Modified Robotic Simple Prostatectomy Technique: A Retrospective Analysis of a Series of 162 Surgeries Performed by a High-volume Surgeon

Modified Robotic Simple Prostatectomy Technique: A Retrospective Analysis of a Series of 162 Surgeries Performed by a High-volume Surgeon | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Modified Robotic Simple Prostatectomy Technique: A Retrospective Analysis of a Series of 162 Surgeries Performed by a High-volume Surgeon Celene Benediti Bragion¹, Maurício Dener Cordeiro², Sandro Mendonça Faria³ This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4947299/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 18 Oct, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted 4 You are reading this latest preprint version Abstract Benign prostatic hyperplasia (BPH) affects up to 80% of men by age 80, with large-gland BPH often treated by simple prostatectomy (SP). This technique significantly improves symptoms but is associated with high rates of complications such as transfusions and infections. Minimally invasive techniques, including robotic-assisted laparoscopic simple suprapubic prostatectomy (RALSP), have emerged as alternatives. This study reports on 162 patients who underwent RALSP from May 2018 to June 2023. The mean age of the patients was 69 years, mean prostate volume 144.8 cm³, mean robot time 78.7 min, and mean blood loss 183.1mL. Results demonstrated significant improvements in the results: prostate volume (mean decrease from 144.8 to 26.6 cm³), mean PSA level decreased from 7.8 to 0.8 (p < 0.0001), mean IPSS decreased from 23.0 to 4.4 (p < 0.0001), and mean uroflowmetry increased from 6.3 to 22.6 ml/s (p < 0.0001). No patient experienced worsening erectile function after surgery. All patients showed absence of stress urinary incontinence within 3 months. Catheterization time decreased from 4.2 to 2.6 days over the study period. The postoperative complication rate was 2.29%, with no need for surgical reintervention for complications. While RALSP showed promising results, further prospective studies are needed to compare it with other techniques. This study highlights RALSP as a viable minimally invasive option for treating large-volume BPH, offering reduced recovery times and fewer complications. Benign prostatic hyperplasia Robotic surgery simple prostatectomy outcome. Figures Figure 1 Figure 2 Figure 3 1. Introduction Benign prostatic hyperplasia (BPH) is a highly prevalent condition in men, the incidence increasing progressively with age and affecting up to 80% of men by age 80 [ 1 ]. Over the last decades, a large variety of options to treat obstructive voiding symptoms and hematuria due to BPH have been developed, and various techniques such as laser vaporization and enucleation, plasma vaporization, bipolar resection, and Holmium Laser Enucleation of Prostate (HoLEP) have proliferated. Despite these advancements, the standard treatment for obstructive urinary symptoms due to large-gland (> 80 g) BPH remains simple prostatectomy (SP) [ 2 ]. In patients requiring surgery, European Association of Urology (EAU) and American Urology Association (AUA) guidelines recommend open SP (OSP) for the surgical treatment of patients with large-volume (> 80 g) glands ( www.EAU.org , www.AUA.org ) [ 3 , 4 ]. Obstructive adenomas are enucleated using the index finger, approaching from within the bladder (Freyer procedure) or through the anterior prostatic capsule (Millin procedure) [ 5 , 6 ]. Open OSP substantially improves International Prostate Symptoms Score (IPSS), urinary flow rate, quality of life, and postvoid residual volumes. However, open SP has also been associated with relatively high rates of perioperative transfusion, prolonged hospital stay, reoperation, and urinary infections [ 6 ]. Over the past few years, minimally invasive (laparoscopic and robotic-assisted) SP has been implemented worldwide, with encouraging results. Minimally invasive techniques emulating OSP have been developed recently and may improve perioperative morbidity with equivalent treatment outcomes. Robotic-assisted laparoscopic simple suprapubic prostatectomy (RALSP) has been described as a novel alternative to open SP [ 6 , 7 , 8 ]. However, despite the promising results, there are few studies reporting the outcomes of RALSP, with currently no prospective randomized comparative study with other enucleation techniques proving its benefit [ 9 ]. Here we describe our initial experience with RALSP, with small modifications to our technique to improve efficiency. Throughout the evolution of our practice, we have been able to reduce the postoperative bladder catheterization time. We also report the simultaneous correction of inguinal hernias, thus highlighting this approach as a clear advantage. Additionally, we analyzed the associated morbidity and the outcomes achieved. 2. Materials and methods 2.1 Patients and materials This was a retrospective analysis of the records of 162 patients who underwent surgery at two medical centers in the country by the same surgeon from May 2018 to June 2023. We included patients with a diagnosis of benign prostatic obstruction undergoing RALSP. The following data were collected: patient age, prostate volume preoperatively and up to 6 months after surgery, prostate-specific antigen (PSA) level preoperative and postoperative up to 6 months, IPSS preoperative and up to 6 months after surgery, urinary flow rate (Qmax) pre- and postoperative maximum, robotic surgical time, estimated blood loss during surgery, length of hospital stay, need for postoperative blood transfusion, duration of postoperative catheterization, use of anticoagulants or antiplatelets, presence of associated hernia, and need for reoperation. To assess differences, we used the non-parametric Wilcoxon test, adopting a significance level of 0.05, which corresponds to a 95% confidence interval. JMP Pro 13 (SAS Institute Inc., Cary, NC, USA) was used for analysis. 2.2. Surgical technique All surgical procedures were performed using the Da Vinci robotic platform (Si, X, or Xi), with the same surgical technique, and by the same surgeon. The technique described below was modified from that described by Patel in 2011 [ 10 ]. Six transperitoneal trocars were used, four of which were robotic, as follows: one 8-mm supra-umbilical trocar; two 8-mm robotic trocars bilaterally in line, 8-cm apart from the first trocar; and the last robotic trocar in line on the left, 8-cm from the previous one. Additionally, a 12-mm trocar in line on the right, at least 8-cm from the lateral trocar, and a 5-mm trocar bisecting between the camera ports and the right side, at least 5-cm from both were used. The patient was positioned in the Trendelenburg position with a tilt of 25 to 28 degrees. The robotic instruments used were monopolar scissors, fenestrated bipolar forceps, tenaculum, and needle holder. A 0-degree camera was used throughout the procedure. An incision was made in the peritoneum with lowering of the bladder and dissection of the fat in the vesicoprostatic transition. Preventive hemostatic ligatures in the vesicoprostatic transitions or the prostatic capsule as described by Patel et al.