Cop+Ed+fisse 2006 37Archivio Italiano di Urologia e Andrologia 2022; 94, 1 ORIGINAL PAPER No conflict of interest declared. INTRODUCTION Benign prostatic hyperplasia (BPH) represents one of the most common diseases in ageing men, affecting over 210 million men worldwide. Up to 50% of men over 50 years experience lower urinary tract symptoms (LUTS) from BPH, requiring medical or surgical therapy (1). Although medical therapy could provide, in selected patients, satis- fying results, the superior efficacy and cost-effectiveness of surgery have led more patients and physicians to pre- fer the surgical approach (2, 3). In addition, urinary retention, impaired renal function and dilatation of the upper urinary tract secondary to obstruction represents a strong indication toward a surgical approach (4). The European Association of Urology (EAU) guidelines cur- rently recommends, for prostate larger than 80 ml, simple prostatectomy, bipolar or monopolar enucleation or laser enucleation/vaporization of the prostate (5). Before the introduction of minimally invasive techniques, as well as novel endoscopic laser approach, open simple prosta- tectomy (OSP) was considered the gold standard treatment. Despite favorable functional outcomes, which comprehend decreased symptoms score, increased flow and decreased post-void residual, OSP is usually associated with substan- tial peri and postoperative complications (including pro- longed catheterization time, increased estimated blood loss and length of hospital stay), reaching a morbidity rate of 42% and a transfusion rate of 24% (6). In order to overcome those limitations, a variety of minimally invasive surgical techniques have been explored to treat large obstructing prostate adenomas. