continuous bladder irrigation was not required for any patient postoperatively and all patients were discharged within 24 hours of the procedure. Two patients developed postoperative urinary tract infections within the 30-day postoperative period and were treated with oral antibiotics (Clavien grade II).

Functional Outcomes: All patients were able to void after catheter removal except one patient with a preexisting diagnosis of neurogenic bladder who resumed clean intermittent catheterization. All patients were continent after catheter removal as defined as using zero pads. Of the 19 patients who had antegrade ejaculation before surgery, eight patients (42%) reported experiencing antegrade ejaculation after surgery.

Conclusions: BNS-RASP is a safe and feasible option to treat benign prostate hypoplasia (BPH). Standardization of each surgical step of RASP will lead to an improvement of different outcomes and make RASP a more desirable option to treat BPH.

Written by: Mohammed Shahait, MBBS, Clinical Instructor of Urology, Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, Twitter: @moshahait; David I.Lee, MD, Chief, Division of Urology, Penn Presbyterian Medical Center, Associate Professor of Surgery and Urology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, Twitter: @davidleegumd

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