Surgical Management of the “Large” Prostate: The Robotic Simple Prostatectomy

NYU Case of the Month, October 2020

Case of the Month Surgical Management of the “Large” Prostate: The Robotic Simple Prostatectomy NYU Case of the Month, October 2020 Benjamin M. Brucker, MD, Alice Drain, MD Department of Urology, NYU Langone Health, New York, NY [Rev Urol. 2020;22(4):174–176] © 2021 MedReviews®, LLC A 66-year-old man presented with acute urinary retention. He first sought medical care for an enlarged prostate about 10 years ago. At that time, he was experiencing a slow urinary stream and was started on an alpha-blocker and a 5-alphareductase inhibitor (5-ARI). He stopped taking the 5-ARI because of unwanted effects on his libido and mild breast tenderness. A year ago, he had an International Prostate Symptom Score (IPSS) of 24 and a Quality of Life (Qol) score of 3 (“mixed”). His lower urinary tract symptoms (LUTS) had progressed steadily over the years, but he became more concerned about 3 months ago when he started to have urinary incontinence. In addition to urgency incontinence, he felt an increasing pelvic pressure and thought his abdomen was more distended. He began sitting to void and was increasingly bothered by nocturia (3 times/night). The patient’s past urologic history also included an elevated serum prostate-specific antigen (PSA) level, resulting in two negative prostate biopsies. The more recent biopsy was done 2 years earlier in conjunction with a prostate MRI (Figure 1). Although the MRI showed no lesion suspicious for prostate cancer, it did show benign prostatic hypertrophy (BPH) with a gland estimated to be 193 g and a sizable median lobe. The patient’s past medical history was notable only for Parkinson disease, which was mild and well controlled with medication. His past surgical history included appendectomy at age 16 years. Physical Examination and Evaluation at NYU Langone Health The patient was a well-developed man who appeared healthy. He had flat facial features and a mild shuffling gait, but he was otherwise neurologically intact. Digital rectal examination revealed normal tone and Figure 1. MRI showing benign prostatic hyperplasia done before last prostate needle biopsy about 2 years prior to presentation. The prostate weight was 193 g. There is thickening of the bladder wall. 174 • Vol. 22 No. 4 • 2020 • Reviews in Urology 4170020_08_RiU0885A_V4_ptg01.indd 174 4/6/21 3:53 PM Robotic Simple Prostatectomy 8 mm Assistant 5 mm Assistant 12 mm Balloon port 8 mm Xi ports Figure 3. Port placement of the transvesical robotic simple prostatectomy (da Vinci Xi; Intuitive Surgical, Sunnyvale, CA). Two assistant ports allowed for retraction and suction to be performed simultaneously. Figure 2. Pressure flow study showing a large bladder capacity. The patient’s involuntary detrusor contraction resulted in a small amount of leakage. On second fill, he mounted a detrusor contraction after being given permission to void with little to no urine flow. Fluoroscopic images (not shown) show little to no funneling of the bladder neck, consistent with obstruction from the prostate. an enlarged but smooth prostate. Abdominal examination was unremarkable. Testicles were non-tender, and no inguinal hernia was found. Results of an attempted noninvasive uroflow were uninterpretable because of a low voided volume. The bladder scan residual at that time showed 850 mL. Serum creatinine was noted to be elevated at 2.2 mg/dL from a baseline of 1.0 mg/dL a year earlier. Renal ultrasound showed mild bilateral hydronephrosis, an enlarged prostate, and a thickened bladder. PSA was 5.7 ng/dL (PSA was 6.2 ng/dL in 2018, just prior to MRI and subsequent biopsy). Urodynamics showed a large bladder capacity (Figure 2) and a high amplitude terminal involuntary detrusor contraction with a small leak. On second fill, the patient was able to mount a high-pressure detrusor contraction (maximum detrusor pressure, 139 cm H2O) with poor flow. Management The patient was acutely managed with clean intermittent catheterization but desired definitive management. He was counseled on the potential therapeutic options and elected to proceed with a robotic benign simple prostatectomy. This was done with a da Vinci Xi robot (Intuitive Surgical, Sunnyvale, CA) via a transvesical approach. An excellent enucleation plane was developed, and the prostatic adenoma was removed in two large parts (Figures 3 and 4). Estimated blood loss was 100 mL. The morning after surgery, the patient was discharged home with a catheter for gravity drainage. At his most recent 3-month visit, the patient remained elated with his urination. His IPSS was 4 and his Qol was 0 (“delighted”). He denied any leakage of urine and had been able to achieve and maintain erections sufficient for penetrative intercourse. His uroflow showed a voided volume of 450 mL/s, a maximum flow rate of 32 mL/s, and an average flow rate of 20 mL/s, with a post-void residual of 0 mL. Follow-up ultrasound showed complete resolution of his hydronephrosis. His serum creatinine level was 0.8 mg/dL. Comment This case brings up some of the issues involved in the management of the “large” prostate. It is well established that BPH with LUTS and benign prostatic obstruction (BPO) are common problems that urologists in the United States are frequently called on to manage. What is unique in this case is the enormous size of the patient’s prostate. This is an important consideration for urologic surgeons, because data suggest that we may be seeing a “stage migration” toward the large prostate. An example of this migration is the nearly 25% increase in Emergency Department visits for urinary retention attributable to BPH in a population of California men between 