Robotic Simple Prostatectomy for Benign Prostatic Hyperplasia
Robotic-assisted simple prostatectomy (RASP) should be considered for patients with large prostates causing lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), as it provides excellent symptom improvement with less blood loss compared to open approaches. 1
Indications for Robotic Simple Prostatectomy
- RASP is indicated for patients with large prostates (generally >60-80g) causing significant LUTS or urinary retention 1
- Consider RASP particularly when other minimally invasive options like bipolar TURP or HoLEP are not available or not preferred by the surgeon 1
- RASP is appropriate for patients with severe obstructive symptoms who have failed medical therapy 1
- RASP can be considered for patients with concomitant bladder pathologies that can be addressed during the same procedure 2
Advantages of Robotic Approach vs. Open Simple Prostatectomy
- Significantly less blood loss (median 200ml vs. higher amounts in open surgery) 3, 4
- Shorter hospital stay (median 1.4-4 days) 3, 5, 4
- Lower transfusion rates (0-3.5%) 3, 6, 4
- Excellent visualization during surgery 2
- Less urethral trauma compared to endoscopic approaches 2
Surgical Considerations
- The procedure can be performed via a transperitoneal or transvesical approach based on surgeon preference and expertise 3, 6
- Median operative time ranges from 97-205 minutes 3, 5
- Conversion rate to open surgery is approximately 3% 4
- Postoperative catheterization time ranges from 3-7 days 3, 5
- Complication rates are generally low (10.6% overall), with most being low-grade complications 4
Outcomes and Efficacy
- Significant improvement in International Prostate Symptom Score (IPSS) from baseline (median decrease from 22-25 to 3-7.25) 3, 5
- Substantial improvement in maximum flow rate (Qmax) from baseline 3, 5
- Reduction in post-void residual volume 3
- Outcomes are comparable to those of open simple prostatectomy but with lower morbidity 2
Post-Operative Pain Management
- NSAIDs such as ketorolac (15-30mg IV) can be used for analgesia, but should be used cautiously in patients with bleeding risk 7
- Acetaminophen should be prioritized for patients with higher bleeding risk 7
- Opioids should be used only as rescue medication when first-line treatments are insufficient 7
- Early catheter removal (day 3 vs. day 5) is associated with less urethral discomfort 7
- Early mobilization helps reduce pain during rest and movement 7
Potential Complications and Management
- Bleeding requiring transfusion (0-3.5% of cases) 3, 6, 4
- Bladder neck contracture or urethral stricture (less common than with endoscopic approaches) 2
- Air embolism (rare, associated with high insufflation pressures) 6
- Postoperative urinary retention or prolonged catheterization 3
Contraindications and Caveats
- Surgeon experience is crucial - outcomes are better in high-volume centers 3, 2
- Patients with severe cardiopulmonary disease may not tolerate pneumoperitoneum required for robotic surgery 2
- Consider patient's overall health status and comorbidities when selecting surgical approach 1
- Prostate cancer may be incidentally found in approximately 4% of cases, requiring appropriate follow-up 4
Comparison with Other Surgical Options
- TURP remains the gold standard for smaller prostates (<60g) 1
- For prostates ≤30g, TUIP should be offered as an option 1
- For large prostates, options include open, laparoscopic, or robotic-assisted prostatectomy depending on surgeon expertise 1
- Bipolar TURP and HoLEP are alternatives for large prostates in centers with appropriate expertise 1
RASP represents an effective and safe minimally invasive option for patients with large prostatic adenomas causing significant LUTS, with excellent functional outcomes and relatively low complication rates.