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A Series Beginning: Robotic Cystolithotomy and Simple Prostatectomy
Peter Chang, MD, Daniel Welchons, MD, Peter Steinberg, MD, Andrew A. Wagner, MD.
Beth Israel Deaconess Medical Center, Boston, MA, USA.
Advances in medical therapy for benign prostatic hyperplasia (BPH) have decreased the prevalence of surgical intervention for bladder outlet obstruction. When surgical relief of the bladder outlet is needed, transurethral resection of the prostate (TURP) accounts for greater than 90% of the prostatectomies performed for BPH. However, an important role still exists for simple prostatectomy: complete surgical enucleation of the prostatic adenoma; indications include a prohibitively large prostatic volume and concurrent bladder stone burden not amenable to cystoscopic intervention. Combination cystolithotomy and simple prostatectomy is most appropriately addressed using a suprapubic transvesical approach, popularized by Freyer in 1900. While effective, this approach can be associated with large volume blood loss. Transfusion rates in the literature have ranged from 0-36%, with the largest series of 1800 patients describing a transfusion rate of 12%. This video abstract describes the first case in our institution’s series of robotic simple prostatectomy, and illustrates the transvesical approach in a case of innumerable bladder stones.
Patient L.S. is a 67 year-old Cape Verdean man with a long history of bladder stones on maximal medical therapy. He is status post cystolithopaxy with EHL in 2006 and 2008. His pre-operative AUA-SI score was 20 with a bother score of 4. CT of the abdomen and pelvis demonstrated innumerable bladder stones and a large median lobe of the prostate that protruded into the bladder lumen.
A robotic-assisted laparoscopic cystolithotomy and transvesical simple prostatectomy was performed, and is demonstrated in the accompanying video. Briefly, a veress needle was used establish pneumoperitoneum. Laproscopic and robotic ports were placed in the identical positions as in robotic-assisted intraperitoneal laparoscopic radical prostatectomy. A large vertical midline incision was made in the bladder, and all bladder stones were placed into a 10 mm Endo-catch bag. After obtaining excellent transvesical exposure of the bladder neck and identifying both ureteral orifices bilaterally, we placed a 0-silk figure-of-eight retracting stitch into the prostatic adenoma. We then enucleated the prostatic adenoma using a combination of sharp and blunt dissection. The adenoma was removed en bloc and placed into a separate 10 mm Endo-catch bag. The prostatic urethral stump was reapproximated with the posterior bladder neck with a single 2-0 vicryl stitch to encourage remucosalization and for additional hemostatic compression. The bladder was closed in two layers.
Total operative time was 150 minutes. Estimated blood loss was 50 cc. No continuous bladder irrigation was required postoperatively. 85 grams of bladder stones and 27 grams of prostatic adenoma were removed. Hospital stay duration was 2 days, and foley catheter duration was 7 days. The patient’s one month post-operative AUA-SI score was 2 with a bother score of 1.
The robotic assisted laparoscopic approach to transvesical cystolithotomy and simple prostatectomy is feasible and may offer the advantages of superior visualization and hemostasis compared to the traditional open approach. This video abstract represents the first in our series of robotic simple prostatectomy at our institution. Additional cases are necessary to further demonstrate safety and efficacy.
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