Modified Robotic Simple Prostatectomy Technique: A Retrospective Analysis of a Series of 162 Surgeries Performed by a High-volume Surgeon

doi:10.21203/rs.3.rs-4947299/v1

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Modified Robotic Simple Prostatectomy Technique: A Retrospective Analysis of a Series of 162 Surgeries Performed by a High-volume Surgeon

https://doi.org/10.21203/rs.3.rs-4947299/v1

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published 18 Oct, 2024

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Benign prostatic hyperplasia (BPH) affects up to 80% of men by age 80, with large-gland BPH often treated by simple prostatectomy (SP). This technique significantly improves symptoms but is associated with high rates of complications such as transfusions and infections. Minimally invasive techniques, including robotic-assisted laparoscopic simple suprapubic prostatectomy (RALSP), have emerged as alternatives.

This study reports on 162 patients who underwent RALSP from May 2018 to June 2023. The mean age of the patients was 69 years, mean prostate volume 144.8 cm³, mean robot time 78.7 min, and mean blood loss 183.1mL. Results demonstrated significant improvements in the results: prostate volume (mean decrease from 144.8 to 26.6 cm³), mean PSA level decreased from 7.8 to 0.8 (p < 0.0001), mean IPSS decreased from 23.0 to 4.4 (p < 0.0001), and mean uroflowmetry increased from 6.3 to 22.6 ml/s (p < 0.0001).

No patient experienced worsening erectile function after surgery. All patients showed absence of stress urinary incontinence within 3 months. Catheterization time decreased from 4.2 to 2.6 days over the study period. The postoperative complication rate was 2.29%, with no need for surgical reintervention for complications.

While RALSP showed promising results, further prospective studies are needed to compare it with other techniques. This study highlights RALSP as a viable minimally invasive option for treating large-volume BPH, offering reduced recovery times and fewer complications.

Benign prostatic hyperplasia

Robotic surgery

simple prostatectomy

outcome.

Benign prostatic hyperplasia (BPH) is a highly prevalent condition in men, the incidence increasing progressively with age and affecting up to 80% of men by age 80 [1]. Over the last decades, a large variety of options to treat obstructive voiding symptoms and hematuria due to BPH have been developed, and various techniques such as laser vaporization and enucleation, plasma vaporization, bipolar resection, and Holmium Laser Enucleation of Prostate (HoLEP) have proliferated. Despite these advancements, the standard treatment for obstructive urinary symptoms due to large-gland (> 80 g) BPH remains simple prostatectomy (SP) [2].

In patients requiring surgery, European Association of Urology (EAU) and American Urology Association (AUA) guidelines recommend open SP (OSP) for the surgical treatment of patients with large-volume (> 80 g) glands (www.EAU.org, www.AUA.org) [3, 4].

Obstructive adenomas are enucleated using the index finger, approaching from within the bladder (Freyer procedure) or through the anterior prostatic capsule (Millin procedure) [5, 6]. Open OSP substantially improves International Prostate Symptoms Score (IPSS), urinary flow rate, quality of life, and postvoid residual volumes. However, open SP has also been associated with relatively high rates of perioperative transfusion, prolonged hospital stay, reoperation, and urinary infections [6].

Over the past few years, minimally invasive (laparoscopic and robotic-assisted) SP has been implemented worldwide, with encouraging results. Minimally invasive techniques emulating OSP have been developed recently and may improve perioperative morbidity with equivalent treatment outcomes. Robotic-assisted laparoscopic simple suprapubic prostatectomy (RALSP) has been described as a novel alternative to open SP [6, 7, 8].

However, despite the promising results, there are few studies reporting the outcomes of RALSP, with currently no prospective randomized comparative study with other enucleation techniques proving its benefit [9]. Here we describe our initial experience with RALSP, with small modifications to our technique to improve efficiency. Throughout the evolution of our practice, we have been able to reduce the postoperative bladder catheterization time. We also report the simultaneous correction of inguinal hernias, thus highlighting this approach as a clear advantage. Additionally, we analyzed the associated morbidity and the outcomes achieved.

