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The Impact of Prostate Size, Median Lobe, and Prior Benign Prostatic Hyperplasia Intervention on Robotic-Assisted Radical Prostatectomy: Technique and Outcomes
Keith J. Kowalczyk, Andy C. Huang, Nathanael D. Hevelone, Stuart R. Lipsitz, Hua-yin Yu, Blakely A. Plaster, Channa A. Amarasekara, William D. UImer, Stephen B. Williams, Jim C. Hu
Brigham and Women's Hospital/Harvard Medical School, Boston, MA

Large prostate size, median lobes, and prior benign prostatic hyperplasia (BPH) surgery pose technical challenges during robotic-assisted radical prostatectomy (RARP). We describe technical modifications to overcome BPH sequelae and associated outcomes.
Materials & Methods:
Retrospective study of prospective data on 951 RARP performed from September 2005 to November 2010. Outcomes were analyzed by prostate weight, prior BPH surgery (n=59), and median lobes >1cm (n=42). Estimated blood loss (EBL), blood transfusions, operative time, positive surgical margins (PSM), and urinary and sexual function were compared.
In unadjusted analysis, men with larger prostates and median lobes experienced higher EBL (213.5 vs. 176.5 mL, p<0.001 and 236.4 vs. 193.3 mL, p=0.002), and larger prostates were associated with more transfusions (4 vs. 1, p=0.037). Operative times were longer for men with larger prostates (164.2 vs. 149.1 minutes, p=0.002), median lobes (185.8 vs. 155.0 minutes, p=0.004) and prior BPH surgical interventions (170.2 vs. 155.4 minutes, p=0.004). Men with prior BPH interventions experienced more prostate base PSM (5.1% vs. 1.2%, p=0.018), but similar overall PSM. In adjusted analyses, median lobes increased both EBL (p=0.006) and operative times (p<0.001) while prior BPH interventions also prolonged operative times. However, prostate size did not affect EBL, PSM or recovery of urinary or sexual function.

Large prostate size and BPH characteristics pose challenges that increase operative times and EBL during RARP, but do not affect recovery of urinary or sexual function. Technical modifications to overcome median lobes and prior BPH surgeries improve both perioperative and long term outcomes.

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