NYU Langone Health Urology Case of the Month October 2020Surgical
Management of the “Large” Prostate: The Robotic Simple
Prostatectomy
Department of Urology Case of the Month
CASE PRESENTATION 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-alpha
reductase inhibitor. He stopped taking the 5-alpha reductase
inhibitor 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 PSA,
resulting in 2 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 grams and a sizable median lobe.
Figure 1. MRI showing BPH, done before last prostate needle biopsy
about 2 years prior to presentation. The prostate weight was 193
grams. There is thickening of the bladder wall.
The patient’s past medical history was notable only for Parkinson’s
disease, which was mild and well controlled with medication. His
past surgical history included appendectomy at age 16.
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PHYSICAL EXAM 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 exam revealed normal tone and
an enlarged but smooth prostate. Abdominal exam 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.
IDC Void
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 via a transvesical approach. An excellent enucleation
plane was developed and the prostatic adenoma was removed in 2
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.
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.
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Figure 4b. Intraoperative photos showing: (Left) 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 fo 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.
Figure 3. Port placement of the transvesical robotic (da Vinci Xi)
simple prostatectomy. Two assistant ports allowed for retraction
and suction to be performed simultaneously.
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/sec, a maximum flow rate
of 32 mL/sec, and an average flow rate of 20 mL/sec, 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
Figure 4a. Gross pathology of suprapubic prostatectomy specimen,
microscopic examination (not shown) consistent with BPH .
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CASE OF THE MONTH
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 (i.e., 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
considered to be 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 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 et al.
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 short-term 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.
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.
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REFERENCES 1. Groves HK, Chang D, Palazzi K, Cohen S, JK Parsons.
The incidence of acute urinary retention secondary to BPH is
increasing
among California men. Prostate Cancer Prostatic Dis.
2013;(16):260-265
2. Filson CP, Wei JT, and Hollingsworth JM. Trends in medical
management of men with lower urinary tract symptoms suggestive of
benign prostatic hyperplasia. Urology. 2013;82(6):1386-1392.
3. McVary KT, Roehrborn CG, Avins AL, Barry MJ, Bruskewitz RC,
Donnell RF, Foster HE Jr, Gonzalez CM, Kaplan SA, Penson DF,
Ulchaker JC, Wei JT. Update on AUA guideline on the management of
benign prostatic hyperplasia. J Urol. 2011;185(5):1793-1803.
4. Meyer D, Weprin S, Zukovski EB, Porpiglia F, Hampton LJ,
Autorino R. Rationale for robotic-assisted simple prostatectomy for
benign prostatic obstruction. Eur Urol Focus.
2018;4(5):643-647.
5. 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(7):770-776.
6. Robert G, Cornu JN, Fourmarier M, Saussine C, Descazeaud A,
Azzouzi AR, Vicaut E, Lukacs B. Multicentre prospective evaluation
of the learning curve of holmium laser enucleation of the prostate
(HoLEP). BJU Int. 2016;117(3):495-499.
7. Sotelo R, Clavijo R, Carmona O, Garcia A, Banda E, Miranda M,
Fagin R. Robotic simple prostatectomy. J Urol.
2008;179:513-515.
8. Johnson B, Sorokin I, Singla N, Roehrborn C, Gahan JC. J
Endourol. 2018;32(9):865-870.
BENJAMIN M. BRUCKER, MD Benjamin M. Brucker, MD, is associate
professor of urology and of obstetrics and gynecology at NYU
Grossman School of Medicine. He is director of Female Pelvic
Medicine and Reconstructive Surgery (FPMRS) and of Neurourology at
NYU Langone Health and program director of the FPMRS Fellowship. He
is board- certified in urology and female pelvic medicine and
reconstructive surgery. Dr. Brucker completed medical school at the
University of Pennsylvania. He remained at the hospital of the
University of Pennsylvania and completed his residency. He has been
at NYU Langone Health since 2010. He has expertise in robotic
surgery, pelvic organ prolapse, bladder dysfunction, incontinence
benign prostate surgery and neurourology.
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646-825-6387
[email protected]
Benjamin Brucker, MD Female Pelvic Medicine and Reconstructive
Surgery, Pelvic Organ Prolapse-Vaginal and Robotic Surgery, Voiding
Dysfunction, Male and Female Incontinence, Benign Prostate Surgery,
Neurourology
646-754-2404
[email protected]
646-825-6318
[email protected]
Frederick Gulmi, MD* Robotic and Minimally Invasive Urology, BPH
and Prostatic Diseases, Male and Female Voiding Dysfunction, Kidney
Stone Disease, Lasers in Urologic Surgery, and Male Sexual
Dysfunction
718-630-8600
[email protected]
646-825-6325
[email protected]
William Huang, MD Urologic Oncology (Open and Robotic) – for Kidney
Cancer (Partial and Complex Radical), Urothelial Cancers (Bladder
and Upper Tract), Prostate and Testicular Cancer
646-744-1503
[email protected]
212-263-6420
[email protected]
Herbert Lepor, MD Prostate Cancer: Elevated PSA, 3D MRI/Ultrasound
Co-registration Prostate Biopsy, Focal (Ablation) of Prostate
Cancer, Open Radical Retropubic Prostatectomy
646-825-6327
[email protected]
Stacy Loeb, MD, MSc** Urologic Oncology, Prostate Cancer, Benign
Prostatic Disease, Men’s Health, General Urology 718-261-9100
[email protected]
Danil Makarov, MD, MHS*** Benign Prostatic Hyperplasia, Erectile
Dysfunction, Urinary Tract Infection, Elevated Prostate-specific
Antigen, Testicular Cancer, Bladder Cancer, Prostate Cancer
718-376-1004
[email protected]
646-754-2419
[email protected]
646-825-6348
[email protected]
646-825-6311
[email protected]
646-825-6326
[email protected]
Mark Silva, MD* Kidney stones, PCNL, Kidney Cancer, UPJ
obstruction, Endourology, Robotic Renal Surgery, Ablation of Renal
Tumors
718-630-8600
[email protected]
646-825-6327
[email protected]
Lauren Stewart, MD Female Pelvic Medicine and Reconstructive
Surgery, Pelvic Organ Prolapse, Incontinence in Women, Female
Voiding Dysfunction
646-825-6324
[email protected]
646-825-6321
[email protected]
James Wysock, MD, MS Urologic Oncology – Prostate Cancer,
MRI-Guided Biopsy, Kidney and Prostate Cancer Surgery, Robotic
Urological Cancer Surgery, Prostate Cancer Image-guided Focal
Therapy (Ablation, HIFU), and Testicular Cancer
646-754-2470
[email protected]
Lee Zhao, MD Robotic and Open Reconstructive Surgery for Ureteral
Obstruction, Fistulas, Urinary Diversions, Urethral Strictures,
Peyronie’s Disease, Penile Prosthesis, and Transgender
Surgery
646-754-2419
[email protected]
Philip Zhao, MD Kidney Stone Disease, Upper Tract Urothelial
Carcinoma, Ureteral Stricture Disease, and BPH/Benign Prostate
Disease
646-754-2434
[email protected]
*at NYU Langone Hospital – Brooklyn ** NYU Langone Ambulatory Care
Rego Park ***NYU Langone Levit Medical †222 East 41st street; NYU
Langone Ambulatory Care Bay Ridge, and NYU Langone Levit
Medical
Our renowned urologic specialists have pioneered numerous advances
in the surgical and pharmacological treatment of urologic
disease.
For questions and/or patient referrals, please contact us by phone
or by e-mail.
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