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Robotic-Assisted Simple Prostatectomy: A Comparison of Primary Simple Prostatectomy versus Salvage Simple Prostatectomy in Treatment of Lower Urinary Tract Symptoms - Beyond the Abstract

Surgical treatment for lower urinary tract symptoms attributable to benign prostatic hyperplasia is a common reason patients seek out a Urologist. With the rise of minimally invasive surgical therapies (MIST), choosing the right operation for the right patient becomes cumbersome. Are thermo-ablative or mechanical treatments more suitable for which particular patients? Taking into account patient history and prostate morphology, the delivery of certain MISTs has become more algorithmic. If sexual function is critical, then Lift® may be appropriate. If a large median lobe is identified, then perhaps a bipolar TURP or HoLEP. But even these situations have become recently debated. However, what has remained steadfast is the fact that large (80 -150 g) or very large (>150 g) are best managed with either laser enucleation or simple prostatectomy.


Though “simple” in its name, simple prostatectomy can be a technically arduous operation oftentimes dealing with massively enlarged benign hyperplasia with varied and complex prostate morphology. Once considered the gold standard treatment for patients with lower urinary tract symptoms attributed to massively enlarged prostate glands (size > 80), open simple prostatectomy has become less in favor given the advancements in robotic surgery.1 In fact, robotic simple prostatectomy (RSP) has become even more efficient by not requiring continuous bladder irrigation when utilizing a complete urethrovesical reconstructive technique.2 Advantages of RSP include shorter hospital stay (outpatient), less blood loss, no CBI, minimal catheter duration, and faster recovery times. Approach to RSP can be transperitoneal vs. extraperitoneal and can be further subdivided by incision type: bladder neck, prostatic capsule, or transvesical.3 Furthermore, when utilizing the robotic approach, the surgeon can also treat associated conditions such as bladder diverticulectomy.4

Unfortunately, at times, MISTs are not efficacious, or worse, inappropriately indicated, i.e., Lift® in patients with glands > 150 cc. In our series of 124 referred patients who underwent robotic simple prostatectomy, we identified 26 performed in the salvage setting – where primary MIST did not work. Of the 26 patients, 19 underwent prior TURP, 3 s/p TUMT, 1 s/p TUNA, and 3 s/p UroLIFT. Regardless of if RSP was performed in the primary or salvage settings, perioperative outcomes such as length of stay, blood loss, operative time, and postoperative functional outcomes such as IPSS, PVR, and Qmax were equivalent. Thus, regardless of prior MIST, salvage RSP is an efficient and durable procedure where patients can expect good functional outcomes despite any prior ineffective surgical therapy.

Written by: Ram A. Pathak, MD, Assistant Professor, Department of Urology, Mayo Clinic Florida

References:

  1. Patel MN, Hemal AK Urol Clin North Am 2014 Nov;41(4):485-92. doi: 10.1016/j.ucl.2014.07.003.
  2. Dubey D, Hemal AK. Indian J Urol. 2012 Apr;28(2):231-2. doi: 10.4103/0970-1591.98479.
  3. Pathak, R.A., Moschovas, M.C., Thiel, D.D., Hemal, A.K. (2022). Robotic Simple Prostatectomy. In: Wiklund, P., Mottrie, A., Gundeti, M.S., Patel, V. (eds) Robotic Urologic Surgery. Springer, Cham.  https://doi.org/10.1007/978-3-031-00363-9_10
  4. Liu S. Pathak RA, Hemal AK. Urology 2021 Jan;147:311-316. doi: 10.1016/j.urology.2020.07.044.
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