EURURO-5448; No. of Pages 9 EUROPEAN UROLOGY XXX (2014) XXX–XXX
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Surgery in Motion
Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience Scott Leslie, Andre Luis de Castro Abreu, Sameer Chopra, Patrick Ramos, Daniel Park, Andre K. Berger, Mihir M. Desai, Inderbir S. Gill, Monish Aron * Institute of Urology, Catherine and Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA, USA
Article info
Abstract
Article history: Accepted December 13, 2013 Published online ahead of print on January 3, 2014
Background: Despite significant developments in transurethral surgery for benign prostatic hyperplasia (BPH), simple prostatectomy remains an excellent option for patients with large glands. Objective: To describe our technique of transvesical robotic simple prostatectomy (RSP). Design, setting, and participants: From May 2011 to April 2013, 25 patients underwent RSP. Surgical procedure: We performed RSP using our technique. Outcome measurements and statistical analysis: Baseline demographics, pathology data, perioperative complications, 90-d complications, and functional outcomes were assessed. Results and limitations: Mean patient age was 72.9 yr (range: 54–88), baseline International Prostate Symptom Score (IPSS) was 23.9 (range: 9–35), prostate volume was 149.6 ml (range: 91–260), postvoid residual (PVR) was 208.1 ml (range: 72–800), maximum flow rate (Qmax) was 11.3 ml/s, and preoperative prostate-specific antigen was 9.4 ng/ml (range: 1.9–56.3). Eight patients were catheter dependent before surgery. Mean operative time was 214 min (range: 165–345), estimated blood loss was 143 ml (range: 50–350), and the hospital stay was 4 d (range: 2–8). There were no intraoperative complications and no conversions to open surgery. Five patients had a concomitant robotic procedure performed. Early functional outcomes demonstrated significant improvement from baseline with an 85% reduction in mean IPSS ( p < 0.0001), an 82.2% reduction in mean PVR ( p = 0.014), and a 77% increase in mean Qmax ( p = 0.20). This study is limited by small sample size and short follow-up period. One patient had a urinary tract infection; two had recurrent hematuria, one requiring transfusion; one patient had clot retention and extravasation, requiring reoperation. Conclusions: Our technique of RSP is safe and effective. Good functional outcomes suggest it is a viable option for BPH and larger glands and can be used for patients requiring concomitant procedures. Patient summary: We describe the technique and report the initial results of a series of cases of transvesical robotic simple prostatectomy. The procedure is both feasible and safe and a good option for benign prostatic hyperplasia with larger glands. # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Keywords: Benign prostatic hyperplasia Simple prostatectomy Robotic surgery Please visit www.europeanurology.com and www.urosource.com to view the accompanying video.
* Corresponding author. 1441 Eastlake Ave., Suite 7416, Los Angeles, CA 90089, USA. Tel. +1 323 865 3700; Fax: +1 323 865 0120. E-mail addresses: [email protected], [email protected] (M. Aron).
1.
Introduction
Management options for men with symptomatic benign prostatic hyperplasia (BPH) have increased over the last 2 decades [1]. Development of newer energy sources has added
to the armamentarium available for transurethral prostate surgery [2], and the use of lasers has gained popularity owing to the lower morbidity compared with traditional transurethral resection of the prostate (TURP) [3]. However, despite these advances, open simple prostatectomy (OSP) remains
0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2013.12.020
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
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Fig. 1 – Port placement for transvesical robotic simple prostatectomy. (A) Schematic view of port placement; (B) operative view of port placement. AS = assistant; Cam = camera.
particularly well suited for patients with large glands (>100 g) due to the greater volume of adenoma removed and the subsequent excellent long-term functional outcomes [4,5]. The first laparoscopic simple prostatectomy (LSP) was performed in 2002 [6], and subsequent series have demonstrated functional outcomes to be equivalent to OSP [7,8]. However, the technical difficulty and steep learning curve of the purely laparoscopic approach has prevented wider acceptance of LSP among urologists. The robotic platform potentially overcomes these constraints by providing stereoscopic three-dimensional (3D) vision and exceptional dexterity to facilitate the more technically demanding steps of the simple prostatectomy procedure. We describe our technique of transvesical robotic simple prostatectomy (RSP) in a contemporary cohort of men with lower urinary tract symptoms (LUTS) secondary to BPH. Perioperative and short-term functional outcomes are described that show RSP to be feasible, safe, and effective. 2.
Methods and patients
2.1.
Study cohort
Between May 2011 and April 2013, 25 patients presenting with BPH-related LUTS underwent RSP. Initial clinical workup included a complete history and physical examination (including digital rectal examination), International Prostate Symptom Score (IPSS), office uroflowmetry, urinalysis, urine culture, serum electrolytes and creatinine, prostate-specific antigen (PSA), renal tract ultrasound scan with postvoid residual (PVR), and transrectal ultrasound (TRUS) with prostate volume calculation. All patients failed medical therapy before opting for surgical intervention. Patients were counseled about the surgical options available including
TURP, laser prostatectomy, and photovaporization. RSP was performed following appropriate informed consent. 2.2.
Positioning
All procedures were performed with the da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) with patients positioned in lithotomy and steep Trendelenburg. Our technique involves a transperitoneal approach with a five- to six-port placement identical to that for robotic radical prostatectomy (Fig. 1). 2.3.
Surgical technique
The dome of the bladder is identified and a midline cystotomy is made to gain transvesical access to the prostate (Fig. 2).
Fig. 2 – Vertical cystotomy at the dome of the bladder providing transvesical access to the adenoma.