[ 10 ] were not used. A capsular incision was made near the vesicoprostatic junction. The plane between the adenoma and the prostatic capsule was identified and dissected with a combination of cauterization and blunt dissection. The anterior vesical neck was then sectioned, followed by maximum anterior and lateral dissection of the adenoma. Next, the anterior commissure was sectioned until the urethra was reached, defining the apical limit medially. Unlike previously described techniques, the dissection of the prostatic adenoma was through its segmentation (sliced), allowing better access and clear visualization of the apex, with safer dissection of the urethra without injury to the sphincter (Figs. 1 and 2). The lateral adenomas were first removed, with good identification of the posterior vesical neck limits, followed by resection of the apices and, when applicable, the median lobe. Dissection at the end of the posterior vesical neck, with or without a median lobe, allows for secure identification of the posterior adenoma, preventing residual benign tissue from being left behind. After complete removal of the adenoma, we reviewed hemostasis, suturing if necessary, at points of greater bleeding, with 3 − 0 Caprofyl. A 360-degree colo-urethral anastomosis was then performed, using the shooting technique with two 3 − 0 V-lok sutures, following a modified van Velthoven technique (Fig. 3 ), and a 20 fr Foley ureteral catheter was placed. Finally, the anterior prostatic capsule was hemostatically sutured to the anterior bladder wall. The fragments of the specimen were then placed in the endocath and removed through the small umbilical incision. In cases of associated inguinal hernia, classical dissection and reduction of hernia sacs were performed before the prostatectomy, with mesh placement at the end and peritoneal closure. Postoperatively, patients remained with bladder irrigation, received a light diet as soon as they were fully awake, and were encouraged to ambulate early. Generally, irrigation was stopped after 24 hr and patients were discharged between 24 and 48 hr after surgery. 3. Results We analyzed 162 medical records, identifying 131 patients with complete data who underwent procedures from January 6, 2018 to June 1, 2023. The mean age of the patients was 69.1 ± 7.4 years, mean prostate volume 144.8 ± 47.1 cm³ (90–478), mean robot time 78.7 ± 9.3 min, and mean blood loss 183.1 ± 9.3 mL (50–560) (Table 1 ). Table 1 – Summary of analyzed variables Variable Mean ± SD Median Range IQR Age, years 69.1 ± 7.4 69 47–90 65–74 Volume 144.8 ± 47.1 140 90–478 118–160 Preoperative PSA level 7.8 ± 3.9 6.7 1.9–18.8 4.7–9.8 IPSS 23.0 ± 3.6 22.5 16–34 20–26 Robot time, min 78.7 ± 9.3 77.5 62–128 72.5–82 Hospital stay, days 1.6 ± 0.5 2 1–4 1–2 Blood loss, mL 183.1 ± 93.4 150 150–560 120–220 Catheter time 3.6 ± 1.1 4 2–6 2–4 IQR, interquartile range; PSA, prostate-specific antigen; IPSS, International Prostate Symptoms Score Among the 131 patients, 26 (19.8%) had an associated inguinal hernia and underwent correction during the same surgical procedure. In total, 24 patients (18%) had previously undergone transurethral resection of the prostate, and 24 (18%) were on antiplatelet or anticoagulant medication. Seven patients had an indwelling catheter before surgery due to urinary retention. Four patients had International Society of Urologic Pathologists grade 1 prostate adenocarcinoma and underwent subsequent robotic radical prostatectomy. During the evaluated period, postoperative catheterization time significantly decreased from 2018 to 2021 (p < 0.0001), from 4.2 days to 2.6 days (Graph 1). Data are mean ± SD. We evaluated patients by prostate volume, IPSS, PSA level, and uroflowmetry before and up to 6 months after surgery. Mean volume decreased from 144.8 to 26.6 (p < 0.0001), Mean PSA level decreased from 7.8 to 0.8 (p < 0.0001). Mean IPSS decreased from 23.0 to 4.4 (p < 0.0001), and mean uroflowmetry increased from 6.3 to 22.6 ml/s (p < 0.0001). No patient experienced worsening erectile function after surgery. All patients showed absence of stress urinary incontinence within 3 months. To verify whether the differences between the groups were significant, we used the non-parametric Wilcoxon signed-rank test, considering that the same patient was evaluated at both times in Table 2 . Table 2 – Comparison of variables pre-surgery and 6 months Y Time N Mean Median Range IQR p-value Volume Pre-surgery 131 144.8 ± 47.1 140 90–478 118–160 < 0.0001 6 months 127 26.6 ± 7.2 27 5–42 20–32 PSA Pre-surgery 131 7.8 ± 3.9 6,7 1.9–18.8 4.7–9.8 < 0.0001 6 months 129 0.8 ± 0.4 0.85 0.2–2.2 0.6–0.99 IPSS Pre-surgery 108 23.0 ± 3.6 22.5 16–34 20–26 < 0.0001 6 months 131 4.4 ± 1.6 4 2–1 3–6 Uroflowmetry Pre-surgery 34 6.3 ± 1.6 6.1 3.8–10 4.925–7.5 < 0.0001 6 months 34 22.6 ± 3.0 22.75 16.7–28 20.22–24.57 IQR, interquartile range; PSA, prostate-specific antigen; IPSS, International Prostate Symptoms Score The postoperative complication rate was 2.29%, with no need for surgical reintervention for complications (Dindo-Clavien Grade I). Only three patients presented bladder clots postoperatively, which were resolved by bladder irrigation and clot aspiration via the bladder catheter. No patients required a blood transfusion. We had no cases of urethral or vesicourethral anastomosis strictures requiring intervention. One case required readmission for clinical treatment of an abdominal wall infection. The presence of postoperative incisional hernia was not evaluated. 4. Discussion The surgical approach to prostatic hyperplasia has evolved significantly with the use of the robotic platform, and various surgical techniques have been described. Our technique for robotic prostatectomy seems safe and effective for treating BPH. We observed significant improvements in prostatic symptoms (preoperative vs postoperative IPSS 23 ± 3.6 vs 4 ± 1.6, p < 0.0001), urinary flow rate (6.3 ± 1.3 vs 22.6 ± 3, p < 0.0001), and prostate volume (144 ± 47 vs 26.6 ± 7.2, p < 0.0001). In addition to the improvements described by Patel et al.