Different Approaches to Robotic Simple Prostatectomy

Abstract INTRODUCTION Robotic simple prostatectomy is becoming widespread for treatment of larger prostates. 1 This video article examines two approaches: retropubic and transvesical. METHODS The retropubic, similar to the open Millin, involves dropping the bladder, developing the space of Retzius, and exposing and incising the anterior prostatic capsule longitudinally. 2 The adenoma is separated from the surgical capsule by sweeping laterally using blunt dissection until the posterior prostatic capsule is reached. The posterior aspect of the bladder neck is approximated to the distal urethra after adenoma excision. In contrast, the transvesical mimics the simple open suprapubic. 3 The bladder is not dropped and the space of Retzius not developed. The bladder dome is incised and 4 stay sutures tack it open. The mucosa is scored posterior to the median lobe to create a plane between the adenoma and the posterior surgical capsule which is continued circumferentially to include the lateral lobes. After adenoma removal, the bladder neck is approximated circumferentially to the distal urethra and the cystotomy is closed. RESULTS We compared results in 20 patients, 10 with each approach. The groups were similar in demographics and preoperative characteristics including BMI, PSA, prostate size, and PVR. Each approach was safely executed robotically without complications in either group and a hospital stay of 1 day in all 20 patients; however, EBL, operative time, and catheter indwell time were all lower for the transvesical group (75 ml vs. 150 ml, p = .067; 140 min vs. 210 min, p = .025; 6 vs. 10 days, p =). CONCLUSION In this retrospective comparison we demonstrate differences in 2 approaches to robotic simple prostatectomy. Preliminary analysis demonstrates both to be safe and efficacious, but there appear to be some advantages for the transvesical approach that deserve prospective evaluation.