Laparoscopy and Robotics Extraperitoneal Approach for Robotic-assisted Simple Prostatectomy Jens-Uwe Stolzenburg, Panagiotis Kallidonis, Hasan Qazi, Phuc Ho Thi, Anja Dietel, Evangelos N. Liatsikos, and Minh Do OBJECTIVE PATIENTS AND METHODS
RESULTS
CONCLUSION
To present the experience with the extraperitoneal approach for robotic-assisted simple prostatectomy (RASP) in a technique replicating the vesicocapsular incision technique of open surgery. RASP was performed on patients with a prostate volume of >80 cm3 with an indication for open enucleation of the prostate. Preoperatively, all patients were evaluated by uroflowmetry, prostatespecific antigen level, and postvoid residual measurement, as well as by the International Prostate Symptom Score questionnaire. All perioperative data were recorded in a prospective database. Follow-up appointments included the aforementioned measurements and were scheduled at 1 and 6 months postoperatively. Ten RASP procedures were successfully performed by the extraperitoneal approach. Mean patient age and prostate volume were 63.1 years (range, 55-74 years) and 129.4 cm3 (range, 90-170 cm3), respectively. Mean operative time was 122.5 minutes (range, 85-140 minutes) and represented the time from the first incision to the closure of the all incisions. The estimated blood loss was minimal (mean value, 230 mL). Transfusions were not necessary. Mean catheterization period was 7.4 days (range, 6-8 days). The symptomatology, as reported by the International Prostate Symptom Score, was improved at the follow-up appointments in comparison with the baseline values. One case of prolonged fever was noted postoperatively and managed by antibiotics. The extraperitoneal approach for RASP proved to be efficient in the management of large prostates. The results are directly comparable with the current available experience with transperitoneal RASP. The extraperitoneal RASP seems to favorably compare with the open simple prostatectomy, while the results are at least comparable with those of conventional laparoscopic approach. UROLOGY 84: 1099e1105, 2014. 2014 Elsevier Inc.
O
pen simple prostatectomy (OSP, or adenomectomy) has been a standard for the management of benign prostatic enlargement (BPE) for decades. The most commonly used techniques are the transverse capsular incision (Millin; open retropubic prostatectomy) and the vesicocapsular incision technique (Freyer; open suprapubic prostatectomy). The latter procedure has undergone refinements including the longitudinal incision of only the bladder without any capsular incision of the prostate (modified Freyer procedure).1 The development of transurethral resection of the prostate superseded OSP, and transurethral resection of the prostate currently represents the gold standard for the surgical management of BPE. OSP remains the most appropriate treatment technique for large prostates (80-100 cm3 volume).2 Nonetheless, technologically advanced Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, University of Leipzig, Leipzig, Germany; the Department of Urology, University of Patras, Patras, Greece; and the Department of Urology, Gartnavel General Hospital, Glasgow, United Kingdom Address correspondence to: Evangelos N. Liatsikos M.D., Ph.D., Department of Urology, University of Patras Medical School, Rion 26 504, Patras, Greece. E-mail: [email protected] Submitted: January 24, 2014, accepted (with revisions): June 27, 2014
ª 2014 Elsevier Inc. All Rights Reserved
approaches such as the holmium laser enucleation of the prostate and laparoscopic or robotic-assisted simple prostatectomy (RASP) have been introduced in an attempt to reduce complications and morbidity.1 The dissemination of robotics allowed the urologists to continue performing surgery in a familiar manner by replicating the open surgical techniques while providing minimally invasive surgery (MIS). This study presents the experience of a urologic center dedicated to MIS, in extraperitoneal approach for RASP replicating the vesicocapsular incision technique of OSP.
PATIENTS AND METHODS Ten patients underwent RASP over a period of 1.5 years. All procedures were performed by 2 surgeons experienced in robotic urologic surgery. An informed consent was obtained from all patients. The indication for RASP was a prostate volume 80 cm3 measured by abdominal or transrectal ultrasound. Five patients had refractory urinary retention, 1 patient had renal insufficiency due to large postvoid residual volume (PVR) that was managed by permanent catheterization, 3 patients had recurrent urinary infections, and 1 patient had http://dx.doi.org/10.1016/j.urology.2014.06.045 0090-4295/14
1099
Figure 1. (A) Patient positioning during the procedure. Notice the shallow Trendelenburg position of approximately 10 -15 . (B) Trocar placement for the extraperitoneal access to robotic-assisted simple prostatectomy. (C) A longitudinal cystotomy has been performed. The protruding middle lobe of the prostatic adenoma is visible along with the bladder mucosa. The ureteral orifices should always be recognized. (D) The cystotomy is kept open by traction sutures between the inner ipsilateral abdominal wall and each side of the cystotomy. (Color version available online.)
severe lower urinary tract symptoms related to BPE. No specific exclusion criteria were applied. Preoperatively, all patients were evaluated by uroflowmetry, provided they were not catheterized; prostate-specific antigen (PSA) level measurement; and the International Prostate Symptom Score (IPSS) questionnaire. Patients with high PSA values were investigated for the presence of prostate cancer before the patient was a candidate for RASP. On the admission day, abdominal ultrasound including the measurement of the post-micturition residual urine volume took place in patients who did not have a permanent urinary catheter because of refractory urinary retention. All perioperative data were recorded in a prospective database. Follow-up appointments were scheduled at 1 and 6 months postoperatively.