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
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Four stay sutures of 2-0 Vicryl on a CT-1 needle are used to keep the edges of the cystotomy open for access to the adenoma (Fig. 3). A traction suture (2-0 Vicryl on a CT-1 needle) is placed through the median lobe of the adenoma to aid with dissection (Fig. 3).Starting posteriorly, an incision is made in the mucosa overlying the adenoma. Once the plane between the prostatic capsule and the adenoma is identified, enucleation is performed using monopolar scissors and blunt dissection (Fig. 4). Upon completion, the adenoma is placed in an Endocatch bag, and hemostasis is obtained by direct cautery and suture ligation of specific bleeding points in the prostatic fossa. A 22F three-way catheter is inserted with the balloon inflated to 30 ml, and the cystotomy is closed with 2-0 V-Loc sutures (Covidien, Norwalk, CT, USA) (Fig. 5). Finally, a Jackson-Pratt drain is placed in the rectovesical pouch followed by extraction of the specimen and closure of fascia and skin. Fig. 3 – Intraoperative view of transvesical robotic simple prostatectomy. The bladder (BL) is retracted and sutured to the abdominal wall. A transverse posterior incision is made at the junction of the trigone and adenoma (AD), and a stitch is placed through the AD allowing for dynamic retraction.
2.4.
Data collection
We prospectively collected demographic and perioperative data including age, baseline symptoms, estimated blood loss (EBL), operative duration, length of stay (LOS), and
Fig. 4 – (A) Mucosal incision around the adenoma followed by (B) enucleation. AD = adenoma; PF = prostatic fossa.
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
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Table 1 – Preoperative characteristics of the patient cohort Patient demographics n Age, yr, mean (range) Body mass index, kg/m2, mean (range) America Society of Anesthesiologists score, mean (range) International Prostate Symptom Score, mean (range) Sexual Health Inventory for Men score, mean (range) PSA, ng/ml, mean (range) Prostate volume, ml, mean (range) Qmax, ml/s, mean (range) Postvoid residual volume, ml, mean (range) BPH-related complications, no. (%) Urinary retention Catheter dependent Urinary tract infection Macroscopic hematuria Bladder calculi Bladder diverticulum Prior prostate surgery, no. (%) TURP TUMT PVP Cystoscopic findings Prostatic urethra length, cm, mean (range) Median lobes, no. (%)
Results 25 72.9 (54–88) 28.2 (19.2–41) 3 (2–4) 23.9 (9–35) 12.8 (0–25) 9.4 149.6 11.3 208.1 13 8 5 8 2 1
(1.9–56.3) (91–260) (4–20) (72–800)
(52) (32) (20) (32) (8) (4)
3 (12) 5 (20) 1 (4) 7.2 (6–10) 15 (60)
BPH = benign prostatic hyperplasia; PSA = prostate-specific antigen; PVP = photovaporization of the prostate; Qmax = maximum flow rate; TUMT = transurethral microwave thermotherapy; TURP = transurethral resection of the prostate. Fig. 5 – (A) FloSeal (optional) applied to prostatic cavity to further ensure hemostasis, followed by (B) cystotomy closure. FL = FloSeal; PF = prostatic fossa.
complications. Pathologic data included specimen weight and histologic assessment. Patients were followed with postoperative uroflowmetry, renal tract ultrasound, and IPSS to assess functional outcomes. 2.5.
were catheter dependent at the time of their operation. Five patients (20%) experienced a urinary tract infection (UTI), and 8 patients (32%) complained of macroscopic hematuria. Two patients had bladder calculi (Fig. 6), and one patient had a large bladder diverticulum (Fig. 7). All patients had failed medical therapy (5a-reductase inhibitors and/or a-blockers), and seven patients had undergone previous surgical intervention for BPH including
Statistical methods
Mean, range, and statistical significance were used to report continuous and categorical data. Statistical significance was determined based on a two-sided significance level of 0.05. Data analysis was performed using SAS v.9.2 software (SAS Institute Inc., Cary, NC, USA). 3.
Results
Table 1 presents the demographic and baseline clinical characteristics of the cohort. Mean patient age was 72.9 yr (range: 54–88); mean body mass index was 28.2 (range: 19.2–41). Mean IPSS was 23.9 (range: 9–35), mean PSA was 9.4 ng/ml (range: 1.9–56.3), mean maximum flow rate (Qmax) was 11.3 ml/s (range: 4.0–20), and mean PVR was 208.1 ml (range: 72–800). Of the 25 patients, 20 (80%) experienced a BPH-related complication. Urinary retention occurred in 13 patients (52%) including 8 patients who had failed their void trial and
Fig. 6 – Sagittal computed tomography scan demonstrating an enlarged prostate and bladder stone (arrow).
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
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Fig. 7 – Fluoroscopic images during a urodynamic study. (A) A large right-sided bladder diverticulum is demonstrated (B and C) that does not empty on voiding.
TURP, transurethral microwave thermotherapy, and photovaporization of the prostate (PVP). Preoperative flexible cystoscopy identified mean prostatic urethra length to be 7.2 cm (range: 6–10) with 15 patients (60%) having a prominent intravesical median lobe. All patients successfully underwent RSP with no intraoperative complications or conversions to open surgery (Table 2). The mean operative duration was 214 min (range: 165–345); mean EBL was 143 ml (range: 50–350). Average LOS was 4 d (range: 2–8), and average length of catheter insertion was 9 d (range: 7–23). Patients underwent a cystogram 1 wk postoperatively prior to catheter removal (Fig. 8). Two patients were noted to have a small leak on initial cystogram necessitating a longer catheter insertion of 18 and 23 d, respectively. Five patients had a concomitant procedure in addition to the simple prostatectomy. These included a bladder diverticulectomy, heminephrectomy for a duplex system, inguinal hernia repair, and two cases of cystolithotomy. All procedures were completed robotically. We report a total of five postoperative complications (20%) in four patients. Despite perioperative injectable third-generation cephalosporin, one patient developed a UTI treated with oral antibiotics (Clavien-Dindo grade 2).