[ 10 ], we believe that our modification allows for safer access to the prostatic apex and surgical planes. Prostate resection occurs under complete visualization when we dissect the specimen in fragments. This approach reduces sphincter traction and facilitates the identification of the boundaries between the capsule and adenoma, allowing for a more anatomical dissection, with better surgical field, improved hemostasis, less bleeding, and better preservation of the bladder neck. Furthermore, even without suturing the prostatic capsule, we found less blood loss than described by other groups [7,11]. The reduction in catheter time was possible in that we observed good surgical outcomes with very low complication rates. Initially, in selected cases, we began to gradually reduce catheter time while maintaining good results. Today, a good proportion of patients are discharged within 48 hr without an indwelling bladder catheter. Younger patients, with good bladder capacity, good quality of vesicourethral anastomosis, and no postoperative complications are candidates for early catheter removal. Conversely, older patients, on antiplatelet or anticoagulant medications, with previous urinary retention or prior transurethral resection of the prostate, probably have longer catheterization time. In our study, earlier postoperative catheter removal did not affect surgical outcomes or increase the number of complications. No prospective randomized study has compared RALSP with other techniques. However, a recent review by Kordan et al.[ 13 ] demonstrated that the technique can indeed be considered a minimally invasive surgery for prostates > 80 g, showing functional results for IPSS, post-void residual urine, Qmax, and quality of life as well as complication rates, blood loss, and hospitalization time as compared with other techniques such as thulium laser vapoenucleation of the prostate ( ThuLEP) and HoLEP. In a recent meta-analysis[ 14 ], RALSP was associated with longer hospital stay and catheterization time and higher TR as compared with laser endoscopic enucleation of the prostate. However, when comparing the results from our study, hospitalization times were similar for RALSP and other techniques (hospital stay 1.6 vs 1.71 days). The same study[ 14 ] demonstrated superiority for ThuLEP versus RALSP in terms of surgical time. This superiority was not demonstrated when considering the mean surgical time of our case series (78.7 vs 85 min). In the meta-analysis of Pandolfo et al.[ 9 ], the catheterization time was significantly shorter in patients undergoing HoLEP and ThuLEP than other patients. However, as compared with the second phase of our study, showing decreased catheterization time, catheterization time was shorter for patients undergoing RALSP than those undergoing laser enucleation (2.6 vs 3.54 days). Given these comparisons, RALSP may be superior to other techniques for hospitalization, catheterization, and surgical time. A potential disadvantage of our technique could be the difficulty in resecting the intravesical component of a larger median lobe. For less experienced surgeons, the lower prostatic exposure due to the subcapsular, extravesical approach might hinder the identification of the intravesical median lobe. The limitations of this study include its retrospective design and the reliance on results from a single surgeon. However, the number of cases reviewed, the reproducibility of the surgical technique, and the uniformity of the identified data greatly favor the method's applicability. We believe that access to the robotic platform is increasingly feasible for most urologists, and by providing updated information on the clinical outcomes of robotic adenectomy, we hope to contribute to clinical decision-making and assist colleagues in choosing the best surgical approach for their patients with BHP. Declarations Funding The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Competing Interests The authors have no relevant financial or non-financial interests to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Sandro Mendonça de Faria, Mauricio Dener Cordeiro and Celene Benediti Bragion. The first draft of the manuscript was written by Celene Benediti Bragion and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript. Ethics approval Ethical approval was waived by the local Ethics Committee of Vera Cruz Hospital and Albert Einstein Israelite Hospital in view of the retrospective nature of the study and all the procedures being performed were part of the routine care References - Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol. 1984;132(3):474–9. doi: 10.1016/s0022-5347(17)49698-4 . - Vince R, Hampton LJ, Vartolomei MD, Shariat SF, Porpiglia F, Autorino R. Robotic assisted simple prostatectomy: recent advances. Curr Opin Urol. 2018;28(3):309–314. doi: 10.1097/MOU.0000000000000499 . - EAU Guidelines. Edn. presented at the EAU Annual Congress Paris April 2024. ISBN 978-94-92671-23-3. - Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA Guideline amendment 2023. J Urol. 2023; 10.1097/JU.0000000000003698 . https://doi.org/10.1097/JU.0000000000003698 - Tubaro A, de Nunzio C. The current role of open surgery in BPH. EAU-EBU Update Ser. 2006;4:191–201. Andrea Tubaro, Cosimo de Nunzio, ISSN 1871–2592, https://doi.org/10.1016/j.eeus.2006.07.002 . - Millin, T. The surgery of prostatic obstructions. Ir J Med Sci 22, 185–189 (1947). https://doi.org/10.1007/BF02937798 - Sotelo R, et al. Robotic simple prostatectomy. J Urol. 2008;179(2):513–5. doi: 10.1016/j.juro.2007.09.065 . - Lucca I, Shariat SF, Hofbauer SL, Klatte T. Outcomes of minimally invasive simple prostatectomy for benign prostatic hyperplasia: a systematic review and meta-analysis. World J Urol. 2015;33(4):563–70. Epub 2014 May 31. doi: 10.1007/s00345-014-1324-3 . - Pandolfo SD, et al. Robotic assisted simple prostatectomy versus other treatment modalities for large benign prostatic hyperplasia: a systematic review and meta-analysis of over 6500 cases. Prostate Cancer Prostatic Dis. 2023;26(3):495–510. Epub 2022 Nov 19. PMID: 36402815. doi: 10.1038/s41391-022-00616-4 . - Coelho RF, Chauhan S, Sivaraman A, Palmer KJ, Orvieto MA, Rocco B, Coughlin G, Patel VR. Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-urethral anastomosis. BJU Int. 2012;109(3):426–33. doi: 10.1111/j.1464-410X.2011.010401.x . Epub 2011 Aug 18. PMID: 21851543. - Yuh B, Laungani R, Perlmutter A, Eun D, Peabody JO, Mohler JL, Stricker H, Guru KA. Robot-assisted Millin's retropubic prostatectomy: case series. Can J Urol. 2008;15(3):4101–5. PMID: 18570717. - Kordan Y, Canda AE, Köseoğlu E, Balbay D, Laguna MP, de la Rosette J. Robotic-Assisted Simple Prostatectomy: A Systematic Review. J Clin Med. 2020;9(6):1798. doi: 10.3390/jcm9061798 . - Xia Z, et al. Robotic-Assisted vs. Open Simple Prostatectomy for Large Prostates: A Meta-Analysis. Front Surg. 2021;8:695318. doi: 10.3389/fsurg.2021.695318 . Graph Graph 1 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Graph1.png Graph 1 – Mean catheterization time Cite Share Download PDF Status: Published Journal Publication published 18 Oct, 2024 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Accepted 05 Oct, 2024 Editor assigned by journal 21 Aug, 2024 Submission checks completed at journal 21 Aug, 2024 First submitted to journal 20 Aug, 2024 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4947299","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":347041539,"identity":"7fed4d2e-8722-43af-af3a-e8eb5fcd55c0","order_by":0,"name":"Celene Benediti Bragion¹","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA+klEQVRIiWNgGAWjYFAC5gYgcQCIGYGMCpAAWAQfYETWcgakhZFoLSB2G1wEN+Bvb2x8XFBxJ5+/f3Hj48J5tdH87UAtPyq24dQiceZgs/GMM88sZ9x42Gw8c9vx3BmHGRsYe87cxqnFQCKxTZq37bABw42DQMa2Y7kNQC3MjG14tMg/bP/N+++wgTxYy5xjufMJapFgbGPmbThsYHC+EailoSZ3AyEtEmcSm6V5jj0zMLzB2GzMc+xA7kagloP4/MLffvjgZ56aOwZy548/fMxTU5c77/zhgw9+VODWgmRfAog8DGYfIEI9yD6wujriFI+CUTAKRsGIAgAzxWIIy2klIQAAAABJRU5ErkJggg==","orcid":"","institution":"Vera Cruz Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Celene","middleName":"Benediti","lastName":"Bragion¹","suffix":""},{"id":347041540,"identity":"d1348096-d95e-4817-838d-a007a9eab283","order_by":1,"name":"Maurício Dener Cordeiro²","email":"","orcid":"","institution":"Hospital Israelita Albert Einstein","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Maurício","middleName":"Dener","lastName":"Cordeiro²","suffix":""},{"id":347041541,"identity":"4acd1138-f689-4a4a-92c1-b98dcaf38f70","order_by":2,"name":"Sandro Mendonça Faria³","email":"","orcid":"","institution":"Hospital Israelita Albert Einstein","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Sandro","middleName":"Mendonça","lastName":"Faria³","suffix":""}],"badges":[],"createdAt":"2024-08-20 20:39:44","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4947299/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4947299/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-024-02129-9","type":"published","date":"2024-10-18T15:58:16+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":66636614,"identity":"3d6f6079-d133-450e-b897-345c01796d40","added_by":"auto","created_at":"2024-10-15 05:36:50","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":15786,"visible":true,"origin":"","legend":"\u003cp\u003eAdenoma Segmentation\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4947299/v1/cc661dcb9b23fbc49adaedc5.jpg"},{"id":66636615,"identity":"2b1ecfcf-f1f5-46c5-86ad-480e2906320e","added_by":"auto","created_at":"2024-10-15 05:36:50","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13990,"visible":true,"origin":"","legend":"\u003cp\u003eClear visualization of the apex\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4947299/v1/bfa7379aba5967a8205de098.jpg"},{"id":66636617,"identity":"10786da0-1830-4755-8ef1-d5771380e83f","added_by":"auto","created_at":"2024-10-15 05:36:50","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":12367,"visible":true,"origin":"","legend":"\u003cp\u003eModified van Velthoven anastomosis\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-4947299/v1/9a8fa7604f5029f5498d0ea2.jpg"},{"id":67149571,"identity":"47384eee-a36e-4098-848e-f347d6cb3c03","added_by":"auto","created_at":"2024-10-21 16:13:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":437736,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4947299/v1/1b40b78b-8b67-4164-9543-609171c9365c.pdf"},{"id":66639997,"identity":"d51403c4-eba1-4e35-91ff-4321d448c433","added_by":"auto","created_at":"2024-10-15 06:03:30","extension":"png","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":24778,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eGraph 1 – Mean catheterization time\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"Graph1.png","url":"https://assets-eu.researchsquare.com/files/rs-4947299/v1/90a50a328276117ffd8149f6.png"}],"financialInterests":"No competing interests reported.","formattedTitle":"Modified Robotic Simple Prostatectomy Technique: A Retrospective Analysis of a Series of 162 Surgeries Performed by a High-volume Surgeon","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eBenign prostatic hyperplasia (BPH) is a highly prevalent condition in men, the incidence increasing progressively with age and affecting up to 80% of men by age 80 [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Over the last decades, a large variety of options to treat obstructive voiding symptoms and hematuria due to BPH have been developed, and various techniques such as laser vaporization and enucleation, plasma vaporization, bipolar resection, and Holmium Laser Enucleation of Prostate (HoLEP) have proliferated. Despite these advancements, the standard treatment for obstructive urinary symptoms due to large-gland (\u0026gt;\u0026thinsp;80 g) BPH remains simple prostatectomy (SP) [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn patients requiring surgery, European Association of Urology (EAU) and American Urology Association (AUA) guidelines recommend open SP (OSP) for the surgical treatment of patients with large-volume (\u0026gt;\u0026thinsp;80 g) glands (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"https://orcid.org/0000-0002-7998-7746\" target=\"_blank\"\u003ewww.EAU.org\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.EAU.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e\u003ca href=\"https://orcid.org/0000-0002-7998-7746\" target=\"_blank\"\u003ewww.AUA.org\u003c/a\u003e\u003c/span\u003e\u003cspan address=\"http://www.AUA.org\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e) [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eObstructive adenomas are enucleated using the index finger, approaching from within the bladder (Freyer procedure) or through the anterior prostatic capsule (Millin procedure) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Open OSP substantially improves International Prostate Symptoms Score (IPSS), urinary flow rate, quality of life, and postvoid residual volumes. However, open SP has also been associated with relatively high rates of perioperative transfusion, prolonged hospital stay, reoperation, and urinary infections [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOver the past few years, minimally invasive (laparoscopic and robotic-assisted) SP has been implemented worldwide, with encouraging results. Minimally invasive techniques emulating OSP have been developed recently and may improve perioperative morbidity with equivalent treatment outcomes. Robotic-assisted laparoscopic simple suprapubic prostatectomy (RALSP) has been described as a novel alternative to open SP [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eHowever, despite the promising results, there are few studies reporting the outcomes of RALSP, with currently no prospective randomized comparative study with other enucleation techniques proving its benefit [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Here we describe our initial experience with RALSP, with small modifications to our technique to improve efficiency. Throughout the evolution of our practice, we have been able to reduce the postoperative bladder catheterization time. We also report the simultaneous correction of inguinal hernias, thus highlighting this approach as a clear advantage. Additionally, we analyzed the associated morbidity and the outcomes achieved.