Extraperitoneal extravesical robot-assisted simple prostatectomy (EE-RASP) with intraprostatic urethral reconstruction

Objective: To describe a safe and effective robot-assisted surgical technique performing prostate enucleation through extraperitoneal and extravesical approach with reconstruction of the prostatic urethra. Patients: We reviewed the first 17 patients with a minimum follow up of one year who underwent extraperitoneal extravesical robot-assisted simple prostatectomy (EE-RASP) with intraprostatic urethral reconstruction between July 2019 and March 2020. Surgical procedure: : The bladder neck and proximal prostatic urethra are dissected bluntly remaining extravesical. After transection of the proximal prostatic urethra and enucleation, continuous anastomosis of the proximal with the spared distal prostatic urethra was performed thereby excluding the prostatic cavity. Our video shows all surgical key steps in a patient suffering from benign bladder outlet obstruction undergoing EE-RASP. Results: Seventeen patients who received EE-RASP were eligible for analysis. The median operative time was 173 min (interquartile range [IQR] 165–186) with blood loss of 200 ml (IQR 150–300). The transurethral catheter was removed on the first postoperative day. During 30 days follow up, one patient experienced Clavien-Dindo grade I and four patients grade II complications. The median peak urinary flow rate and post void residual volume at the 1-year follow up were 21 ml/s (IQR 16–26) and 0 ml (IQR 0–40), respectively. All patients remained continent and had significant improvement in IPSS, maximum urinary flow rate, and post void residual volume (p<0.001). Conclusions: Extraperitoneal extravesical robot-assisted simple prostatectomy with intraprostatic urethral reconstruction is a safe procedure providing improved functional outcome. The reconstruction of the prostatic urethra excludes the prostatic cavity and therefore reduces the postoperative risk of bleeding complications and early irritative symptoms.