Table 2 – Perioperative outcomes and complications Results Perioperative outcomes Operative time, min, mean (range) Blood loss, ml, mean (range) Concomitant procedures, no. (%) Blood transfusions, no. (%) Conversions, no. (%) Length of hospital stay, d, mean (range) Length of catheter insertion, d, mean (range) Preoperative hemoglobin, g/dl, mean (range) Lowest postoperative hemoglobin, g/dl, mean (range) Clavien-Dindo complications, no. (%) Grade 1 Grade 2 Grade 3a Grade 3b Grade 4 or 5
214 (165–345) 143 (50–350) 5 (20) 1 (4) 0 (100) 4.0 (2–16) 9.0 (7–23) 14.0 (10.0–18.5) 11.3 (8.4–14.6)
Two patients were readmitted following recurrent hematuria leading to clot retention and the need for recatheterization and bladder irrigation (Clavien-Dindo grade 3a). Both patients restarted anticoagulation therapy that was halted for their initial surgery. In one case the hemoglobin dropped to 8.4 g/dl requiring transfusion with a total of 3 units of packed red cells (Clavien-Dindo grade 2). In both cases, the hematuria resolved with bladder irrigation and cessation of the anticoagulation. The final complication involved a blocked catheter on postoperative day 1 due to clot retention within the bladder associated with extravasation into the peritoneal cavity. The patient underwent robotic exploration with opening of the cystotomy and clot evacuation under general anesthesia (Clavien-Dindo grade 3b). The patient subsequently had an uneventful postoperative recovery and was discharged on day 4. The mean specimen weight of the resected adenoma was 88.0 g (range: 50–172). Three cases of prostate cancer were identified including two patients with a small focus of Gleason 6 (pT1a) who are currently on active surveillance. The third patient was found to have Gleason 7 (3 + 4) involving the left lobe. Follow-up TRUS biopsy demonstrated residual Gleason 7 cancer, and the patient was subsequently treated with focal cryotherapy. Early functional outcomes were assessed postoperatively with a mean follow-up of 6 mo (Table 3). Mean postoperative IPSS was 3.58 (range: 0–6), which represented an 85% improvement from preoperative scores ( p < 0.01). Mean postoperative PVR was 36.9 ml (range: 0–175) indicating an 82.2% reduction ( p = 0.014). Mean Qmax increased from 11.3 ml/s preoperatively to 20 ml/s following surgery (77.0% improvement); however, this did not reach statistical significance ( p = 0.20). One patient was wearing one pad per day at 5 mo postoperatively for mild urinary incontinence. None of the other patients had any incontinence or erectile dysfunction as a result of the procedure. 4.
0 2 2 1 0
(0) (8) (8) (4) (0)
Discussion
Our series represents one of the largest RSP cohorts in the literature, demonstrating good perioperative outcomes with excellent short-term symptomatic and functional improvements. TURP and OSP are traditionally the main
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
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Fig. 8 – Anteroposterior and oblique views of a postoperative cystogram demonstrating no leak and a large prostatic fossa occupied by the catheter balloon.
surgical options for men with BPH, with the latter most appropriate for larger glands (>100 g). Improved morbidity profiles of newer technologies such as PVP and holmium laser enucleation of the prostate (HoLEP) make these viable options alongside TURP and OSP. Randomized trials comparing these laser treatments with OSP for large glands have demonstrated equivalent short-term outcomes in terms of improvements in IPSS, Qmax, and PVR [9,10]. One of the concerns about OSP is the high rate of adverse events, specifically perioperative bleeding. In a randomized trial comparing HoLEP with OSP for glands >100 g, Kuntz and Lehrich [11] demonstrated a higher rate of adverse events in the OSP group (26.7% vs 15%), largely a result of the 13.3% rate of perioperative blood transfusion. This high transfusion rate with OSP is consistently reported in the literature. A large series of 902 patients undergoing OSP demonstrated an overall complication rate of 17.3% with 68 patients (7.5%) requiring a blood transfusion due to excessive bleeding [12]. In a prospective study of 56 patients, the mean EBL was 1181.3 ml (range: 500–2020) with 36% of patients receiving a blood transfusion [13]. Mariano et al. [6] first demonstrated the benefits of the minimally invasive approach in terms of less pain and shorter convalescence compared with OSP [7]. However, in a study comparing the morbidity of LSP and OSP, bleeding was still noted to be significant in both groups with a transfusion rate
Table 3 – Prostate-specific antigen and functional outcomes on follow-up
PSA IPSS Qmax PVR
Preoperative
Postoperative
Mean (range)
Mean (range)
9.4 23.9 11.3 208.1
(1.9–56.3) (9–35) (4–20) (72–800)
1.48 (0.06–4.0) 3.58 (0–6) 20 (12–35) 36.9 (0–175)
Percent change
p value
84.3 85.0 +77.0 82.2
0.012 1000 ml) and two patients developing significant postoperative hematuria requiring cystoscopic clot evacuation and coagulation of bleeding tissue within
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
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Fig. 9 – (A) Robotic cystolithotomy with concomitant simple prostatectomy; (B) respective specimen weighting 155 g.
the prostatic fossa. Although single-port RSP is feasible, the high complications rate indicates further refinement of ports, instrumentation, and robotics is necessary before it can be more widely endorsed. Never before have we been presented with such a wide array of treatment options for men with BPH. Newer laser techniques have been increasingly utilized, offering an improved morbidity profile over traditional options such as TURP and OSP. The purely laparoscopic approach to simple prostatectomy has been explored over the last decade but has not been embraced enthusiastically owing to its technical difficulty and reports indicating no improvement in adverse events when compared with conventional OSP. The unmatched dexterity and vision afforded by the robotic platform allows a more precise anatomic dissection of the adenoma and facilitates accurate and swift intracorporeal suturing to control bleeding. These factors combined offer
Fig. 10 – Concomitant robotic mesh repair of inguinal hernia.
excellent short-term perioperative outcomes as well as durable functional improvements. This series adds to the growing evidence that RSP not only confers the benefits of minimally invasive surgery but is also associated with low rates of postoperative complications comparable with that of transurethral laser techniques. Our report is still limited by a small sample size. A future study with a larger patient cohort would be beneficial to determine the reproducibility of this study’s results. In addition, some patients currently have a short postoperative follow-up. Long-term outcomes are beneficial for this type of study. Finally, we did not address the costs of using the robot for the procedure. However, in a RSP series by Matei et al. [22], the overall costs of RSP were less than for OSP and equivalent to TURP. Although initial operative costs were higher for RSP, they identified lower hospitalization costs when compared with both OSP and TURP [22].