Surgical Technique Patient Positioning. The patient is positioned in a supine position with his legs abducted. The extraperitoneal approach does not require the steep Trendelenburg position of 20 -25 headdown tilt of the transperitoneal approach. A 10 -15 angle is sufficient and allows longer operative time without cardiopulmonary limitations (Fig. 1A). Development of Extraperitoneal Space. A 15-mm incision is made 1 cm below and lateral to the right of the umbilicus (right paraumbilical incision); a blunt dissection is carried out to the anterior rectus sheath. A small horizontal incision is made in the anterior rectus sheath. This opening is enlarged, the rectus 1100
muscle fibers are bluntly dissected, and the posterior rectus muscle sheath is eventually visible. The space between the rectus muscle and the posterior rectus sheath is bluntly developed by finger dissection in the direction of the preperitoneal space. A balloon trocar is inserted through the incision and inflated under visual control. Thus, the preperitoneal space is developed. The main landmarks during balloon inflation are the epigastric vessels and the pubic arch. The balloon trocar is deflated and removed. Stay sutures are placed on the anterior rectus sheath incision, and the Hassan-type optical trocar is introduced. Trocar Placement. An 8-mm robotic trocar is inserted 4 fingerbreadths to the left and lateral to the midline on the hypothetical line between the umbilicus and the pubic arch (Fig. 1B). A 12-mm conventional laparoscopic trocar is placed 2 fingerbreadths medially to the right anterior superior iliac spine. The site of insertion should be chosen as cephalad as the free edge of peritoneum allows. This port is used by the assistant for instruments such as the suction, clip applicators, and insertion and extraction of needles and sutures. An 8-mm robotic trocar is placed 5 fingerbreadths to the right from the umbilicus on a hypothetical line between the anterior superior iliac spine and the umbilicus. The last trocar is again an 8-mm robotic trocar and is inserted 3 fingerbreadths medial to the left anterior superior iliac spine (on a hypothetical line from the anterior superior iliac spine to the umbilicus). In contrast to other authors, a sixth 5-mm port is not necessary in the currently described approach.3-5 Robot docking follows with 2 robotic instruments, UROLOGY 84 (5), 2014
Figure 2. (A) Gradual development of the plane between the prostatic capsule and the adenoma has been initiated at the 10-o’clock position and extended to the left side. The dotted line shows exactly the plane between the prostatic capsule and adenoma. (B) The posterior side of the adenoma has been prepared. The dotted line shows the margin of the prostatic adenoma, which has been prepared. (C) The one lobe is being excised. The excision of the whole adenoma en bloc may be difficult in cases with very large adenomas. The preparation and excision of the one lobe separately from the other could be considered. (D) The adenoma has been excised and the prostatic fossa (dotted line) is visible. Notice the lack of any significant bleeding and that no hemostatic sutures are necessary. The trigonization of the bladder is performed. The bladder mucosa is sutured to prostatic fossa. (Color version available online.)
1 operating on the left side and 1 on the right side. The instruments used include a Hot Shears (monopolar curved scissors), fenestrated bipolar forceps, large needle driver, and ProGrasp forceps (Intuitive Surgical, Inc, Sunnyvale, CA). The bipolar and ProGrasp forceps are used through the left robotic trocars, whereas the curved scissors and needle driver are alternating through the right trocar. Cystotomy Incision. The fat overlying the bladder is dissected, and the anterior bladder wall is adequately exposed. Using the robotic scissors, a longitudinal cystotomy incision is made from the anterior bladder wall toward the neck of the bladder (Fig. 1C). The incision is extended approximately 2 cm over the anterior bladder wall and the same length over the prostatic capsule. The incision is used as a window by retracting the bladder wall with the use of sutures, which are placed on the ipsilateral abdominal wall and allows the cystotomy to remain open during the procedure (Fig. 1D). The bladder neck is exposed, and the protruding adenoma is visible. The ureteral orifices are identified. Enucleation of the Adenoma. Ligation of the dorsal venous complex is not always necessary. In cases of troublesome bleeding from the anterior prostatic surface, the dorsal venous complex may be ligated with the use of a 2-0 VICRYL suture (MH plus needle), which is passed underneath the plexus from right to left. A circumferential incision of the mucosa around the limits of the prostatic adenoma using the robotic monopolar curved scissors is performed, and the plane between the UROLOGY 84 (5), 2014
adenoma and the prostatic capsule is gradually developed. The development of this plane starts at the 10- and 2-o’clock positions (for the left and the right sides, respectively) and is circumferentially extended to both sides using blunt and sharp dissections as well as bipolar coagulation (Fig. 2A). This step requires meticulous attention to staying in the correct plane, which is relatively avascular. The dissection is then focused on one of the lobes and is directed toward the apex of the prostate (Fig. 2B). When eventually both lobes have been developed, careful dissection of the adenoma at the apex follows. At this point, the margin of dissection is carefully directed over the adenoma ensuring that the maximum possible length of the urethra is preserved avoiding damage to the external urethral sphincter. The identification of the verumontanum is useful and important for the apical dissection of the adenoma as the proximal dissection ascertains that the urethral sphincter is not injured. The whole prostatic adenoma is not dissected en bloc; initially, the removal of the first lobe takes place and is followed by the second lobe (Fig. 2C). Large middle lobes can be dissected first by grasping the lobe and carefully dissecting it away from the surgical capsule without injuring the ureteral orifices. The bipolar coagulation should be meticulously used to obtain a bloodless surgical field. Only at the apex, the use of coagulation should be avoided because injury to the external sphincter is possible. The adenoma is retrieved with an endoscopic specimen bag. Hemostasis and Bladder Closure. Careful hemostasis of any bleeding vessels within the prostatic fossa must be accomplished 1101
Table 1. Perioperative characteristics of the patients
Age (y) PSA level value (ng/dL) Prostate volume (cm3) Postvoid residual urine volume (mL) Maximum urinary flow, Qmax (mL/s) IPSS Total operative time (min) Access and robot docking time (min) Estimated blood loss (mL) Prostate weight resected (mL) Drainage time (d) Catheterization time (d) Hospitalization time (d)
Mean
Range
SD
63.1 7.31 143.9 121.9 9.37 21.90 122.5 20 228.8 102.0 1.7 7.4 8.4
55-74 4.17-11.92 90-250 70-170 5.2-11.5 16-30 85-140 15-30 50-540 55-140 1-3 6-8 7-9
6.624 2.561 46.8 34.7 1.987 5.446 16.87 5.27 131.7 28.01 0.82 0.97 0.96
Benign Prostatic Hyperplasiaerelated Conditions Urinary retention Renal insufficiency Recurrent urinary tract infections Severe LUTS
6 patients, permanent urethral or suprapubic catheter 1 patient 3 patients 1 patient
IPSS, International Prostate Symptom Score; LUTS, lower urinary tract symptoms; PSA, prostate-specific antigen; SD, standard deviation.
by bipolar diathermy. Suturing at the 5- and 7-o’clock positions of the prostatic capsule with a 2-0 VICRYL suture (UR-6) needle might be necessary. The posterior bladder urothelium is also sutured deep in the prostatic fossa near the urethra (bladder neck trigonization; Fig. 2D). This smoothens the posterior contour, facilitating catheterization, which may otherwise inadvertently undermine the “step” between the bladder and prostatic fossa. A 3-way Foley type catheter is then inserted, and the bladder cystotomy is closed by running a 3-0 VICRYL suture (UR-6 needle) or a 3-0 V-Loc (Covidien, New Haven, CT) suture. A second layer with running or interrupted suturing is advised. The suture line is checked for leakage by injection of 200-mL sterile water through the Foley catheter. Specimen Retrieval. A drain is placed through the lateral left 8-mm trocar posterior to the pubic arch. The endoscopic bag is removed through the elongated incision of the 12-mm trocar. Postoperative Management. The patient is managed by continuous bladder irrigation. The irrigation is stopped when hematuria is clinically insignificant. The drain is removed on the first or second postoperative day. The catheter is routinely removed on the sixth postoperative day (or on the eighth postoperative day in the first cases) after the performance of cystography. Complications encountered during the postoperative period are classified according to Dindo et al.6
RESULTS Ten RASP procedures were performed without the need for conversion to transperitoneal robotic or open approach. Perioperative data of the current series are listed in Table 1. Mean patient age and prostate volume were 63.1 years (range, 55-74 years) and 143.9 cm3 (range, 90-250 cm3), respectively. Five patients had higher than the normal PSA values and underwent prostatic biopsy for the exclusion of prostate cancer, which revealed benign prostatic hyperplasia and chronic inflammation in all the cases. One patient had an event 1102
of acute renal insufficiency due to the chronic urinary retention. After stabilization of the renal function, the patient had stage 1 chronic renal insufficiency. He was unable to void preoperatively and was included to the 6 patients who had a permanent urinary catheter. None of the patients had a diagnosis of stress or urge incontinence preoperatively. Perioperative results are listed in Table 1. All procedures were successfully accomplished by the aforementioned technique. Mean operative time was 122.5 minutes (range, 85-140 minutes) and represented the time from the first incision to the closure of the all incisions. Mean time for development of extraperitoneal access and robot docking was 20 minutes (range, 15-30 minutes). Mean estimated blood loss was 230 mL (range, 50-540 mL). Transfusions were not necessary. One case of prolonged fever was noted postoperatively and managed by antibiotics without extending the hospital stay of the patient (grade II). Late complications such as bladder neck contracture and urethral strictures were not noted in the current series. Catheter was removed on the eighth postoperative day in the first 7 patients and on the sixth postoperative day in the remaining 3 patients. Mean catheterization period was 7.4 days (range, 6-8 days). All patients were continent after the removal of the urinary catheter and were able to void. Mean hospitalization time was 8.4 days (range, 7-9 days). Follow-up of the current series of patients over a period of 6 months showed that the urinary flow was clearly improved with a mean maximum urinary flow of 20.7 2.49 mL/s at the 1-month follow-up. Mean PVR was reduced at 1 month (58 mL [range, 30-100 mL]) and remained stable at 6 months (57.5 mL [range, 25-90 mL]). The symptomatology, as reported by IPSS, was improved (mean IPSS of 8 2.67) at the 1-month follow-up appointment in comparison with that of the UROLOGY 84 (5), 2014
0 0 0 0 0 0 Not reported 0 (25-350) (100-300) (50-500) (150-900) (10-700) (50-500) 160 228.8 (50-540) 139.3 208 206 375 118 219
4.6 4.8 (4-6) 13 (12-14) 8.9 (6-14) 7.4 (5-14) 8.8 (5-14) Not reported 7.4 (6-8) (70-172) (75-120) (148-278) (60-180) (134-300) (90-270) 220 122.5 (85-140) 128.8 90 183 106 187 179
Trans Trans Trans Trans Trans Trans Trans Extra 46.4 157 (90-300) 136.5 (86-265) 81 (47-153) 106.6 (37-240) 163 (110-220) Not reported 129.4 (90-170)
1 1 0 298 (60-800) 558 (150-1125) 500 (100-1100) 7 (6-9) Not reported 6 (3-15) 205 (120-300) 211 (178-230) 210 (150-330) Trans Trans Extra 77.7 (40-106) Not reported 100 (90-180)
Uffort et al18 Coehlo et al4 Sutherland et al11 Clavijo et al3 Matei et al10 Vora et al12 Dubey and Hemal8 Current series
Sotelo et al Yuh et al13 John et al9
7
7 3 13 (finger enucleation in 3 cases) 15 6 9 10 35 13 3 10
Transfusions Mean Blood Loss, mL Mean Catheterization (Range), d Mean Operative Time (Range), min Access Mean Prostate Volume (Range), mL Number of Patients Study
Table 2. Summary of reports on robotic-assisted simple prostatectomy in literature
UROLOGY 84 (5), 2014
baseline values. Nevertheless, symptomatology was further improved (mean IPSS of 3.4 1.84) at 6 months after the procedure, while maximum flow remained similar at 21.6 2.17 mL/s.
COMMENT Sotelo et al7 were the first to propose RASP and replicated the technique of OSP with the added advantages of MIS such as reduced blood loss and faster convalescence. Several investigators have also presented their experience and technical modifications of RASP.3,4,8-13 Nevertheless, the transperitoneal access was used by most of the investigators. The experience with the extraperitoneal approach counts only 13 published cases with the use of 3-arm technique and finger enucleation of the prostate in their last 3 cases.9 The latter represented a change in technique to achieve improved operative times and lower blood loss. Thus, the efficiency of the presented technique should be to some extent questioned. The extraperitoneal approach represents a significant point of interest at our institution, and the efficacy of the method in performing laparoscopic radical prostatectomy has been well established.14 Robotic-assisted radical prostatectomy is also performed extraperitoneally at our institution.15 The extraperitoneal approach in the case of laparoscopic and robotic-assisted radical prostatectomy has been proven to be related to a lower rate of bowelrelated complications and faster patient convalescence in comparison with the transperitoneal access.16,17 Thus, the decision for extraperitoneal RASP was based on our experience and the aforementioned advantages. We describe a standardized technique based on the use of 4 robotic arms with extraperitoneal access to the prevesical space, although John et al9 proposed the use of 3 robotic arms. The technique is performed through 5 ports, which is an advantage over the 6-port techniques described for the transperitoneal approach.3-5 The current series showed that the blood loss was minimal and directly comparable with those reported in literature (Table 2).3-5,7,9-13,18 The operative time was comparable, if not lower, with the transperitoneal series. It should be noted that most of the authors do not specifically define the operative time, which represents the time from robot docking to the end of the procedure (robotic time) or the procedure from skin incision to the closure of the incisions.3,4,10 We currently present the time measurement for the establishment of the access and robot docking as well as the total operative time. Mean operative time of 20 minutes for the creation of the extraperitoneal space, placement of the trocars, and docking of the robotic system showed the efficacy of the extraperitoneal approach for RASP (Table 2). The complication rate was acceptable, and the complications were managed without the need for additional interventions. Catheterization time was initially 8 days. In the literature, the catheterization time varies, and some investigators remove the catheter even on the fifth 1103
