Benign prostate hyperplasia (BPH) is a common condition causing progressive lower urinary tract symptoms in aging males. According to current guidelines, patients with symptomatic or complicated BPH unresponsive to medical therapy are candidates for surgery. Giant prostate hyperplasia (GPH) is a rare entity, defined as massive prostate hyperplasia weighing over 500 gr. To date, only 15 cases of GPH have been reported in the literature. To the best of our knowledge, this is the first reported case of robot-assisted simple prostatectomy (RASP) for the management of GPH.
We report a case of a 74-year-old man with 10-years of clean intermittent catheterization for urinary retention that was transferred from another hospital for uncontrolled macroscopic hematuria with clots, acute urinary retention, and a palpable solid mass in suprapubic region at physical examination. Routine laboratory analyses revealed an elevated total prostate-specific antigen (37.4 ng/ml). Preoperative CT-urogram showed an abnormally enlarged prostate measuring 990 cc, occupying the whole pelvic cavity. Trans rectal ultrasound-guided prostate biopsy revealed benign prostatic hyperplasia, associated with acute inflammation. RASP was performed with a transperitoneal trans-vesical approach. A 6-port configuration was adopted, similar to robotic radical prostatectomy, but with all ports shifted cranially to allow better access to the target anatomy. In this video we show the key surgical steps of the procedure. The bladder was incised transversely at the dome using Hot-Shears monopolar curved scissors, without dropping it. The incision was approximately at the upper third of the bladder dome. To allow better exposure, Keith needles were placed full thickness through the bladder wall on both side and were fixed to the abdominal wall to retraction. Ureteric orifices were identified and carefully avoided during the operation. The incision of the adenoma was started in the 6-o'clock position to find the correct plane between the adenoma and the peripheral zone of the gland (surgical capsule). The surgical plane was developed in a circumferential direction on both sides of the giant adenoma. The robotic tenaculum was used to pull on the adenoma cranially during dissection. The incision of prostatic urethra was performed under direct vision, using the Foley as a guide. After hemostasis with bipolar coagulation, a circumferential reapproximating of the bladder neck and the urethral stump was performed using 3-0 V-Loc barbed sutures. The bladder was closed in three layers with 3-0 V-Loc barbed suture. The water test was performed. Bladder was filled with 120 cc to confirm watertight bladder closure.
Total operative time and estimated blood loss were 240 min and 1000 cc, respectively. Continuous bladder irrigation was used for 24 hours. Drain was removed on post-operative day (POD) 1. Patient was discharged home on POD 4 with 3-way catheter in place and draining clear urine. Voiding trial was passed on POD 10.
In conclusion, GPH is a rare clinical entity which can be challenging to manage. In this study, we report a successful robotic management of GPH using a transperitoneal trans-vesical approach with good perioperative outcomes.