Fig. 11 – Bladder diverticulum. Neck of diverticulum scored with electrocautery. Note ureteral catheter in right ureteric orifice and tip of urethral catheter advanced into neck of diverticulum. AD = adenoma; DN = diverticulum neck; FC = Foley catheter; UC = ureteral catheter.
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
EURURO-5448; No. of Pages 9 EUROPEAN UROLOGY XXX (2014) XXX–XXX
5.
Conclusions
9
[5] Varkarakis I, Kyriakakis Z, Delis A, Protogerou V, Deliveliotis C. Long-term results of open transvesical prostatectomy from a con-
Our technique of transvesical RSP in men with BPH from large glands demonstrates excellent improvements in functional outcomes with an acceptable perioperative morbidity profile. It is of particular benefit in those patients with associated pathology requiring a concomitant procedure. Prospective studies comparing RSP with endoscopic laser options are required to further define their respective roles for men with BPH.
temporary series of patients. Urology 2004;64:306–10. [6] Mariano MB, Graziottin TM, Tefilli MV. Laparoscopic prostatectomy with vascular control for benign prostatic hyperplasia. J Urol 2002; 167:2528–9. [7] Baumert H, Ballaro A, Dugardin F, Kaisary AV. Laparoscopic versus open simple prostatectomy: a comparative study. J Urol 2006;175: 1691–4. [8] McCullough TC, Heldwein FL, Soon SJ, et al. Laparoscopic versus open simple prostatectomy: an evaluation of morbidity. J Endourol 2009;23:129–33.
Author contributions: Monish Aron had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
[9] Alivizatos G, Skolarikos A, Chalikopoulos D, et al. Transurethral photoselective vaporization versus transvesical open enucleation for prostatic adenomas >80 ml: 12-mo results of a randomized prospective study. Eur Urol 2008;54:427–37.
Study concept and design: Leslie, Abreu, Aron. Acquisition of data: Chopra, Ramos.
[10] Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100
Analysis and interpretation of data: Park.
grams: 5-year follow-up results of a randomised clinical trial. Eur
Drafting of the manuscript: Leslie, Abreu, Chopra, Aron.
Urol 2008;53:160–8.
Critical revision of the manuscript for important intellectual content: Gill,
[11] Kuntz RM, Lehrich K. Transurethral holmium laser enucleation
Desai, Aron.
versus transvesical open enucleation for prostate adenoma greater
Statistical analysis: Chopra.
than 100 gm.: a randomized prospective trial of 120 patients. J Urol
Obtaining funding: None. Administrative, technical, or material support: Park, Berger.
2002;168:1465–9. [12] Gratzke C, Schlenker B, Seitz M, et al. Complications and early
Supervision: Aron, Gill, Desai.
postoperative outcome after open prostatectomy in patients with
Other (specify): Video compilation: Berger, Chopra, Abreu.
benign prostatic enlargement: results of a prospective multicenter
Financial disclosures: Monish Aron certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None.
study. J Urol 2007;177:1419–22. [13] Helfand B, Mouli S, Dedhia R, McVary KT. Management of lower urinary tract symptoms secondary to benign prostatic hyperplasia with open prostatectomy: results of a contemporary series. J Urol 2006;176:2557–61, discussion 2561. [14] Sotelo R, Clavijo R, Carmona O, et al. Robotic simple prostatectomy. J Urol 2008;179:513–5. [15] John H, Bucher C, Engel N, Fischer B, Fehr JL. Preperitoneal robotic prostate adenomectomy. Urology 2009;73:811–5. [16] Uffort EE. Robotic-assisted laparoscopic simple prostatectomy:
Appendix A. Supplementary data
an alternative minimal invasive approach for prostate adenoma. J Robot Surg 2010;4:7–10.
The Surgery in Motion video accompanying this article can be found in the online version at http://dx.doi.org/10.1016/ j.eururo.2013.12.020 and via www.europeanurology.com.
[17] Sutherland DE, Perez DS, Weeks DC. Robot-assisted simple prostatectomy for severe benign prostatic hyperplasia. J Endourol 2011; 25:641–4. [18] Coelho RF, Chauhan S, Sivaraman A, et al. Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-
References [1] Yu X, Elliott SP, Wilt TJ, McBean AM. Practice patterns in benign prostatic hyperplasia surgical therapy: the dramatic increase in mini-
urethral anastomosis. BJU Int 2012;109:426–33. [19] Vora A, Mittal S, Hwang J, Bandi G. Robot-assisted simple prostatectomy: multi-institutional outcomes for glands larger than 100 grams. J Endourol 2012;26:499–502.
mally invasive technologies. J Urol 2008;180:241–5, discussion 245.
