Jacob A. Baber, MD

 illustrate a robotic solution to the complex problem of very large prostate glands causing severe lower urinary tract symptoms. Although many approaches have been employed to treat men with glands over 100 grams, such as serial transurethral resections, holmium laser enucleation, holmium laser ablation, and open simple prostatectomy, the widespread adoption of and comfort with robotic surgery among urologists makes the robotic simple prostatectomy an attractive option. Here, the authors illustrate the finer points of this surgery and demonstrate how to achieve optimal outcomes.

	Commentary on the videos is provided by 

  assistant professor of surgery (urology), University of Utah, and  

'Y'tube Section Editor James M. Hotaling, MD, MS,

 assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.	 	Many treatment options exist for the management of BPH. For patients with large glands, simple prostatectomy should be considered. This video depicts a minimally invasive robotic approach for a large symptomatic prostatic adenoma with bladder calculi.	

 Surgeons from the University of Connecticut have a similar approach to the robotic simple prostatectomy familiar to most urologists. Concurrent removal of bladder stones or repair of a diverticulum is easily combined with this approach when the retropubic space is developed. The use of traction sutures passed through the abdominal wall with an endoscopic closure device is a quick technique demonstrated here. Personally, I find the pigtail ureteral stents too cumbersome during the enucleation, as they often get in the way. Most of the time, one can see the ureteral orifice and avoid a stent altogether. As shown, a large prostate adenoma may need division prior to complete enucleation. It is easy to place too much traction using a tenaculum, and these surgeons avoid that by maintaining good visualization and dividing the adenoma when dissecting the apex. Retrigonization is accomplished with interrupted vicryl sutures. The series of simple prostatectomies from this group mimics our experience with favorable postoperative outcomes and minimal complications.

 One of the main advantages of the robotic approach is the ease with which concurrent procedures can be performed. Here, the authors show how clear visualization is critical to performing these procedures. They also illustrate the use of stents to help identify the ureteral orifice, which can help to minimize complications.

 is a urology resident at the University of Connecticut, Farmington. 

 is a urology robotics and oncology fellow and 

 is director of robotic surgery at Hartford Hospital, West Hartford, CT.

 is assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.

Articles

This video from Michael Lao, MD, Jacob A. Baber, MD, and Joseph R. Wagner, MD, depicts a minimally invasive robotic approach for a large symptomatic prostatic adenoma with bladder calculi.

Author | Jacob A. Baber, MD

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