postoperative day.12 The large cystotomy in the current series should be considered as a parameter attributing to >5 days of catheterization. Nevertheless, the extraperitoneal approach and the increasing experience provided confidence for the earlier removal of the catheter because any urine leakage would remain in the extraperitoneal space, and intraperitoneal complications related to the latter event would be avoided. Thus, we removed the catheter without any sequelae on the sixth postoperative day in the last 3 cases. The presented hospitalization time does not reflect the true outcome of the technique as it is related to the health system factors of the country of our institution. There is no comparative study between RASP and OSP available in the literature. Nevertheless, the former seems to provide favorable results. OSP has been associated with bleeding complications, transfusions, and postoperative infection.19,20 On the contrary, the RASP has been related to low morbidity and excellent postoperative functional outcome (Table 2). Laparoscopic simple prostatectomy (LSP) represents another alternative for the management of large prostates. A recent systematic review summarized the experience with LSP and showed that LSP is associated with lower blood loss, reduced need for irrigation, shorter postoperative catheterization period, and shorter hospital stay in comparison with those of OSP. Nevertheless, the extended operative time of LSP was a disadvantage. The aforementioned results should be carefully interpreted because the experience with LSP is limited, and further investigation is necessary.21 When considering the current experience with LSP and RASP,3-5,7-12,21 RASP is probably at least comparable with LSP. The lack of comparative evidence in the literature does not allow the extraction of any solid conclusions. An added advantage of robotics is the lack of a steep learning curve associated with laparoscopy.22 The robotic system facilitates the effort to overcome the learning curve.23 It is the subjective opinion of the authors that the robotic approach simplifies the performance of LSP and is based on their extensive experience with conventional laparoscopic and robotic-assisted laparoscopic procedures. The satisfactory operative outcomes could be attributed to the extensive experience of the surgeons and the efficiency of robotic-assistance in overcoming the learning curve.10 The excellent visualization provided by the robotic system allowed the efficient use of the bipolar cautery and contributed to the low blood loss and the minimal need for postoperative bladder irrigation. The patients required irrigation only on the day of the procedure and on the first postoperative day. Suturing or plication of the posterior prostatic capsule is not necessary because all bleedings were stopped directly by coagulation. An additional advantage of RASP is considered to be the efficient excision of the whole prostatic adenoma without leaving a residual tissue.10 Eventually, the combination of the aforementioned advantages with the extraperitoneal approach resulted into an efficient 1104
technique with promising results. The transperitoneal access is useful for performing extended pelvic lymph node dissection in case of radical prostatectomy, but in RASP, this is not needed. The prostate is an extraperitoneal organ and OSP, on which RASP is based, is an extraperitoneal technique. We would therefore go as far as suggesting that RASP should only be performed extraperitoneally. Limitation of the present study is the number of patients, which is low for any solid conclusions. The followup of the patients is limited to 6 months as the patients represent referrals to our centers, and further follow-up is performed by their treating physicians. The present study lacks additional urodynamic evaluation of the patients other than those with uroflow and PVR. The lack of a comparative evaluation of the current approach with the transperitoneal approach does not allow any conclusion regarding the superiority of one approach over the other. Moreover, there are new technologies that are currently evaluated in the surgical management of BPE, and we have not attempted any comparison. Only further clinical investigation would elucidate the advantages of each technique, set the appropriate indications, and eventually establish newer techniques. The cost efficiency of RASP could only be evaluated by proper economic studies.
CONCLUSION The extraperitoneal RASP proved to be efficient in the management of large prostates. The results are at least comparable with the current available experience with transperitoneal RASP. Clinical comparative studies would elucidate the advantages of the technique.
References 1. Freyer PJ. A recent series of 60 cases of total enucleation of the prostate for radical cure of enlargement of that organ. Br Med J. 1905;1:1085-1089. 2. Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol. 2013; 64:118-140. 3. Clavijo R, Carmona O, De Andrade R, et al. Robot-assisted intrafascial simple prostatectomy: novel technique. J Endourol. 2013; 27:328-332. 4. Coelho RF, Chauhan S, Sivaraman A, et al. Modified technique of robotic-assisted simple prostatectomy: advantages of a vesicourethral anastomosis. BJU Int. 2012;109:426-433. 5. Thuroff JW, Leicht W, Kamal MM, et al. Robot-assisted laparoscopic enucleation of benign prostatic hyperplasia (BPH). BJU Int. 2012;110:1388-1405. 6. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205-213. 7. Sotelo R, Clavijo R, Carmona O, et al. Robotic simple prostatectomy. J Urol. 2008;179:513-515. 8. Dubey D, Hemal AK. Robotic-assisted simple prostatectomy with complete urethrovesical reconstruction. Indian J Urol. 2012;28: 231-232. 9. John H, Bucher C, Engel N, et al. Preperitoneal robotic prostate adenomectomy. Urology. 2009;73:811-815.
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10. Matei DV, Brescia A, Mazzoleni F, et al. Robot-assisted simple prostatectomy (RASP): does it make sense? BJU Int. 2012;110: E972-E979. 11. Sutherland DE, Perez DS, Weeks DC. Robot-assisted simple prostatectomy for severe benign prostatic hyperplasia. J Endourol. 2011; 25:641-644. 12. Vora A, Mittal S, Hwang J, et al. Robot-assisted simple prostatectomy: multi-institutional outcomes for glands larger than 100 grams. J Endourol. 2012;26:499-502. 13. Yuh B, Laungani R, Perlmutter A, et al. Robot-assisted Millin’s retropubic prostatectomy: case series. Can J Urol. 2008;15:4101-4105. 14. Stolzenburg JU, Kallidonis P, Minh D, et al. Endoscopic extraperitoneal radical prostatectomy: evolution of the technique and experience with 2400 cases. J Endourol. 2009;23:1467-1472. 15. Stolzenburg JU, Qazi HA, Holze S, et al. Evaluating the learning curve of experienced laparoscopic surgeons in robot-assisted radical prostatectomy. J Endourol. 2013;27:80-85. 16. Atug F, Castle EP, Woods M, et al. Transperitoneal versus extraperitoneal robotic-assisted radical prostatectomy: is one better than the other? Urology. 2006;68:1077-1081. 17. Chung JS, Kim WT, Ham WS, et al. Comparison of oncological results, functional outcomes, and complications for transperitoneal
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18.
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versus extraperitoneal robot-assisted radical prostatectomy: a single surgeon’s experience. J Endourol. 2011;25:787-792. Uffort EE, Jensen JC. Robotic-assisted laparoscopic simple prostatectomy: an alternative minimal invasive approach for prostate adenoma. J Robotic Surg. 2010;4:7-10. Gratzke C, Schlenker B, Seitz M, et al. Complications and early postoperative outcome after open prostatectomy in patients with benign prostatic enlargement: results of a prospective multicenter study. J Urol. 2007;177:1419-1422. Serretta V, Morgia G, Fondacaro L, et al. Open prostatectomy for benign prostatic enlargement in southern Europe in the late 1990s: a contemporary series of 1800 interventions. Urology. 2002;60: 623-627. Asimakopoulos AD, Mugnier C, Hoepffner JL, et al. The surgical treatment of a large prostatic adenoma: the laparoscopic approachea systematic review. J Endourol. 2012;26:960-967. Castillo OA, Bolufer E, Lopez-Fontana G, et al. [Laparoscopic simple prostatectomy (adenomectomy): experience in 59 consecutive patients]. Actas Urol Esp. 2011;35:434-437. Mirheydar HS, Parsons JK. Diffusion of robotics into clinical practice in the United States: process, patient safety, learning curves, and the public health. World J Urol. 2013;31:455-461.
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RESULTS
CONCLUSION
To present the experience with the extraperitoneal approach for robotic-assisted simple prostatectomy (RASP) in a technique replicating the vesicocapsular incision technique of open surgery. RASP was performed on patients with a prostate volume of >80 cm3 with an indication for open enucleation of the prostate. Preoperatively, all patients were evaluated by uroflowmetry, prostatespecific antigen level, and postvoid residual measurement, as well as by the International Prostate Symptom Score questionnaire. All perioperative data were recorded in a prospective database. Follow-up appointments included the aforementioned measurements and were scheduled at 1 and 6 months postoperatively. Ten RASP procedures were successfully performed by the extraperitoneal approach. Mean patient age and prostate volume were 63.1 years (range, 55-74 years) and 129.4 cm3 (range, 90-170 cm3), respectively. Mean operative time was 122.5 minutes (range, 85-140 minutes) and represented the time from the first incision to the closure of the all incisions. The estimated blood loss was minimal (mean value, 230 mL). Transfusions were not necessary. Mean catheterization period was 7.4 days (range, 6-8 days). The symptomatology, as reported by the International Prostate Symptom Score, was improved at the follow-up appointments in comparison with the baseline values. One case of prolonged fever was noted postoperatively and managed by antibiotics. The extraperitoneal approach for RASP proved to be efficient in the management of large prostates. The results are directly comparable with the current available experience with transperitoneal RASP. The extraperitoneal RASP seems to favorably compare with the open simple prostatectomy, while the results are at least comparable with those of conventional laparoscopic approach. UROLOGY 84: 1099e1105, 2014. 2014 Elsevier Inc.
O
pen simple prostatectomy (OSP, or adenomectomy) has been a standard for the management of benign prostatic enlargement (BPE) for decades. The most commonly used techniques are the transverse capsular incision (Millin; open retropubic prostatectomy) and the vesicocapsular incision technique (Freyer; open suprapubic prostatectomy). The latter procedure has undergone refinements including the longitudinal incision of only the bladder without any capsular incision of the prostate (modified Freyer procedure).1 The development of transurethral resection of the prostate superseded OSP, and transurethral resection of the prostate currently represents the gold standard for the surgical management of BPE. OSP remains the most appropriate treatment technique for large prostates (80-100 cm3 volume).2 Nonetheless, technologically advanced Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, University of Leipzig, Leipzig, Germany; the Department of Urology, University of Patras, Patras, Greece; and the Department of Urology, Gartnavel General Hospital, Glasgow, United Kingdom Address correspondence to: Evangelos N. Liatsikos M.D., Ph.D., Department of Urology, University of Patras Medical School, Rion 26 504, Patras, Greece. E-mail: [email protected] Submitted: January 24, 2014, accepted (with revisions): June 27, 2014
ª 2014 Elsevier Inc. All Rights Reserved
approaches such as the holmium laser enucleation of the prostate and laparoscopic or robotic-assisted simple prostatectomy (RASP) have been introduced in an attempt to reduce complications and morbidity.1 The dissemination of robotics allowed the urologists to continue performing surgery in a familiar manner by replicating the open surgical techniques while providing minimally invasive surgery (MIS). This study presents the experience of a urologic center dedicated to MIS, in extraperitoneal approach for RASP replicating the vesicocapsular incision technique of OSP.
PATIENTS AND METHODS Ten patients underwent RASP over a period of 1.5 years. All procedures were performed by 2 surgeons experienced in robotic urologic surgery. An informed consent was obtained from all patients. The indication for RASP was a prostate volume 80 cm3 measured by abdominal or transrectal ultrasound. Five patients had refractory urinary retention, 1 patient had renal insufficiency due to large postvoid residual volume (PVR) that was managed by permanent catheterization, 3 patients had recurrent urinary infections, and 1 patient had http://dx.doi.org/10.1016/j.urology.2014.06.045 0090-4295/14
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Figure 1. (A) Patient positioning during the procedure. Notice the shallow Trendelenburg position of approximately 10 -15 . (B) Trocar placement for the extraperitoneal access to robotic-assisted simple prostatectomy. (C) A longitudinal cystotomy has been performed. The protruding middle lobe of the prostatic adenoma is visible along with the bladder mucosa. The ureteral orifices should always be recognized. (D) The cystotomy is kept open by traction sutures between the inner ipsilateral abdominal wall and each side of the cystotomy. (Color version available online.)
severe lower urinary tract symptoms related to BPE. No specific exclusion criteria were applied. Preoperatively, all patients were evaluated by uroflowmetry, provided they were not catheterized; prostate-specific antigen (PSA) level measurement; and the International Prostate Symptom Score (IPSS) questionnaire. Patients with high PSA values were investigated for the presence of prostate cancer before the patient was a candidate for RASP. On the admission day, abdominal ultrasound including the measurement of the post-micturition residual urine volume took place in patients who did not have a permanent urinary catheter because of refractory urinary retention. All perioperative data were recorded in a prospective database. Follow-up appointments were scheduled at 1 and 6 months postoperatively.
Surgical Technique Patient Positioning. The patient is positioned in a supine position with his legs abducted. The extraperitoneal approach does not require the steep Trendelenburg position of 20 -25 headdown tilt of the transperitoneal approach. A 10 -15 angle is sufficient and allows longer operative time without cardiopulmonary limitations (Fig. 1A). Development of Extraperitoneal Space. A 15-mm incision is made 1 cm below and lateral to the right of the umbilicus (right paraumbilical incision); a blunt dissection is carried out to the anterior rectus sheath. A small horizontal incision is made in the anterior rectus sheath. This opening is enlarged, the rectus 1100
muscle fibers are bluntly dissected, and the posterior rectus muscle sheath is eventually visible. The space between the rectus muscle and the posterior rectus sheath is bluntly developed by finger dissection in the direction of the preperitoneal space. A balloon trocar is inserted through the incision and inflated under visual control. Thus, the preperitoneal space is developed. The main landmarks during balloon inflation are the epigastric vessels and the pubic arch. The balloon trocar is deflated and removed. Stay sutures are placed on the anterior rectus sheath incision, and the Hassan-type optical trocar is introduced. Trocar Placement. An 8-mm robotic trocar is inserted 4 fingerbreadths to the left and lateral to the midline on the hypothetical line between the umbilicus and the pubic arch (Fig. 1B). A 12-mm conventional laparoscopic trocar is placed 2 fingerbreadths medially to the right anterior superior iliac spine. The site of insertion should be chosen as cephalad as the free edge of peritoneum allows. This port is used by the assistant for instruments such as the suction, clip applicators, and insertion and extraction of needles and sutures. An 8-mm robotic trocar is placed 5 fingerbreadths to the right from the umbilicus on a hypothetical line between the anterior superior iliac spine and the umbilicus. The last trocar is again an 8-mm robotic trocar and is inserted 3 fingerbreadths medial to the left anterior superior iliac spine (on a hypothetical line from the anterior superior iliac spine to the umbilicus). In contrast to other authors, a sixth 5-mm port is not necessary in the currently described approach.3-5 Robot docking follows with 2 robotic instruments, UROLOGY 84 (5), 2014
Figure 2. (A) Gradual development of the plane between the prostatic capsule and the adenoma has been initiated at the 10-o’clock position and extended to the left side. The dotted line shows exactly the plane between the prostatic capsule and adenoma. (B) The posterior side of the adenoma has been prepared. The dotted line shows the margin of the prostatic adenoma, which has been prepared. (C) The one lobe is being excised. The excision of the whole adenoma en bloc may be difficult in cases with very large adenomas. The preparation and excision of the one lobe separately from the other could be considered. (D) The adenoma has been excised and the prostatic fossa (dotted line) is visible. Notice the lack of any significant bleeding and that no hemostatic sutures are necessary. The trigonization of the bladder is performed. The bladder mucosa is sutured to prostatic fossa. (Color version available online.)
1 operating on the left side and 1 on the right side. The instruments used include a Hot Shears (monopolar curved scissors), fenestrated bipolar forceps, large needle driver, and ProGrasp forceps (Intuitive Surgical, Inc, Sunnyvale, CA). The bipolar and ProGrasp forceps are used through the left robotic trocars, whereas the curved scissors and needle driver are alternating through the right trocar. Cystotomy Incision. The fat overlying the bladder is dissected, and the anterior bladder wall is adequately exposed. Using the robotic scissors, a longitudinal cystotomy incision is made from the anterior bladder wall toward the neck of the bladder (Fig. 1C). The incision is extended approximately 2 cm over the anterior bladder wall and the same length over the prostatic capsule. The incision is used as a window by retracting the bladder wall with the use of sutures, which are placed on the ipsilateral abdominal wall and allows the cystotomy to remain open during the procedure (Fig. 1D). The bladder neck is exposed, and the protruding adenoma is visible. The ureteral orifices are identified. Enucleation of the Adenoma. Ligation of the dorsal venous complex is not always necessary. In cases of troublesome bleeding from the anterior prostatic surface, the dorsal venous complex may be ligated with the use of a 2-0 VICRYL suture (MH plus needle), which is passed underneath the plexus from right to left. A circumferential incision of the mucosa around the limits of the prostatic adenoma using the robotic monopolar curved scissors is performed, and the plane between the UROLOGY 84 (5), 2014
adenoma and the prostatic capsule is gradually developed. The development of this plane starts at the 10- and 2-o’clock positions (for the left and the right sides, respectively) and is circumferentially extended to both sides using blunt and sharp dissections as well as bipolar coagulation (Fig. 2A). This step requires meticulous attention to staying in the correct plane, which is relatively avascular. The dissection is then focused on one of the lobes and is directed toward the apex of the prostate (Fig. 2B). When eventually both lobes have been developed, careful dissection of the adenoma at the apex follows. At this point, the margin of dissection is carefully directed over the adenoma ensuring that the maximum possible length of the urethra is preserved avoiding damage to the external urethral sphincter. The identification of the verumontanum is useful and important for the apical dissection of the adenoma as the proximal dissection ascertains that the urethral sphincter is not injured. The whole prostatic adenoma is not dissected en bloc; initially, the removal of the first lobe takes place and is followed by the second lobe (Fig. 2C). Large middle lobes can be dissected first by grasping the lobe and carefully dissecting it away from the surgical capsule without injuring the ureteral orifices. The bipolar coagulation should be meticulously used to obtain a bloodless surgical field. Only at the apex, the use of coagulation should be avoided because injury to the external sphincter is possible. The adenoma is retrieved with an endoscopic specimen bag. Hemostasis and Bladder Closure. Careful hemostasis of any bleeding vessels within the prostatic fossa must be accomplished 1101
Table 1. Perioperative characteristics of the patients
Age (y) PSA level value (ng/dL) Prostate volume (cm3) Postvoid residual urine volume (mL) Maximum urinary flow, Qmax (mL/s) IPSS Total operative time (min) Access and robot docking time (min) Estimated blood loss (mL) Prostate weight resected (mL) Drainage time (d) Catheterization time (d) Hospitalization time (d)
Mean
Range
SD
63.1 7.31 143.9 121.9 9.37 21.90 122.5 20 228.8 102.0 1.7 7.4 8.4
55-74 4.17-11.92 90-250 70-170 5.2-11.5 16-30 85-140 15-30 50-540 55-140 1-3 6-8 7-9
6.624 2.561 46.8 34.7 1.987 5.446 16.87 5.27 131.7 28.01 0.82 0.97 0.96
Benign Prostatic Hyperplasiaerelated Conditions Urinary retention Renal insufficiency Recurrent urinary tract infections Severe LUTS
6 patients, permanent urethral or suprapubic catheter 1 patient 3 patients 1 patient
IPSS, International Prostate Symptom Score; LUTS, lower urinary tract symptoms; PSA, prostate-specific antigen; SD, standard deviation.
by bipolar diathermy. Suturing at the 5- and 7-o’clock positions of the prostatic capsule with a 2-0 VICRYL suture (UR-6) needle might be necessary. The posterior bladder urothelium is also sutured deep in the prostatic fossa near the urethra (bladder neck trigonization; Fig. 2D). This smoothens the posterior contour, facilitating catheterization, which may otherwise inadvertently undermine the “step” between the bladder and prostatic fossa. A 3-way Foley type catheter is then inserted, and the bladder cystotomy is closed by running a 3-0 VICRYL suture (UR-6 needle) or a 3-0 V-Loc (Covidien, New Haven, CT) suture. A second layer with running or interrupted suturing is advised. The suture line is checked for leakage by injection of 200-mL sterile water through the Foley catheter. Specimen Retrieval. A drain is placed through the lateral left 8-mm trocar posterior to the pubic arch. The endoscopic bag is removed through the elongated incision of the 12-mm trocar. Postoperative Management. The patient is managed by continuous bladder irrigation. The irrigation is stopped when hematuria is clinically insignificant. The drain is removed on the first or second postoperative day. The catheter is routinely removed on the sixth postoperative day (or on the eighth postoperative day in the first cases) after the performance of cystography. Complications encountered during the postoperative period are classified according to Dindo et al.6
RESULTS Ten RASP procedures were performed without the need for conversion to transperitoneal robotic or open approach. Perioperative data of the current series are listed in Table 1. Mean patient age and prostate volume were 63.1 years (range, 55-74 years) and 143.9 cm3 (range, 90-250 cm3), respectively. Five patients had higher than the normal PSA values and underwent prostatic biopsy for the exclusion of prostate cancer, which revealed benign prostatic hyperplasia and chronic inflammation in all the cases. One patient had an event 1102
of acute renal insufficiency due to the chronic urinary retention. After stabilization of the renal function, the patient had stage 1 chronic renal insufficiency. He was unable to void preoperatively and was included to the 6 patients who had a permanent urinary catheter. None of the patients had a diagnosis of stress or urge incontinence preoperatively. Perioperative results are listed in Table 1. All procedures were successfully accomplished by the aforementioned technique. Mean operative time was 122.5 minutes (range, 85-140 minutes) and represented the time from the first incision to the closure of the all incisions. Mean time for development of extraperitoneal access and robot docking was 20 minutes (range, 15-30 minutes). Mean estimated blood loss was 230 mL (range, 50-540 mL). Transfusions were not necessary. One case of prolonged fever was noted postoperatively and managed by antibiotics without extending the hospital stay of the patient (grade II). Late complications such as bladder neck contracture and urethral strictures were not noted in the current series. Catheter was removed on the eighth postoperative day in the first 7 patients and on the sixth postoperative day in the remaining 3 patients. Mean catheterization period was 7.4 days (range, 6-8 days). All patients were continent after the removal of the urinary catheter and were able to void. Mean hospitalization time was 8.4 days (range, 7-9 days). Follow-up of the current series of patients over a period of 6 months showed that the urinary flow was clearly improved with a mean maximum urinary flow of 20.7 2.49 mL/s at the 1-month follow-up. Mean PVR was reduced at 1 month (58 mL [range, 30-100 mL]) and remained stable at 6 months (57.5 mL [range, 25-90 mL]). The symptomatology, as reported by IPSS, was improved (mean IPSS of 8 2.67) at the 1-month follow-up appointment in comparison with that of the UROLOGY 84 (5), 2014
0 0 0 0 0 0 Not reported 0 (25-350) (100-300) (50-500) (150-900) (10-700) (50-500) 160 228.8 (50-540) 139.3 208 206 375 118 219
4.6 4.8 (4-6) 13 (12-14) 8.9 (6-14) 7.4 (5-14) 8.8 (5-14) Not reported 7.4 (6-8) (70-172) (75-120) (148-278) (60-180) (134-300) (90-270) 220 122.5 (85-140) 128.8 90 183 106 187 179
Trans Trans Trans Trans Trans Trans Trans Extra 46.4 157 (90-300) 136.5 (86-265) 81 (47-153) 106.6 (37-240) 163 (110-220) Not reported 129.4 (90-170)
1 1 0 298 (60-800) 558 (150-1125) 500 (100-1100) 7 (6-9) Not reported 6 (3-15) 205 (120-300) 211 (178-230) 210 (150-330) Trans Trans Extra 77.7 (40-106) Not reported 100 (90-180)
Uffort et al18 Coehlo et al4 Sutherland et al11 Clavijo et al3 Matei et al10 Vora et al12 Dubey and Hemal8 Current series
Sotelo et al Yuh et al13 John et al9
7
7 3 13 (finger enucleation in 3 cases) 15 6 9 10 35 13 3 10
Transfusions Mean Blood Loss, mL Mean Catheterization (Range), d Mean Operative Time (Range), min Access Mean Prostate Volume (Range), mL Number of Patients Study
Table 2. Summary of reports on robotic-assisted simple prostatectomy in literature
UROLOGY 84 (5), 2014
baseline values. Nevertheless, symptomatology was further improved (mean IPSS of 3.4 1.84) at 6 months after the procedure, while maximum flow remained similar at 21.6 2.17 mL/s.
COMMENT Sotelo et al7 were the first to propose RASP and replicated the technique of OSP with the added advantages of MIS such as reduced blood loss and faster convalescence. Several investigators have also presented their experience and technical modifications of RASP.3,4,8-13 Nevertheless, the transperitoneal access was used by most of the investigators. The experience with the extraperitoneal approach counts only 13 published cases with the use of 3-arm technique and finger enucleation of the prostate in their last 3 cases.9 The latter represented a change in technique to achieve improved operative times and lower blood loss. Thus, the efficiency of the presented technique should be to some extent questioned. The extraperitoneal approach represents a significant point of interest at our institution, and the efficacy of the method in performing laparoscopic radical prostatectomy has been well established.14 Robotic-assisted radical prostatectomy is also performed extraperitoneally at our institution.15 The extraperitoneal approach in the case of laparoscopic and robotic-assisted radical prostatectomy has been proven to be related to a lower rate of bowelrelated complications and faster patient convalescence in comparison with the transperitoneal access.16,17 Thus, the decision for extraperitoneal RASP was based on our experience and the aforementioned advantages. We describe a standardized technique based on the use of 4 robotic arms with extraperitoneal access to the prevesical space, although John et al9 proposed the use of 3 robotic arms. The technique is performed through 5 ports, which is an advantage over the 6-port techniques described for the transperitoneal approach.3-5 The current series showed that the blood loss was minimal and directly comparable with those reported in literature (Table 2).3-5,7,9-13,18 The operative time was comparable, if not lower, with the transperitoneal series. It should be noted that most of the authors do not specifically define the operative time, which represents the time from robot docking to the end of the procedure (robotic time) or the procedure from skin incision to the closure of the incisions.3,4,10 We currently present the time measurement for the establishment of the access and robot docking as well as the total operative time. Mean operative time of 20 minutes for the creation of the extraperitoneal space, placement of the trocars, and docking of the robotic system showed the efficacy of the extraperitoneal approach for RASP (Table 2). The complication rate was acceptable, and the complications were managed without the need for additional interventions. Catheterization time was initially 8 days. In the literature, the catheterization time varies, and some investigators remove the catheter even on the fifth 1103