[20] Skolarikos A, Papachristou C, Athanasiadis G, Chalikopoulos D,
[2] Metcalfe C, Poon KS. Long-term results of surgical techniques and
Deliveliotis C, Alivizatos G. Eighteen-month results of a randomized
procedures in men with benign prostatic hyperplasia. Curr Urol Rep
prospective study comparing transurethral photoselective vapor-
2011;12:265–73.
ization with transvesical open enucleation for prostatic adenomas
[3] Reich O, Gratzke C, Bachmann A, et al. Morbidity, mortality and early outcome of transurethral resection of the prostate: a prospective multicenter evaluation of 10,654 patients. J Urol 2008;180: 246–9. [4] Suer E, Gokce I, Yaman O, Anafarta K, Gogus O. Open prostatectomy is still a valid option for large prostates: a high-volume, singlecenter experience. Urology 2008;72:90–4.
greater than 80 cc. J Endourol 2008;22:2333–40. [21] Fareed K, Zaytoun OM, Autorino R, et al. Robotic single port suprapubic transvesical enucleation of the prostate (R-STEP): initial experience. BJU Int 2012;110:732–7. [22] Matei DV, Brescia A, Mazzoleni F, et al. Robot-assisted simple prostatectomy (RASP): does it make sense? BJU Int 2012;110: E972–9.
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
available at www.sciencedirect.com journal homepage: www.europeanurology.com
Surgery in Motion
Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience Scott Leslie, Andre Luis de Castro Abreu, Sameer Chopra, Patrick Ramos, Daniel Park, Andre K. Berger, Mihir M. Desai, Inderbir S. Gill, Monish Aron * Institute of Urology, Catherine and Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA, USA
Article info
Abstract
Article history: Accepted December 13, 2013 Published online ahead of print on January 3, 2014
Background: Despite significant developments in transurethral surgery for benign prostatic hyperplasia (BPH), simple prostatectomy remains an excellent option for patients with large glands. Objective: To describe our technique of transvesical robotic simple prostatectomy (RSP). Design, setting, and participants: From May 2011 to April 2013, 25 patients underwent RSP. Surgical procedure: We performed RSP using our technique. Outcome measurements and statistical analysis: Baseline demographics, pathology data, perioperative complications, 90-d complications, and functional outcomes were assessed. Results and limitations: Mean patient age was 72.9 yr (range: 54–88), baseline International Prostate Symptom Score (IPSS) was 23.9 (range: 9–35), prostate volume was 149.6 ml (range: 91–260), postvoid residual (PVR) was 208.1 ml (range: 72–800), maximum flow rate (Qmax) was 11.3 ml/s, and preoperative prostate-specific antigen was 9.4 ng/ml (range: 1.9–56.3). Eight patients were catheter dependent before surgery. Mean operative time was 214 min (range: 165–345), estimated blood loss was 143 ml (range: 50–350), and the hospital stay was 4 d (range: 2–8). There were no intraoperative complications and no conversions to open surgery. Five patients had a concomitant robotic procedure performed. Early functional outcomes demonstrated significant improvement from baseline with an 85% reduction in mean IPSS ( p < 0.0001), an 82.2% reduction in mean PVR ( p = 0.014), and a 77% increase in mean Qmax ( p = 0.20). This study is limited by small sample size and short follow-up period. One patient had a urinary tract infection; two had recurrent hematuria, one requiring transfusion; one patient had clot retention and extravasation, requiring reoperation. Conclusions: Our technique of RSP is safe and effective. Good functional outcomes suggest it is a viable option for BPH and larger glands and can be used for patients requiring concomitant procedures. Patient summary: We describe the technique and report the initial results of a series of cases of transvesical robotic simple prostatectomy. The procedure is both feasible and safe and a good option for benign prostatic hyperplasia with larger glands. # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.
Keywords: Benign prostatic hyperplasia Simple prostatectomy Robotic surgery Please visit www.europeanurology.com and www.urosource.com to view the accompanying video.
* Corresponding author. 1441 Eastlake Ave., Suite 7416, Los Angeles, CA 90089, USA. Tel. +1 323 865 3700; Fax: +1 323 865 0120. E-mail addresses: [email protected], [email protected] (M. Aron).
1.
Introduction
Management options for men with symptomatic benign prostatic hyperplasia (BPH) have increased over the last 2 decades [1]. Development of newer energy sources has added
to the armamentarium available for transurethral prostate surgery [2], and the use of lasers has gained popularity owing to the lower morbidity compared with traditional transurethral resection of the prostate (TURP) [3]. However, despite these advances, open simple prostatectomy (OSP) remains
0302-2838/$ – see back matter # 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved. http://dx.doi.org/10.1016/j.eururo.2013.12.020
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
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Fig. 1 – Port placement for transvesical robotic simple prostatectomy. (A) Schematic view of port placement; (B) operative view of port placement. AS = assistant; Cam = camera.
particularly well suited for patients with large glands (>100 g) due to the greater volume of adenoma removed and the subsequent excellent long-term functional outcomes [4,5]. The first laparoscopic simple prostatectomy (LSP) was performed in 2002 [6], and subsequent series have demonstrated functional outcomes to be equivalent to OSP [7,8]. However, the technical difficulty and steep learning curve of the purely laparoscopic approach has prevented wider acceptance of LSP among urologists. The robotic platform potentially overcomes these constraints by providing stereoscopic three-dimensional (3D) vision and exceptional dexterity to facilitate the more technically demanding steps of the simple prostatectomy procedure. We describe our technique of transvesical robotic simple prostatectomy (RSP) in a contemporary cohort of men with lower urinary tract symptoms (LUTS) secondary to BPH. Perioperative and short-term functional outcomes are described that show RSP to be feasible, safe, and effective. 2.
Methods and patients
2.1.
Study cohort
Between May 2011 and April 2013, 25 patients presenting with BPH-related LUTS underwent RSP. Initial clinical workup included a complete history and physical examination (including digital rectal examination), International Prostate Symptom Score (IPSS), office uroflowmetry, urinalysis, urine culture, serum electrolytes and creatinine, prostate-specific antigen (PSA), renal tract ultrasound scan with postvoid residual (PVR), and transrectal ultrasound (TRUS) with prostate volume calculation. All patients failed medical therapy before opting for surgical intervention. Patients were counseled about the surgical options available including
TURP, laser prostatectomy, and photovaporization. RSP was performed following appropriate informed consent. 2.2.