\u003c/p\u003e"},{"header":"2. Materials and methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003e2.1 Patients and materials\u003c/h2\u003e \u003cp\u003eThis was a retrospective analysis of the records of 162 patients who underwent surgery at two medical centers in the country by the same surgeon from May 2018 to June 2023. We included patients with a diagnosis of benign prostatic obstruction undergoing RALSP. The following data were collected: patient age, prostate volume preoperatively and up to 6 months after surgery, prostate-specific antigen (PSA) level preoperative and postoperative up to 6 months, IPSS preoperative and up to 6 months after surgery, urinary flow rate (Qmax) pre- and postoperative maximum, robotic surgical time, estimated blood loss during surgery, length of hospital stay, need for postoperative blood transfusion, duration of postoperative catheterization, use of anticoagulants or antiplatelets, presence of associated hernia, and need for reoperation.\u003c/p\u003e \u003cp\u003eTo assess differences, we used the non-parametric Wilcoxon test, adopting a significance level of 0.05, which corresponds to a 95% confidence interval. JMP Pro 13 (SAS Institute Inc., Cary, NC, USA) was used for analysis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e2.2. Surgical technique\u003c/h2\u003e \u003cp\u003eAll surgical procedures were performed using the Da Vinci robotic platform (Si, X, or Xi), with the same surgical technique, and by the same surgeon. The technique described below was modified from that described by Patel in 2011 [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSix transperitoneal trocars were used, four of which were robotic, as follows: one 8-mm supra-umbilical trocar; two 8-mm robotic trocars bilaterally in line, 8-cm apart from the first trocar; and the last robotic trocar in line on the left, 8-cm from the previous one. Additionally, a 12-mm trocar in line on the right, at least 8-cm from the lateral trocar, and a 5-mm trocar bisecting between the camera ports and the right side, at least 5-cm from both were used. The patient was positioned in the Trendelenburg position with a tilt of 25 to 28 degrees.\u003c/p\u003e \u003cp\u003eThe robotic instruments used were monopolar scissors, fenestrated bipolar forceps, tenaculum, and needle holder. A 0-degree camera was used throughout the procedure.\u003c/p\u003e \u003cp\u003eAn incision was made in the peritoneum with lowering of the bladder and dissection of the fat in the vesicoprostatic transition.\u003c/p\u003e \u003cp\u003ePreventive hemostatic ligatures in the vesicoprostatic transitions or the prostatic capsule as described by Patel et al.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] were not used. A capsular incision was made near the vesicoprostatic junction. The plane between the adenoma and the prostatic capsule was identified and dissected with a combination of cauterization and blunt dissection. The anterior vesical neck was then sectioned, followed by maximum anterior and lateral dissection of the adenoma. Next, the anterior commissure was sectioned until the urethra was reached, defining the apical limit medially. Unlike previously described techniques, the dissection of the prostatic adenoma was through its segmentation (sliced), allowing better access and clear visualization of the apex, with safer dissection of the urethra without injury to the sphincter (Figs.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e and 2).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe lateral adenomas were first removed, with good identification of the posterior vesical neck limits, followed by resection of the apices and, when applicable, the median lobe. Dissection at the end of the posterior vesical neck, with or without a median lobe, allows for secure identification of the posterior adenoma, preventing residual benign tissue from being left behind. After complete removal of the adenoma, we reviewed hemostasis, suturing if necessary, at points of greater bleeding, with 3\u0026thinsp;\u0026minus;\u0026thinsp;0 Caprofyl. A 360-degree colo-urethral anastomosis was then performed, using the shooting technique with two 3\u0026thinsp;\u0026minus;\u0026thinsp;0 V-lok sutures, following a modified van Velthoven technique (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e3\u003c/span\u003e), and a 20 fr Foley ureteral catheter was placed. Finally, the anterior prostatic capsule was hemostatically sutured to the anterior bladder wall. The fragments of the specimen were then placed in the endocath and removed through the small umbilical incision. In cases of associated inguinal hernia, classical dissection and reduction of hernia sacs were performed before the prostatectomy, with mesh placement at the end and peritoneal closure.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003ePostoperatively, patients remained with bladder irrigation, received a light diet as soon as they were fully awake, and were encouraged to ambulate early. Generally, irrigation was stopped after 24 hr and patients were discharged between 24 and 48 hr after surgery.\u003c/p\u003e \u003c/div\u003e"},{"header":"3. Results","content":"\u003cp\u003eWe analyzed 162 medical records, identifying 131 patients with complete data who underwent procedures from January 6, 2018 to June 1, 2023. The mean age of the patients was 69.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4 years, mean prostate volume 144.8\u0026thinsp;\u0026plusmn;\u0026thinsp;47.1 cm\u0026sup3; (90\u0026ndash;478), mean robot time 78.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3 min, and mean blood loss 183.1\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3 mL (50\u0026ndash;560) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Summary of analyzed variables\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eIQR\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e69.1\u0026thinsp;\u0026plusmn;\u0026thinsp;7.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47\u0026ndash;90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e65\u0026ndash;74\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVolume\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e144.8\u0026thinsp;\u0026plusmn;\u0026thinsp;47.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e90\u0026ndash;478\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e118\u0026ndash;160\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative PSA level\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.9\u0026ndash;18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.7\u0026ndash;9.