2.1 Patients and materials

This was a retrospective analysis of the records of 162 patients who underwent surgery at two medical centers in the country by the same surgeon from May 2018 to June 2023. We included patients with a diagnosis of benign prostatic obstruction undergoing RALSP. The following data were collected: patient age, prostate volume preoperatively and up to 6 months after surgery, prostate-specific antigen (PSA) level preoperative and postoperative up to 6 months, IPSS preoperative and up to 6 months after surgery, urinary flow rate (Qmax) pre- and postoperative maximum, robotic surgical time, estimated blood loss during surgery, length of hospital stay, need for postoperative blood transfusion, duration of postoperative catheterization, use of anticoagulants or antiplatelets, presence of associated hernia, and need for reoperation.

To assess differences, we used the non-parametric Wilcoxon test, adopting a significance level of 0.05, which corresponds to a 95% confidence interval. JMP Pro 13 (SAS Institute Inc., Cary, NC, USA) was used for analysis.

2.2. Surgical technique

All surgical procedures were performed using the Da Vinci robotic platform (Si, X, or Xi), with the same surgical technique, and by the same surgeon. The technique described below was modified from that described by Patel in 2011 [10].

Six transperitoneal trocars were used, four of which were robotic, as follows: one 8-mm supra-umbilical trocar; two 8-mm robotic trocars bilaterally in line, 8-cm apart from the first trocar; and the last robotic trocar in line on the left, 8-cm from the previous one. Additionally, a 12-mm trocar in line on the right, at least 8-cm from the lateral trocar, and a 5-mm trocar bisecting between the camera ports and the right side, at least 5-cm from both were used. The patient was positioned in the Trendelenburg position with a tilt of 25 to 28 degrees.

The robotic instruments used were monopolar scissors, fenestrated bipolar forceps, tenaculum, and needle holder. A 0-degree camera was used throughout the procedure.

An incision was made in the peritoneum with lowering of the bladder and dissection of the fat in the vesicoprostatic transition.

Preventive hemostatic ligatures in the vesicoprostatic transitions or the prostatic capsule as described by Patel et al.[10] were not used. A capsular incision was made near the vesicoprostatic junction. The plane between the adenoma and the prostatic capsule was identified and dissected with a combination of cauterization and blunt dissection. The anterior vesical neck was then sectioned, followed by maximum anterior and lateral dissection of the adenoma. Next, the anterior commissure was sectioned until the urethra was reached, defining the apical limit medially. Unlike previously described techniques, the dissection of the prostatic adenoma was through its segmentation (sliced), allowing better access and clear visualization of the apex, with safer dissection of the urethra without injury to the sphincter (Figs. 1 and 2).

The lateral adenomas were first removed, with good identification of the posterior vesical neck limits, followed by resection of the apices and, when applicable, the median lobe. Dissection at the end of the posterior vesical neck, with or without a median lobe, allows for secure identification of the posterior adenoma, preventing residual benign tissue from being left behind. After complete removal of the adenoma, we reviewed hemostasis, suturing if necessary, at points of greater bleeding, with 3 − 0 Caprofyl. A 360-degree colo-urethral anastomosis was then performed, using the shooting technique with two 3 − 0 V-lok sutures, following a modified van Velthoven technique (Fig. 3), and a 20 fr Foley ureteral catheter was placed. Finally, the anterior prostatic capsule was hemostatically sutured to the anterior bladder wall. The fragments of the specimen were then placed in the endocath and removed through the small umbilical incision. In cases of associated inguinal hernia, classical dissection and reduction of hernia sacs were performed before the prostatectomy, with mesh placement at the end and peritoneal closure.

Postoperatively, patients remained with bladder irrigation, received a light diet as soon as they were fully awake, and were encouraged to ambulate early. Generally, irrigation was stopped after 24 hr and patients were discharged between 24 and 48 hr after surgery.

We analyzed 162 medical records, identifying 131 patients with complete data who underwent procedures from January 6, 2018 to June 1, 2023. The mean age of the patients was 69.1 ± 7.4 years, mean prostate volume 144.8 ± 47.1 cm³ (90–478), mean robot time 78.7 ± 9.3 min, and mean blood loss 183.1 ± 9.3 mL (50–560) (Table 1).