Positioning
All procedures were performed with the da Vinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) with patients positioned in lithotomy and steep Trendelenburg. Our technique involves a transperitoneal approach with a five- to six-port placement identical to that for robotic radical prostatectomy (Fig. 1). 2.3.
Surgical technique
The dome of the bladder is identified and a midline cystotomy is made to gain transvesical access to the prostate (Fig. 2).
Fig. 2 – Vertical cystotomy at the dome of the bladder providing transvesical access to the adenoma.
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Four stay sutures of 2-0 Vicryl on a CT-1 needle are used to keep the edges of the cystotomy open for access to the adenoma (Fig. 3). A traction suture (2-0 Vicryl on a CT-1 needle) is placed through the median lobe of the adenoma to aid with dissection (Fig. 3).Starting posteriorly, an incision is made in the mucosa overlying the adenoma. Once the plane between the prostatic capsule and the adenoma is identified, enucleation is performed using monopolar scissors and blunt dissection (Fig. 4). Upon completion, the adenoma is placed in an Endocatch bag, and hemostasis is obtained by direct cautery and suture ligation of specific bleeding points in the prostatic fossa. A 22F three-way catheter is inserted with the balloon inflated to 30 ml, and the cystotomy is closed with 2-0 V-Loc sutures (Covidien, Norwalk, CT, USA) (Fig. 5). Finally, a Jackson-Pratt drain is placed in the rectovesical pouch followed by extraction of the specimen and closure of fascia and skin. Fig. 3 – Intraoperative view of transvesical robotic simple prostatectomy. The bladder (BL) is retracted and sutured to the abdominal wall. A transverse posterior incision is made at the junction of the trigone and adenoma (AD), and a stitch is placed through the AD allowing for dynamic retraction.
2.4.
Data collection
We prospectively collected demographic and perioperative data including age, baseline symptoms, estimated blood loss (EBL), operative duration, length of stay (LOS), and
Fig. 4 – (A) Mucosal incision around the adenoma followed by (B) enucleation. AD = adenoma; PF = prostatic fossa.
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
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Table 1 – Preoperative characteristics of the patient cohort Patient demographics n Age, yr, mean (range) Body mass index, kg/m2, mean (range) America Society of Anesthesiologists score, mean (range) International Prostate Symptom Score, mean (range) Sexual Health Inventory for Men score, mean (range) PSA, ng/ml, mean (range) Prostate volume, ml, mean (range) Qmax, ml/s, mean (range) Postvoid residual volume, ml, mean (range) BPH-related complications, no. (%) Urinary retention Catheter dependent Urinary tract infection Macroscopic hematuria Bladder calculi Bladder diverticulum Prior prostate surgery, no. (%) TURP TUMT PVP Cystoscopic findings Prostatic urethra length, cm, mean (range) Median lobes, no. (%)
Results 25 72.9 (54–88) 28.2 (19.2–41) 3 (2–4) 23.9 (9–35) 12.8 (0–25) 9.4 149.6 11.3 208.1 13 8 5 8 2 1
(1.9–56.3) (91–260) (4–20) (72–800)
(52) (32) (20) (32) (8) (4)
3 (12) 5 (20) 1 (4) 7.2 (6–10) 15 (60)
BPH = benign prostatic hyperplasia; PSA = prostate-specific antigen; PVP = photovaporization of the prostate; Qmax = maximum flow rate; TUMT = transurethral microwave thermotherapy; TURP = transurethral resection of the prostate. Fig. 5 – (A) FloSeal (optional) applied to prostatic cavity to further ensure hemostasis, followed by (B) cystotomy closure. FL = FloSeal; PF = prostatic fossa.
complications. Pathologic data included specimen weight and histologic assessment. Patients were followed with postoperative uroflowmetry, renal tract ultrasound, and IPSS to assess functional outcomes. 2.5.
were catheter dependent at the time of their operation. Five patients (20%) experienced a urinary tract infection (UTI), and 8 patients (32%) complained of macroscopic hematuria. Two patients had bladder calculi (Fig. 6), and one patient had a large bladder diverticulum (Fig. 7). All patients had failed medical therapy (5a-reductase inhibitors and/or a-blockers), and seven patients had undergone previous surgical intervention for BPH including
Statistical methods
Mean, range, and statistical significance were used to report continuous and categorical data. Statistical significance was determined based on a two-sided significance level of 0.05. Data analysis was performed using SAS v.9.2 software (SAS Institute Inc., Cary, NC, USA). 3.
Results
Table 1 presents the demographic and baseline clinical characteristics of the cohort. Mean patient age was 72.9 yr (range: 54–88); mean body mass index was 28.2 (range: 19.2–41). Mean IPSS was 23.9 (range: 9–35), mean PSA was 9.4 ng/ml (range: 1.9–56.3), mean maximum flow rate (Qmax) was 11.3 ml/s (range: 4.0–20), and mean PVR was 208.1 ml (range: 72–800). Of the 25 patients, 20 (80%) experienced a BPH-related complication. Urinary retention occurred in 13 patients (52%) including 8 patients who had failed their void trial and
Fig. 6 – Sagittal computed tomography scan demonstrating an enlarged prostate and bladder stone (arrow).
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Fig. 7 – Fluoroscopic images during a urodynamic study. (A) A large right-sided bladder diverticulum is demonstrated (B and C) that does not empty on voiding.
