Is robotic surgery an option for a male patient with Benign Prostatic Hyperplasia (BPH)?

Robotic Surgery for BPH

Yes, robotic-assisted simple prostatectomy is a recommended surgical option for male patients with BPH, particularly those with large prostates (typically >60-80g), and is now considered a viable alternative to open simple prostatectomy according to the 2018 AUA guidelines. 1

When Robotic Surgery Should Be Considered

Clinicians should consider open, laparoscopic, or robotic-assisted prostatectomy for patients with large prostates, depending on their expertise with these techniques. 1 The AUA guidelines explicitly recognize robotic-assisted simple prostatectomy as no longer "investigational" and recommend it as an appropriate treatment modality. 2

Specific Indications for Surgical Intervention (Including Robotic Approach):

• Absolute indications: Renal insufficiency secondary to BPH, refractory urinary retention after failed catheter removal, recurrent urinary tract infections, recurrent bladder stones, or gross hematuria due to BPH 1, 3
• Relative indications: Moderate-to-severe LUTS refractory to or unwilling to use medical therapy 3
• Prostate size consideration: While "large" is relative, robotic simple prostatectomy is particularly suited for prostates >60-80g where transurethral approaches may be less optimal 1, 4, 5

Advantages of Robotic Approach Over Open Surgery

The robotic technique offers several clinically meaningful benefits compared to traditional open simple prostatectomy:

• Reduced blood loss and transfusion risk: Blood transfusions are 3-4 times less likely with robotic versus open approach 2
• Lower major complication rate: Major complications occur half as frequently with robotic surgery 2
• Shorter hospital stay: Median length of stay is 1.6-4 days for robotic versus longer for open 4, 6, 2
• Faster catheter removal: Typically 3-4 days postoperatively 4, 6
• Comparable functional outcomes: Flow rates, symptom scores (IPSS), and PSA decline are equivalent between approaches 2

Expected Outcomes with Robotic Simple Prostatectomy

Based on high-quality case series, patients can expect:

• Operative time: Median 97-112 minutes 4, 6
• Blood loss: Median 200 mL 4
• Complication rate: Approximately 30% overall, with major complications (Clavien-Dindo 3b) in only 4.5% 4
• Functional improvement: Median postoperative IPSS of 3-6 (from preoperative 20-25), Qmax of 23-24 mL/s (from 5-7 mL/s) 4, 6
• Continence: Excellent preservation with minimal stress incontinence reported 6

Important Caveats and Decision-Making Factors

The choice between robotic, laparoscopic, or open approach should be based on surgeon expertise with these techniques, patient medical comorbidities, and prostatic anatomy. 1, 7 Not all providers have access to robotic technology, and some surgeons achieve excellent results with transurethral approaches (bipolar TURP, HoLEP) even for prostates >60g. 1

Common Pitfalls to Avoid:

• Don't assume robotic surgery is appropriate for all BPH cases: TURP remains the gold standard for most BPH surgeries and should be the primary consideration for prostates <60-80g 1, 3, 7
• Ensure proper patient counseling: All surgical interventions for BPH can cause ejaculatory dysfunction and may worsen erectile dysfunction 1
• Consider surgeon experience: Robotic simple prostatectomy has a relatively short learning curve for surgeons experienced in robotic surgery 5
• Evaluate for simultaneous pathology: Robotic approach facilitates concurrent treatment of bladder stones and bladder diverticula 5

Alternative Surgical Options

For patients who are not candidates for robotic surgery or when expertise is unavailable, other options include:

• TURP (monopolar or bipolar): Remains the benchmark standard for most BPH cases 1, 3
• Open simple prostatectomy: Traditional approach for large prostates, though with higher morbidity 2
• Laser enucleation (HoLEP): Effective transurethral option for large prostates in experienced hands 1
• For high-risk non-surgical candidates: Intermittent catheterization, indwelling catheter, or prostatic stents (though stents carry significant complications including encrustation, infection, and chronic pain) 3, 7