postoperative day.12 The large cystotomy in the current series should be considered as a parameter attributing to >5 days of catheterization. Nevertheless, the extraperitoneal approach and the increasing experience provided confidence for the earlier removal of the catheter because any urine leakage would remain in the extraperitoneal space, and intraperitoneal complications related to the latter event would be avoided. Thus, we removed the catheter without any sequelae on the sixth postoperative day in the last 3 cases. The presented hospitalization time does not reflect the true outcome of the technique as it is related to the health system factors of the country of our institution. There is no comparative study between RASP and OSP available in the literature. Nevertheless, the former seems to provide favorable results. OSP has been associated with bleeding complications, transfusions, and postoperative infection.19,20 On the contrary, the RASP has been related to low morbidity and excellent postoperative functional outcome (Table 2). Laparoscopic simple prostatectomy (LSP) represents another alternative for the management of large prostates. A recent systematic review summarized the experience with LSP and showed that LSP is associated with lower blood loss, reduced need for irrigation, shorter postoperative catheterization period, and shorter hospital stay in comparison with those of OSP. Nevertheless, the extended operative time of LSP was a disadvantage. The aforementioned results should be carefully interpreted because the experience with LSP is limited, and further investigation is necessary.21 When considering the current experience with LSP and RASP,3-5,7-12,21 RASP is probably at least comparable with LSP. The lack of comparative evidence in the literature does not allow the extraction of any solid conclusions. An added advantage of robotics is the lack of a steep learning curve associated with laparoscopy.22 The robotic system facilitates the effort to overcome the learning curve.23 It is the subjective opinion of the authors that the robotic approach simplifies the performance of LSP and is based on their extensive experience with conventional laparoscopic and robotic-assisted laparoscopic procedures. The satisfactory operative outcomes could be attributed to the extensive experience of the surgeons and the efficiency of robotic-assistance in overcoming the learning curve.10 The excellent visualization provided by the robotic system allowed the efficient use of the bipolar cautery and contributed to the low blood loss and the minimal need for postoperative bladder irrigation. The patients required irrigation only on the day of the procedure and on the first postoperative day. Suturing or plication of the posterior prostatic capsule is not necessary because all bleedings were stopped directly by coagulation. An additional advantage of RASP is considered to be the efficient excision of the whole prostatic adenoma without leaving a residual tissue.10 Eventually, the combination of the aforementioned advantages with the extraperitoneal approach resulted into an efficient 1104
technique with promising results. The transperitoneal access is useful for performing extended pelvic lymph node dissection in case of radical prostatectomy, but in RASP, this is not needed. The prostate is an extraperitoneal organ and OSP, on which RASP is based, is an extraperitoneal technique. We would therefore go as far as suggesting that RASP should only be performed extraperitoneally. Limitation of the present study is the number of patients, which is low for any solid conclusions. The followup of the patients is limited to 6 months as the patients represent referrals to our centers, and further follow-up is performed by their treating physicians. The present study lacks additional urodynamic evaluation of the patients other than those with uroflow and PVR. The lack of a comparative evaluation of the current approach with the transperitoneal approach does not allow any conclusion regarding the superiority of one approach over the other. Moreover, there are new technologies that are currently evaluated in the surgical management of BPE, and we have not attempted any comparison. Only further clinical investigation would elucidate the advantages of each technique, set the appropriate indications, and eventually establish newer techniques. The cost efficiency of RASP could only be evaluated by proper economic studies.
CONCLUSION The extraperitoneal RASP proved to be efficient in the management of large prostates. The results are at least comparable with the current available experience with transperitoneal RASP. Clinical comparative studies would elucidate the advantages of the technique.
References 1. Freyer PJ. A recent series of 60 cases of total enucleation of the prostate for radical cure of enlargement of that organ. Br Med J. 1905;1:1085-1089. 2. Oelke M, Bachmann A, Descazeaud A, et al. EAU guidelines on the treatment and follow-up of non-neurogenic male lower urinary tract symptoms including benign prostatic obstruction. Eur Urol. 2013; 64:118-140. 3. Clavijo R, Carmona O, De Andrade R, et al. Robot-assisted intrafascial simple prostatectomy: novel technique. J Endourol. 2013; 27:328-332. 4. Coelho RF, Chauhan S, Sivaraman A, et al. Modified technique of robotic-assisted simple prostatectomy: advantages of a vesicourethral anastomosis. BJU Int. 2012;109:426-433. 5. Thuroff JW, Leicht W, Kamal MM, et al. Robot-assisted laparoscopic enucleation of benign prostatic hyperplasia (BPH). BJU Int. 2012;110:1388-1405. 6. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205-213. 7. Sotelo R, Clavijo R, Carmona O, et al. Robotic simple prostatectomy. J Urol. 2008;179:513-515. 8. Dubey D, Hemal AK. Robotic-assisted simple prostatectomy with complete urethrovesical reconstruction. Indian J Urol. 2012;28: 231-232. 9. John H, Bucher C, Engel N, et al. Preperitoneal robotic prostate adenomectomy. Urology. 2009;73:811-815.
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10. Matei DV, Brescia A, Mazzoleni F, et al. Robot-assisted simple prostatectomy (RASP): does it make sense? BJU Int. 2012;110: E972-E979. 11. Sutherland DE, Perez DS, Weeks DC. Robot-assisted simple prostatectomy for severe benign prostatic hyperplasia. J Endourol. 2011; 25:641-644. 12. Vora A, Mittal S, Hwang J, et al. Robot-assisted simple prostatectomy: multi-institutional outcomes for glands larger than 100 grams. J Endourol. 2012;26:499-502. 13. Yuh B, Laungani R, Perlmutter A, et al. Robot-assisted Millin’s retropubic prostatectomy: case series. Can J Urol. 2008;15:4101-4105. 14. Stolzenburg JU, Kallidonis P, Minh D, et al. Endoscopic extraperitoneal radical prostatectomy: evolution of the technique and experience with 2400 cases. J Endourol. 2009;23:1467-1472. 15. Stolzenburg JU, Qazi HA, Holze S, et al. Evaluating the learning curve of experienced laparoscopic surgeons in robot-assisted radical prostatectomy. J Endourol. 2013;27:80-85. 16. Atug F, Castle EP, Woods M, et al. Transperitoneal versus extraperitoneal robotic-assisted radical prostatectomy: is one better than the other? Urology. 2006;68:1077-1081. 17. Chung JS, Kim WT, Ham WS, et al. Comparison of oncological results, functional outcomes, and complications for transperitoneal
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