title: Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-urethral anastomosis.
abstract: OBJECTIVE
  To describe a technical modification during robotic-assisted simple prostatectomy (RASP) aiming to decrease perioperative blood loss, shorten the length of hospital stay and eliminate the need of postoperative continuous bladder irrigation. To describe perioperative outcomes, pathological findings and functional outcomes of our single-surgeon series using this technique.
  
  
  METHODS
  We analysed six consecutive patients who underwent RASP using our technical modification between February and September 2010. Transrectal ultrasonography (TRUS) guided prostate biopsy was performed in all cases and revealed benign prostatic hyperplasia in two cases and benign prostatic hyperplasia plus chronic prostatitis in four cases. The mean estimated prostate volume in the TRUS was 157 ± 74 (range 90-300) mL and the average preoperative International Prostate Symptom score was 19.8 ± 9.6 (10-32). Two patients were in urinary retention before surgery. Our technique of RASP includes the standard operative steps reported during open and laparoscopic simple prostatectomy; however, with the addition of some technical modifications during the reconstructive part of the procedure. Following the resection of the adenoma, instead of performing the classical 'trigonization' of the bladder neck and closure of the prostatic capsule, we propose three modified surgical steps: plication of the posterior prostatic capsule, a modified van Velthoven continuous vesico-urethral anastomosis and, finally, suture of the anterior prostatic capsule to the anterior bladder wall.
  
  
  RESULTS
  The patients' average age was 69 ± 4.9 (63-74) years; the mean estimated blood loss was 208 ± 66 (100-300) mL and the mean operative time was 90 ± 17.6 (75-120) min. All patients were discharged on postoperative day 1 without the need of continuous bladder irrigation at any time after RASP. No blood transfusion or perioperative complications were reported. The mean weight of the surgical specimen was 145 ± 41.6 (84-186) g. Histopathological evaluation revealed benign prostatic hyperplasia plus chronic prostatitis in five patients and prostatic adenocarcinoma (Gleason score 3+3, pT1a) with negative surgical margins in one patient. The mean serum prostate-specific antigen level decreased from 7 ± 2.5 (4.2-11) ng/mL preoperatively to 1.05 ± 0.8 (0.2-2.5) after RASP. Significant improvement from baseline was reported in the average International Prostate Symptom score (average preoperative vs postoperative, 19.8 ± 9.6 vs 5.5 ± 2.5, P= 0.01) and in mean maximum urine flow (average preoperative vs postoperative 7.75 ± 3.3 vs 19 ± 4.5 mL/s, P= 0.019) at 2 months after RASP. All patients were continent (defined as the use of no pads) at 2 months after RASP.
  
  
  CONCLUSIONS
  Our modified technique of RASP is a safe and feasible option for treatment of lower urinary tract symptoms caused by large prostatic adenomas. Potential advantages of our technique include reduced blood loss, lower blood transfusion rates and shorter length of hospital stay with no need of postoperative continuous bladder irrigation. Larger series with longer follow-up are necessary to determine long-term outcomes in comparison to open simple prostatectomy or to the standard technique of RASP.
authors.affiliation: Global Robotics Institute, Florida Hospital Celebration Health, USA.
authors.forename: Rafael F
authors.initials: RF
authors.lastname: Coelho
authors.forename: Sanket
authors.initials: S
authors.lastname: Chauhan
authors.forename: Ananthakrishnan
authors.initials: A
authors.lastname: Sivaraman
authors.forename: Kenneth J
authors.initials: KJ
authors.lastname: Palmer
authors.forename: Marcelo A
authors.initials: MA
authors.lastname: Orvieto
authors.forename: Bernardo
authors.initials: B
authors.lastname: Rocco
authors.forename: Geoff
authors.initials: G
authors.lastname: Coughlin
authors.forename: Vipul R
authors.initials: VR
authors.lastname: Patel
mesh_terms: D000368:Aged; D000714:Anastomosis, Surgical; D016063:Blood Loss, Surgical / Q000517:prevention & control / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay / Q000706:statistics & numerical data; D008297:Male; D009929:Organ Size; D011468:Prostatectomy / Q000379:methods*; D011470:Prostatic Hyperplasia / Q000473:pathology / Q000601:surgery*; D012008:Recurrence; D012189:Retrospective Studies; D012371:Robotics / Q000379:methods*; D016896:Treatment Outcome; D014521:Urethra / Q000601:surgery*; D001743:Urinary Bladder / Q000601:surgery*; D016055:Urinary Retention / Q000601:surgery