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIPSS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20\u0026ndash;26\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eRobot time, min\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e78.7\u0026thinsp;\u0026plusmn;\u0026thinsp;9.3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e77.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e62\u0026ndash;128\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e72.5\u0026ndash;82\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eHospital stay, days\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e1.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u0026ndash;2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBlood loss, mL\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e183.1\u0026thinsp;\u0026plusmn;\u0026thinsp;93.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e150\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e150\u0026ndash;560\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e120\u0026ndash;220\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eCatheter time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e3.6\u0026thinsp;\u0026plusmn;\u0026thinsp;1.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2\u0026ndash;4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIQR, interquartile range; PSA, prostate-specific antigen; IPSS, International Prostate Symptoms Score\u003c/p\u003e \u003cp\u003eAmong the 131 patients, 26 (19.8%) had an associated inguinal hernia and underwent correction during the same surgical procedure. In total, 24 patients (18%) had previously undergone transurethral resection of the prostate, and 24 (18%) were on antiplatelet or anticoagulant medication. Seven patients had an indwelling catheter before surgery due to urinary retention.\u003c/p\u003e \u003cp\u003eFour patients had International Society of Urologic Pathologists grade 1 prostate adenocarcinoma and underwent subsequent robotic radical prostatectomy. During the evaluated period, postoperative catheterization time significantly decreased from 2018 to 2021 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), from 4.2 days to 2.6 days (Graph 1).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eData are mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD.\u003c/p\u003e \u003cp\u003eWe evaluated patients by prostate volume, IPSS, PSA level, and uroflowmetry before and up to 6 months after surgery. Mean volume decreased from 144.8 to 26.6 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), Mean PSA level decreased from 7.8 to 0.8 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). Mean IPSS decreased from 23.0 to 4.4 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and mean uroflowmetry increased from 6.3 to 22.6 ml/s (p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001).\u003c/p\u003e \u003cp\u003eNo patient experienced worsening erectile function after surgery. All patients showed absence of stress urinary incontinence within 3 months.\u003c/p\u003e \u003cp\u003eTo verify whether the differences between the groups were significant, we used the non-parametric Wilcoxon signed-rank test, considering that the same patient was evaluated at both times in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003e\u0026ndash; Comparison of variables pre-surgery and 6 months\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eY\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eN\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eMedian\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eRange\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eIQR\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eVolume\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e144.8\u0026thinsp;\u0026plusmn;\u0026thinsp;47.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e140\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e90\u0026ndash;478\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e118\u0026ndash;160\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e26.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e5\u0026ndash;42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20\u0026ndash;32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePSA\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e7.8\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6,7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.9\u0026ndash;18.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.7\u0026ndash;9.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e129\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e0.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.2\u0026ndash;2.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.6\u0026ndash;0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eIPSS\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e108\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e23.0\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16\u0026ndash;34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20\u0026ndash;26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e131\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e4.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2\u0026ndash;1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e3\u0026ndash;6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eUroflowmetry\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePre-surgery\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e3.8\u0026ndash;10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e4.925\u0026ndash;7.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e22.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e16.7\u0026ndash;28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e20.22\u0026ndash;24.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIQR, interquartile range; PSA, prostate-specific antigen; IPSS, International Prostate Symptoms Score\u003c/p\u003e \u003cp\u003eThe postoperative complication rate was 2.29%, with no need for surgical reintervention for complications (Dindo-Clavien Grade I). Only three patients presented bladder clots postoperatively, which were resolved by bladder irrigation and clot aspiration via the bladder catheter. No patients required a blood transfusion. We had no cases of urethral or vesicourethral anastomosis strictures requiring intervention. One case required readmission for clinical treatment of an abdominal wall infection. The presence of postoperative incisional hernia was not evaluated.\u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003eThe surgical approach to prostatic hyperplasia has evolved significantly with the use of the robotic platform, and various surgical techniques have been described. Our technique for robotic prostatectomy seems safe and effective for treating BPH.\u003c/p\u003e \u003cp\u003eWe observed significant improvements in prostatic symptoms (preoperative vs postoperative IPSS 23\u0026thinsp;\u0026plusmn;\u0026thinsp;3.6 vs 4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.6, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), urinary flow rate (6.3\u0026thinsp;\u0026plusmn;\u0026thinsp;1.3 vs 22.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001), and prostate volume (144\u0026thinsp;\u0026plusmn;\u0026thinsp;47 vs 26.6\u0026thinsp;\u0026plusmn;\u0026thinsp;7.2, p\u0026thinsp;\u0026lt;\u0026thinsp;0.0001). In addition to the improvements described by Patel et al.[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], we believe that our modification allows for safer access to the prostatic apex and surgical planes. Prostate resection occurs under complete visualization when we dissect the specimen in fragments. This approach reduces sphincter traction and facilitates the identification of the boundaries between the capsule and adenoma, allowing for a more anatomical dissection, with better surgical field, improved hemostasis, less bleeding, and better preservation of the bladder neck. Furthermore, even without suturing the prostatic capsule, we found less blood loss than described by other groups [7,11].\u003c/p\u003e \u003cp\u003eThe reduction in catheter time was possible in that we observed good surgical outcomes with very low complication rates. Initially, in selected cases, we began to gradually reduce catheter time while maintaining good results. Today, a good proportion of patients are discharged within 48 hr without an indwelling bladder catheter. Younger patients, with good bladder capacity, good quality of vesicourethral anastomosis, and no postoperative complications are candidates for early catheter removal. Conversely, older patients, on antiplatelet or anticoagulant medications, with previous urinary retention or prior transurethral resection of the prostate, probably have longer catheterization time. In our study, earlier postoperative catheter removal did not affect surgical outcomes or increase the number of complications.\u003c/p\u003e \u003cp\u003eNo prospective randomized study has compared RALSP with other techniques. However, a recent review by Kordan et al.[\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e] demonstrated that the technique can indeed be considered a minimally invasive surgery for prostates\u0026thinsp;\u0026gt;\u0026thinsp;80 g, showing functional results for IPSS, post-void residual urine, Qmax, and quality of life as well as complication rates, blood loss, and hospitalization time as compared with other techniques such as thulium laser vapoenucleation of the prostate \u003cb\u003e(\u003c/b\u003eThuLEP) and HoLEP.\u003c/p\u003e \u003cp\u003eIn a recent meta-analysis[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e], RALSP was associated with longer hospital stay and catheterization time and higher TR as compared with laser endoscopic enucleation of the prostate. However, when comparing the results from our study, hospitalization times were similar for RALSP and other techniques (hospital stay 1.6 vs 1.71 days). The same study[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e] demonstrated superiority for ThuLEP versus RALSP in terms of surgical time. This superiority was not demonstrated when considering the mean surgical time of our case series (78.7 vs 85 min).\u003c/p\u003e \u003cp\u003eIn the meta-analysis of Pandolfo et al.[\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e], the catheterization time was significantly shorter in patients undergoing HoLEP and ThuLEP than other patients. However, as compared with the second phase of our study, showing decreased catheterization time, catheterization time was shorter for patients undergoing RALSP than those undergoing laser enucleation (2.6 vs 3.54 days). Given these comparisons, RALSP may be superior to other techniques for hospitalization, catheterization, and surgical time.\u003c/p\u003e \u003cp\u003eA potential disadvantage of our technique could be the difficulty in resecting the intravesical component of a larger median lobe. For less experienced surgeons, the lower prostatic exposure due to the subcapsular, extravesical approach might hinder the identification of the intravesical median lobe.\u003c/p\u003e \u003cp\u003eThe limitations of this study include its retrospective design and the reliance on results from a single surgeon. However, the number of cases reviewed, the reproducibility of the surgical technique, and the uniformity of the identified data greatly favor the method's applicability.\u003c/p\u003e \u003cp\u003eWe believe that access to the robotic platform is increasingly feasible for most urologists, and by providing updated information on the clinical outcomes of robotic adenectomy, we hope to contribute to clinical decision-making and assist colleagues in choosing the best surgical approach for their patients with BHP.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other support were received during the preparation of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Sandro Mendon\u0026ccedil;a de Faria, Mauricio Dener Cordeiro and Celene Benediti Bragion. The first draft of the manuscript was written by Celene Benediti Bragion and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was waived by the local Ethics Committee of Vera Cruz Hospital and\u0026nbsp;Albert Einstein Israelite Hospital\u0026nbsp;in view of the retrospective nature of the study and all the procedures being performed were part of the routine care\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e- Berry SJ, Coffey DS, Walsh PC, Ewing LL. The development of human benign prostatic hyperplasia with age. J Urol. 1984;132(3):474\u0026ndash;9. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/s0022-5347(17)49698-4\u003c/span\u003e\u003cspan address=\"10.1016/s0022-5347(17)49698-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Vince R, Hampton LJ, Vartolomei MD, Shariat SF, Porpiglia F, Autorino R. Robotic assisted simple prostatectomy: recent advances. Curr Opin Urol. 2018;28(3):309\u0026ndash;314. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/MOU.0000000000000499\u003c/span\u003e\u003cspan address=\"10.1097/MOU.0000000000000499\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- EAU Guidelines. Edn. presented at the EAU Annual Congress Paris April 2024. ISBN 978-94-92671-23-3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Sandhu JS, Bixler BR, Dahm P, et al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia (BPH): AUA Guideline amendment 2023. J Urol. 2023;\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1097/JU.0000000000003698\u003c/span\u003e\u003cspan address=\"10.1097/JU.0000000000003698\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. https://doi.org/10.1097/JU.0000000000003698\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Tubaro A, de Nunzio C. The current role of open surgery in BPH. EAU-EBU Update Ser. 2006;4:191\u0026ndash;201. Andrea Tubaro, Cosimo de Nunzio, ISSN 1871\u0026ndash;2592, \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1016/j.eeus.2006.07.002\u003c/span\u003e\u003cspan address=\"10.1016/j.eeus.2006.07.002\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Millin, T. The surgery of prostatic obstructions. Ir J Med Sci 22, 185\u0026ndash;189 (1947). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1007/BF02937798\u003c/span\u003e\u003cspan address=\"10.1007/BF02937798\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Sotelo R, et al. Robotic simple prostatectomy. J Urol. 2008;179(2):513\u0026ndash;5. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.juro.2007.09.065\u003c/span\u003e\u003cspan address=\"10.1016/j.juro.2007.09.065\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Lucca I, Shariat SF, Hofbauer SL, Klatte T. Outcomes of minimally invasive simple prostatectomy for benign prostatic hyperplasia: a systematic review and meta-analysis. World J Urol. 2015;33(4):563\u0026ndash;70. Epub 2014 May 31. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s00345-014-1324-3\u003c/span\u003e\u003cspan address=\"10.1007/s00345-014-1324-3\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Pandolfo SD, et al. Robotic assisted simple prostatectomy versus other treatment modalities for large benign prostatic hyperplasia: a systematic review and meta-analysis of over 6500 cases. Prostate Cancer Prostatic Dis. 2023;26(3):495\u0026ndash;510. Epub 2022 Nov 19. PMID: 36402815. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1038/s41391-022-00616-4\u003c/span\u003e\u003cspan address=\"10.1038/s41391-022-00616-4\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Coelho RF, Chauhan S, Sivaraman A, Palmer KJ, Orvieto MA, Rocco B, Coughlin G, Patel VR. Modified technique of robotic-assisted simple prostatectomy: advantages of a vesico-urethral anastomosis. BJU Int. 2012;109(3):426\u0026ndash;33. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1111/j.1464-410X.2011.010401.x\u003c/span\u003e\u003cspan address=\"10.1111/j.1464-410X.2011.010401.x\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e. Epub 2011 Aug 18. PMID: 21851543.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Yuh B, Laungani R, Perlmutter A, Eun D, Peabody JO, Mohler JL, Stricker H, Guru KA. Robot-assisted Millin's retropubic prostatectomy: case series. Can J Urol. 2008;15(3):4101\u0026ndash;5. PMID: 18570717.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Kordan Y, Canda AE, K\u0026ouml;seoğlu E, Balbay D, Laguna MP, de la Rosette J. Robotic-Assisted Simple Prostatectomy: A Systematic Review. J Clin Med. 2020;9(6):1798. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3390/jcm9061798\u003c/span\u003e\u003cspan address=\"10.3390/jcm9061798\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003e- Xia Z, et al. Robotic-Assisted vs. Open Simple Prostatectomy for Large Prostates: A Meta-Analysis. Front Surg. 2021;8:695318. doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fsurg.2021.695318\u003c/span\u003e\u003cspan address=\"10.3389/fsurg.2021.695318\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Graph","content":"\u003cp\u003eGraph 1 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Benign prostatic hyperplasia, Robotic surgery, simple prostatectomy, outcome.","lastPublishedDoi":"10.21203/rs.3.rs-4947299/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4947299/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBenign prostatic hyperplasia (BPH) affects up to 80% of men by age 80, with large-gland BPH often treated by simple prostatectomy (SP). This technique significantly improves symptoms but is associated with high rates of complications such as transfusions and infections. Minimally invasive techniques, including robotic-assisted laparoscopic simple suprapubic prostatectomy (RALSP), have emerged as alternatives.\u003c/p\u003e\n\u003cp\u003eThis study reports on 162 patients who underwent RALSP from May 2018 to June 2023. The mean age of the patients was 69 years, mean prostate volume 144.8 cm³, mean robot time 78.7 min, and mean blood loss 183.1mL. Results demonstrated significant improvements in the results: prostate volume (mean decrease from 144.8 to 26.6 cm³), mean PSA level decreased from 7.8 to 0.8 (p \u0026lt; 0.0001), mean IPSS decreased from 23.0 to 4.4 (p \u0026lt; 0.0001), and mean uroflowmetry increased from 6.3 to 22.6 ml/s (p \u0026lt; 0.0001).\u003c/p\u003e\n\u003cp\u003eNo patient experienced worsening erectile function after surgery. All patients showed absence of stress urinary incontinence within 3 months. Catheterization time decreased from 4.2 to 2.6 days over the study period. The postoperative complication rate was 2.29%, with no need for surgical reintervention for complications.\u003c/p\u003e\n\u003cp\u003eWhile RALSP showed promising results, further prospective studies are needed to compare it with other techniques. This study highlights RALSP as a viable minimally invasive option for treating large-volume BPH, offering reduced recovery times and fewer complications.\u003c/p\u003e","manuscriptTitle":"Modified Robotic Simple Prostatectomy Technique: A Retrospective Analysis of a Series of 162 Surgeries Performed by a High-volume Surgeon","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-10-15 05:36:46","doi":"10.21203/rs.3.rs-4947299/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2024-10-05T20:02:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2024-08-21T23:32:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2024-08-21T10:38:06+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2024-08-20T20:38:26+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"34b70569-8342-4c6b-a72a-0938c239c33f","owner":[],"postedDate":"October 15th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2024-10-21T16:09:16+00:00","versionOfRecord":{"articleIdentity":"rs-4947299","link":"https://doi.org/10.1007/s11701-024-02129-9","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2024-10-18 15:58:16","publishedOnDateReadable":"October 18th, 2024"},"versionCreatedAt":"2024-10-15 05:36:46","video":"","vorDoi":"10.1007/s11701-024-02129-9","vorDoiUrl":"https://doi.org/10.1007/s11701-024-02129-9","workflowStages":[]},"version":"v1","identity":"rs-4947299","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4947299","identity":"rs-4947299","version":["v1"]},"buildId":"zQwnuV7TCBrMSSSToR1PI","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}