2007 and 2010.1 After the number of transurethral resections of prostates (TURPs) peaked in the late 1980s, there was a reduction that continued into the early 1990s. Around this time, the use of medical management significantly increased, as more pharmacologic agents became available, and guidelines encouraged a stepwise approach emphasizing medical management.2 Increasing medical comorbidities and population demographics (ie, Baby Boomers) have also been suggested as reasons for this shift to an increased number of large prostates. The benign prostatectomy is in no way new or novel but has been the gold standard for managing the large prostate. In fact, it was first described in 1900 by Peter Freyer. Although the technique of open prostatectomy has been modified, it has continued to Vol. 22 No. 4 • 2020 • Reviews in Urology • 175 4170020_08_RiU0885A_V4_ptg01.indd 175 4/6/21 3:53 PM Robotic Simple Prostatectomy continued Figure 4. (Left) Gross pathology of suprapubic prostatectomy specimen, microscopic examination (not shown) consistent with BPH. Intraoperative photos showing (middle) transverse bladder incision. With this approach, the retropubic space is left intact. If the surgeon elects to utilize an inverted “U”, it can minimize the need for holding sutures thereby keeping the leaflet out of the surgical field. (Right) After successful enucleation, the bladder was “re-trigonalized” by pulling the trigone down the cut urethral edge. This may aid in preventing circumferential bladder neck contracture, aid in hemostasis, and aid in the ease of urethral catheterization. have significant morbidity, long hospitalization stays, and a significant transfusion rate.3 So, what are the viable surgical alternatives to the open simple prostatectomy? Laser enucleation was described in the 1990s. And since that time, some have touted the endoscopic technique of enucleating the prostate as the ideal way to surgically manage BPH, even in the setting of the large prostate, as some considered the technique to be “size independent.”4 However, historically this technique has had slow uptake and very low utilization in the United States.5 Undoubtedly, various factors contribute to the use of surgical tools and techniques, but one reason often cited for the low uptake of laser enucleation is the steep learning curve.6 On the other hand, access, comfort, and advancements with the robotic platform have led to the tremendous growth of robotics in the field of urology. Urologic surgeons have been eager to use the robots for a large array of indications. The robotic approach to benign prostatectomy may improve surgical outcomes for men with very large glands and significantly reduce morbidity. Sotelo and colleagues first published a description of robot-assisted simple prostatectomy in 2008.7 Although various approaches and techniques have subsequently been developed and described, overall, the robotic simple prostatectomy shows excellent functional outcomes equal to those of open simple prostatectomy. The advantage of the minimally invasive robotic approach is unequivocally the reduction of blood loss, lower transfusion rates, and shorter hospital length of stay. Data suggest that these advantages come with only a marginal, often considered inconsequential, increase in shortterm hospital costs. Even though the robotic approach may not be accessible to all surgeons, it has been established that its learning curve is substantially shorter than that of laser enucleation.8 The robotic benign prostatectomy offers a very effective treatment for the large prostate. Our patient did not have concomitant conditions, but inguinal hernia, bladder stones, and bladder diverticulum are all more common in these advanced cases. The robotic approach allows these conditions to be addressed easily. We continue to improve the technique, and new and better tools further minimize morbidity and improve outcomes here at NYU Langone Health. Although experts are needed to carry out robotic benign prostatectomy safely and efficiently, this procedure can be successfully implemented in a center with an established and strong robotic program. Over many years of medical management, our patient had unfortunately experienced significant progression of his BPH with LUTS. Following robotic simple prostatectomy, his renal function returned to normal, his bladder contractility was preserved, and his voiding was successful again. References 1. 2. 3. 4. 5. 6. 7. 8. Groves HK, Chang D, Palazzi K, et al. The incidence of acute urinary retention secondary to BPH is increasing among California men. Prostate Cancer Prostatic Dis. 2013;16:260-265. Filson CP, Wei JT, Hollingsworth JM. Trends in medical management of men with lower urinary tract symptoms suggestive of benign prostatic hyperplasia. Urology. 2013;82:1386-1392. McVary KT, Roehrborn CG, Avins AL, et al. Update on AUA guideline on the management of benign prostatic hyperplasia. J Urol. 2011;185:1793-1803. Meyer D, Weprin S, Zukovski EB, et al. Rationale for robotic-assisted simple prostatectomy for benign prostatic obstruction. Eur Urol Focus. 2018;4:643-647. Robles J, Pais V, Miller N. Mind the gaps: adoption and underutilization of holmium laser enucleation of the prostate in the United States from 2008 to 2014. J Endourol. 2020;34:770-776. Robert G, Cornu JN, Fourmarier M, et al. Multicentre prospective evaluation of the learning curve of holmium laser enucleation of the prostate (HoLEP). BJU Int. 2016; 117:495-499. Sotelo R, Clavijo R, Carmona O, et al. Robotic simple prostatectomy. J Urol. 2008;179:513-515. Johnson B, Sorokin I, Singla N, et al. J Endourol. 2018;32:865-870. 176 • Vol. 22 No. 4 • 2020 • Reviews in Urology 4170020_08_RiU0885A_V4_ptg01.indd 176 4/6/21 3:53 PM