Table 1

– Summary of analyzed variables
Variable	Mean ± SD	Median	Range	IQR
Age, years	69.1 ± 7.4	69	47–90	65–74
Volume	144.8 ± 47.1	140	90–478	118–160
Preoperative PSA level	7.8 ± 3.9	6.7	1.9–18.8	4.7–9.8
IPSS	23.0 ± 3.6	22.5	16–34	20–26
Robot time, min	78.7 ± 9.3	77.5	62–128	72.5–82
Hospital stay, days	1.6 ± 0.5	2	1–4	1–2
Blood loss, mL	183.1 ± 93.4	150	150–560	120–220
Catheter time	3.6 ± 1.1	4	2–6	2–4

IQR, interquartile range; PSA, prostate-specific antigen; IPSS, International Prostate Symptoms Score

Among the 131 patients, 26 (19.8%) had an associated inguinal hernia and underwent correction during the same surgical procedure. In total, 24 patients (18%) had previously undergone transurethral resection of the prostate, and 24 (18%) were on antiplatelet or anticoagulant medication. Seven patients had an indwelling catheter before surgery due to urinary retention.

Four patients had International Society of Urologic Pathologists grade 1 prostate adenocarcinoma and underwent subsequent robotic radical prostatectomy. During the evaluated period, postoperative catheterization time significantly decreased from 2018 to 2021 (p < 0.0001), from 4.2 days to 2.6 days (Graph 1).

Data are mean ± SD.

We evaluated patients by prostate volume, IPSS, PSA level, and uroflowmetry before and up to 6 months after surgery. Mean volume decreased from 144.8 to 26.6 (p < 0.0001), Mean PSA level decreased from 7.8 to 0.8 (p < 0.0001). Mean IPSS decreased from 23.0 to 4.4 (p < 0.0001), and mean uroflowmetry increased from 6.3 to 22.6 ml/s (p < 0.0001).

No patient experienced worsening erectile function after surgery. All patients showed absence of stress urinary incontinence within 3 months.

To verify whether the differences between the groups were significant, we used the non-parametric Wilcoxon signed-rank test, considering that the same patient was evaluated at both times in Table 2.

Table 2

– Comparison of variables pre-surgery and 6 months
Y	Time	N	Mean	Median	Range	IQR	p-value
Volume	Pre-surgery	131	144.8 ± 47.1	140	90–478	118–160	< 0.0001
	6 months	127	26.6 ± 7.2	27	5–42	20–32
PSA	Pre-surgery	131	7.8 ± 3.9	6,7	1.9–18.8	4.7–9.8	< 0.0001
	6 months	129	0.8 ± 0.4	0.85	0.2–2.2	0.6–0.99
IPSS	Pre-surgery	108	23.0 ± 3.6	22.5	16–34	20–26	< 0.0001
	6 months	131	4.4 ± 1.6	4	2–1	3–6
Uroflowmetry	Pre-surgery	34	6.3 ± 1.6	6.1	3.8–10	4.925–7.5	< 0.0001
	6 months	34	22.6 ± 3.0	22.75	16.7–28	20.22–24.57

IQR, interquartile range; PSA, prostate-specific antigen; IPSS, International Prostate Symptoms Score

The postoperative complication rate was 2.29%, with no need for surgical reintervention for complications (Dindo-Clavien Grade I). Only three patients presented bladder clots postoperatively, which were resolved by bladder irrigation and clot aspiration via the bladder catheter. No patients required a blood transfusion. We had no cases of urethral or vesicourethral anastomosis strictures requiring intervention. One case required readmission for clinical treatment of an abdominal wall infection. The presence of postoperative incisional hernia was not evaluated.

The surgical approach to prostatic hyperplasia has evolved significantly with the use of the robotic platform, and various surgical techniques have been described. Our technique for robotic prostatectomy seems safe and effective for treating BPH.