TURP, transurethral microwave thermotherapy, and photovaporization of the prostate (PVP). Preoperative flexible cystoscopy identified mean prostatic urethra length to be 7.2 cm (range: 6–10) with 15 patients (60%) having a prominent intravesical median lobe. All patients successfully underwent RSP with no intraoperative complications or conversions to open surgery (Table 2). The mean operative duration was 214 min (range: 165–345); mean EBL was 143 ml (range: 50–350). Average LOS was 4 d (range: 2–8), and average length of catheter insertion was 9 d (range: 7–23). Patients underwent a cystogram 1 wk postoperatively prior to catheter removal (Fig. 8). Two patients were noted to have a small leak on initial cystogram necessitating a longer catheter insertion of 18 and 23 d, respectively. Five patients had a concomitant procedure in addition to the simple prostatectomy. These included a bladder diverticulectomy, heminephrectomy for a duplex system, inguinal hernia repair, and two cases of cystolithotomy. All procedures were completed robotically. We report a total of five postoperative complications (20%) in four patients. Despite perioperative injectable third-generation cephalosporin, one patient developed a UTI treated with oral antibiotics (Clavien-Dindo grade 2).
Table 2 – Perioperative outcomes and complications Results Perioperative outcomes Operative time, min, mean (range) Blood loss, ml, mean (range) Concomitant procedures, no. (%) Blood transfusions, no. (%) Conversions, no. (%) Length of hospital stay, d, mean (range) Length of catheter insertion, d, mean (range) Preoperative hemoglobin, g/dl, mean (range) Lowest postoperative hemoglobin, g/dl, mean (range) Clavien-Dindo complications, no. (%) Grade 1 Grade 2 Grade 3a Grade 3b Grade 4 or 5
214 (165–345) 143 (50–350) 5 (20) 1 (4) 0 (100) 4.0 (2–16) 9.0 (7–23) 14.0 (10.0–18.5) 11.3 (8.4–14.6)
Two patients were readmitted following recurrent hematuria leading to clot retention and the need for recatheterization and bladder irrigation (Clavien-Dindo grade 3a). Both patients restarted anticoagulation therapy that was halted for their initial surgery. In one case the hemoglobin dropped to 8.4 g/dl requiring transfusion with a total of 3 units of packed red cells (Clavien-Dindo grade 2). In both cases, the hematuria resolved with bladder irrigation and cessation of the anticoagulation. The final complication involved a blocked catheter on postoperative day 1 due to clot retention within the bladder associated with extravasation into the peritoneal cavity. The patient underwent robotic exploration with opening of the cystotomy and clot evacuation under general anesthesia (Clavien-Dindo grade 3b). The patient subsequently had an uneventful postoperative recovery and was discharged on day 4. The mean specimen weight of the resected adenoma was 88.0 g (range: 50–172). Three cases of prostate cancer were identified including two patients with a small focus of Gleason 6 (pT1a) who are currently on active surveillance. The third patient was found to have Gleason 7 (3 + 4) involving the left lobe. Follow-up TRUS biopsy demonstrated residual Gleason 7 cancer, and the patient was subsequently treated with focal cryotherapy. Early functional outcomes were assessed postoperatively with a mean follow-up of 6 mo (Table 3). Mean postoperative IPSS was 3.58 (range: 0–6), which represented an 85% improvement from preoperative scores ( p < 0.01). Mean postoperative PVR was 36.9 ml (range: 0–175) indicating an 82.2% reduction ( p = 0.014). Mean Qmax increased from 11.3 ml/s preoperatively to 20 ml/s following surgery (77.0% improvement); however, this did not reach statistical significance ( p = 0.20). One patient was wearing one pad per day at 5 mo postoperatively for mild urinary incontinence. None of the other patients had any incontinence or erectile dysfunction as a result of the procedure. 4.
0 2 2 1 0
(0) (8) (8) (4) (0)
Discussion
Our series represents one of the largest RSP cohorts in the literature, demonstrating good perioperative outcomes with excellent short-term symptomatic and functional improvements. TURP and OSP are traditionally the main
Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
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Fig. 8 – Anteroposterior and oblique views of a postoperative cystogram demonstrating no leak and a large prostatic fossa occupied by the catheter balloon.
surgical options for men with BPH, with the latter most appropriate for larger glands (>100 g). Improved morbidity profiles of newer technologies such as PVP and holmium laser enucleation of the prostate (HoLEP) make these viable options alongside TURP and OSP. Randomized trials comparing these laser treatments with OSP for large glands have demonstrated equivalent short-term outcomes in terms of improvements in IPSS, Qmax, and PVR [9,10]. One of the concerns about OSP is the high rate of adverse events, specifically perioperative bleeding. In a randomized trial comparing HoLEP with OSP for glands >100 g, Kuntz and Lehrich [11] demonstrated a higher rate of adverse events in the OSP group (26.7% vs 15%), largely a result of the 13.3% rate of perioperative blood transfusion. This high transfusion rate with OSP is consistently reported in the literature. A large series of 902 patients undergoing OSP demonstrated an overall complication rate of 17.3% with 68 patients (7.5%) requiring a blood transfusion due to excessive bleeding [12]. In a prospective study of 56 patients, the mean EBL was 1181.3 ml (range: 500–2020) with 36% of patients receiving a blood transfusion [13]. Mariano et al. [6] first demonstrated the benefits of the minimally invasive approach in terms of less pain and shorter convalescence compared with OSP [7]. However, in a study comparing the morbidity of LSP and OSP, bleeding was still noted to be significant in both groups with a transfusion rate
Table 3 – Prostate-specific antigen and functional outcomes on follow-up
PSA IPSS Qmax PVR
Preoperative
Postoperative
Mean (range)
Mean (range)
9.4 23.9 11.3 208.1
(1.9–56.3) (9–35) (4–20) (72–800)
1.48 (0.06–4.0) 3.58 (0–6) 20 (12–35) 36.9 (0–175)
Percent change
p value
84.3 85.0 +77.0 82.2
0.012 1000 ml) and two patients developing significant postoperative hematuria requiring cystoscopic clot evacuation and coagulation of bleeding tissue within
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Fig. 9 – (A) Robotic cystolithotomy with concomitant simple prostatectomy; (B) respective specimen weighting 155 g.
