Robotic suprapubic simple prostatectomy: Step-by-step approach

This video, along with videos from Michael Lao, MD, Jacob A. Baber, MD, and Joseph R. Wagner, MD; and Stephen Summers, MD, and Ross Anderson, 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 Stephen Summers, MD, 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.

Simple prostatectomy can be performed via a suprapubic or retropubic approach using an open or minimally invasive technique. Given the three-dimensional visualization, operative field magnification, and improved laparoscopic tissue handling with wristed instruments, the robot-assisted approach is increasing as the chosen technique by many urologists. This video illustrates a safe and effective way to treat a large-volume prostate causing obstructive lower urinary tract symptoms.

Dr. Summers: The posterior approach without taking down the bladder has the advantage of preserving the space of Retzius. This is a consideration should the patient ever need a radical prostatectomy for cancer. The approach is quick, and closure of the bladder at the conclusion of the procedure is easy. Surgeons use retraction sutures anchored to the peritoneum to aid in visualization. A suture placed in the adenoma for traction is also helpful and facilitates use of the third arm for exposure. In my opinion, the disadvantage of this approach is slightly inferior visualization during the enucleation, as one’s camera is limited within the bladder. Overall, the surgeons from the Naval Medical Center demonstrate a technique that is easily learned for dealing with large prostate glands.

Dr. Hotaling: Here the authors employ a posterior approach in combination with retraction sutures anchored to the peritoneum as well as a traction suture in the adenoma to optimize exposure. One of the main advantages of this technique is its reproducibility and the strict adherence to anatomic planes in the exposure, dissection, and enucleation of the gland.

Nicholas R. Rocco, MD

Michael G. Santomauro, MD

Dr. Rocco is a urology resident and Dr. Santomauro is a minimally invasive specialist and director of the robotic surgery program at the Naval Medical Center San Diego.

'Y'tube Section Editor James M. Hotaling, MD, MS, is assistant professor of surgery (urology) at the Center for Reconstructive Urology and Men's Health, University of Utah, Salt Lake City.