We observed significant improvements in prostatic symptoms (preoperative vs postoperative IPSS 23 ± 3.6 vs 4 ± 1.6, p < 0.0001), urinary flow rate (6.3 ± 1.3 vs 22.6 ± 3, p < 0.0001), and prostate volume (144 ± 47 vs 26.6 ± 7.2, p < 0.0001). In addition to the improvements described by Patel et al.[10], we believe that our modification allows for safer access to the prostatic apex and surgical planes. Prostate resection occurs under complete visualization when we dissect the specimen in fragments. This approach reduces sphincter traction and facilitates the identification of the boundaries between the capsule and adenoma, allowing for a more anatomical dissection, with better surgical field, improved hemostasis, less bleeding, and better preservation of the bladder neck. Furthermore, even without suturing the prostatic capsule, we found less blood loss than described by other groups [7,11].

The reduction in catheter time was possible in that we observed good surgical outcomes with very low complication rates. Initially, in selected cases, we began to gradually reduce catheter time while maintaining good results. Today, a good proportion of patients are discharged within 48 hr without an indwelling bladder catheter. Younger patients, with good bladder capacity, good quality of vesicourethral anastomosis, and no postoperative complications are candidates for early catheter removal. Conversely, older patients, on antiplatelet or anticoagulant medications, with previous urinary retention or prior transurethral resection of the prostate, probably have longer catheterization time. In our study, earlier postoperative catheter removal did not affect surgical outcomes or increase the number of complications.

No prospective randomized study has compared RALSP with other techniques. However, a recent review by Kordan et al.[13] demonstrated that the technique can indeed be considered a minimally invasive surgery for prostates > 80 g, showing functional results for IPSS, post-void residual urine, Qmax, and quality of life as well as complication rates, blood loss, and hospitalization time as compared with other techniques such as thulium laser vapoenucleation of the prostate (ThuLEP) and HoLEP.

In a recent meta-analysis[14], RALSP was associated with longer hospital stay and catheterization time and higher TR as compared with laser endoscopic enucleation of the prostate. However, when comparing the results from our study, hospitalization times were similar for RALSP and other techniques (hospital stay 1.6 vs 1.71 days). The same study[14] demonstrated superiority for ThuLEP versus RALSP in terms of surgical time. This superiority was not demonstrated when considering the mean surgical time of our case series (78.7 vs 85 min).

In the meta-analysis of Pandolfo et al.[9], the catheterization time was significantly shorter in patients undergoing HoLEP and ThuLEP than other patients. However, as compared with the second phase of our study, showing decreased catheterization time, catheterization time was shorter for patients undergoing RALSP than those undergoing laser enucleation (2.6 vs 3.54 days). Given these comparisons, RALSP may be superior to other techniques for hospitalization, catheterization, and surgical time.

A potential disadvantage of our technique could be the difficulty in resecting the intravesical component of a larger median lobe. For less experienced surgeons, the lower prostatic exposure due to the subcapsular, extravesical approach might hinder the identification of the intravesical median lobe.

The limitations of this study include its retrospective design and the reliance on results from a single surgeon. However, the number of cases reviewed, the reproducibility of the surgical technique, and the uniformity of the identified data greatly favor the method's applicability.

We believe that access to the robotic platform is increasingly feasible for most urologists, and by providing updated information on the clinical outcomes of robotic adenectomy, we hope to contribute to clinical decision-making and assist colleagues in choosing the best surgical approach for their patients with BHP.

Funding

The authors declare that no funds, grants, or other support were received during the preparation of this manuscript.

Competing Interests

The authors have no relevant financial or non-financial interests to disclose.

Author Contributions

All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Sandro Mendonça de Faria, Mauricio Dener Cordeiro and Celene Benediti Bragion. The first draft of the manuscript was written by Celene Benediti Bragion and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Ethics approval

Ethical approval was waived by the local Ethics Committee of Vera Cruz Hospital and Albert Einstein Israelite Hospital in view of the retrospective nature of the study and all the procedures being performed were part of the routine care

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Graph 1 is available in the Supplementary Files section.

No competing interests reported.

Graph1.png
Graph 1 – Mean catheterization time

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Journal Publication

published 18 Oct, 2024

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Editorial decision: Accepted
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Modified Robotic Simple Prostatectomy Technique: A Retrospective Analysis of a Series of 162 Surgeries Performed by a High-volume Surgeon

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1. Introduction

2. Materials and methods

2.1 Patients and materials

2.2. Surgical technique

3. Results

4. Discussion

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