the prostatic fossa. Although single-port RSP is feasible, the high complications rate indicates further refinement of ports, instrumentation, and robotics is necessary before it can be more widely endorsed. Never before have we been presented with such a wide array of treatment options for men with BPH. Newer laser techniques have been increasingly utilized, offering an improved morbidity profile over traditional options such as TURP and OSP. The purely laparoscopic approach to simple prostatectomy has been explored over the last decade but has not been embraced enthusiastically owing to its technical difficulty and reports indicating no improvement in adverse events when compared with conventional OSP. The unmatched dexterity and vision afforded by the robotic platform allows a more precise anatomic dissection of the adenoma and facilitates accurate and swift intracorporeal suturing to control bleeding. These factors combined offer
Fig. 10 – Concomitant robotic mesh repair of inguinal hernia.
excellent short-term perioperative outcomes as well as durable functional improvements. This series adds to the growing evidence that RSP not only confers the benefits of minimally invasive surgery but is also associated with low rates of postoperative complications comparable with that of transurethral laser techniques. Our report is still limited by a small sample size. A future study with a larger patient cohort would be beneficial to determine the reproducibility of this study’s results. In addition, some patients currently have a short postoperative follow-up. Long-term outcomes are beneficial for this type of study. Finally, we did not address the costs of using the robot for the procedure. However, in a RSP series by Matei et al. [22], the overall costs of RSP were less than for OSP and equivalent to TURP. Although initial operative costs were higher for RSP, they identified lower hospitalization costs when compared with both OSP and TURP [22].
Fig. 11 – Bladder diverticulum. Neck of diverticulum scored with electrocautery. Note ureteral catheter in right ureteric orifice and tip of urethral catheter advanced into neck of diverticulum. AD = adenoma; DN = diverticulum neck; FC = Foley catheter; UC = ureteral catheter.
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5.
Conclusions
9
[5] Varkarakis I, Kyriakakis Z, Delis A, Protogerou V, Deliveliotis C. Long-term results of open transvesical prostatectomy from a con-
Our technique of transvesical RSP in men with BPH from large glands demonstrates excellent improvements in functional outcomes with an acceptable perioperative morbidity profile. It is of particular benefit in those patients with associated pathology requiring a concomitant procedure. Prospective studies comparing RSP with endoscopic laser options are required to further define their respective roles for men with BPH.
temporary series of patients. Urology 2004;64:306–10. [6] Mariano MB, Graziottin TM, Tefilli MV. Laparoscopic prostatectomy with vascular control for benign prostatic hyperplasia. J Urol 2002; 167:2528–9. [7] Baumert H, Ballaro A, Dugardin F, Kaisary AV. Laparoscopic versus open simple prostatectomy: a comparative study. J Urol 2006;175: 1691–4. [8] McCullough TC, Heldwein FL, Soon SJ, et al. Laparoscopic versus open simple prostatectomy: an evaluation of morbidity. J Endourol 2009;23:129–33.
Author contributions: Monish Aron had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
[9] Alivizatos G, Skolarikos A, Chalikopoulos D, et al. Transurethral photoselective vaporization versus transvesical open enucleation for prostatic adenomas >80 ml: 12-mo results of a randomized prospective study. Eur Urol 2008;54:427–37.
Study concept and design: Leslie, Abreu, Aron. Acquisition of data: Chopra, Ramos.
[10] Kuntz RM, Lehrich K, Ahyai SA. Holmium laser enucleation of the prostate versus open prostatectomy for prostates greater than 100
Analysis and interpretation of data: Park.
grams: 5-year follow-up results of a randomised clinical trial. Eur
Drafting of the manuscript: Leslie, Abreu, Chopra, Aron.
Urol 2008;53:160–8.
Critical revision of the manuscript for important intellectual content: Gill,
[11] Kuntz RM, Lehrich K. Transurethral holmium laser enucleation
Desai, Aron.
versus transvesical open enucleation for prostate adenoma greater
Statistical analysis: Chopra.
than 100 gm.: a randomized prospective trial of 120 patients. J Urol
Obtaining funding: None. Administrative, technical, or material support: Park, Berger.
2002;168:1465–9. [12] Gratzke C, Schlenker B, Seitz M, et al. Complications and early
Supervision: Aron, Gill, Desai.
postoperative outcome after open prostatectomy in patients with
Other (specify): Video compilation: Berger, Chopra, Abreu.
benign prostatic enlargement: results of a prospective multicenter
Financial disclosures: Monish Aron certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patents filed, received, or pending), are the following: None. Funding/Support and role of the sponsor: None.
study. J Urol 2007;177:1419–22. [13] Helfand B, Mouli S, Dedhia R, McVary KT. Management of lower urinary tract symptoms secondary to benign prostatic hyperplasia with open prostatectomy: results of a contemporary series. J Urol 2006;176:2557–61, discussion 2561. [14] Sotelo R, Clavijo R, Carmona O, et al. Robotic simple prostatectomy. J Urol 2008;179:513–5. [15] John H, Bucher C, Engel N, Fischer B, Fehr JL. Preperitoneal robotic prostate adenomectomy. Urology 2009;73:811–5. [16] Uffort EE. Robotic-assisted laparoscopic simple prostatectomy:
Appendix A. Supplementary data
an alternative minimal invasive approach for prostate adenoma. J Robot Surg 2010;4:7–10.
The Surgery in Motion video accompanying this article can be found in the online version at http://dx.doi.org/10.1016/ j.eururo.2013.12.020 and via www.europeanurology.com.
[17] Sutherland DE, Perez DS, Weeks DC. Robot-assisted simple prostatectomy for severe benign prostatic hyperplasia. J Endourol 2011; 25:641–4. [18] Coelho RF, Chauhan S, Sivaraman A, et al. Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-
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Please cite this article in press as: Leslie S, et al. Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience. Eur Urol (2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020
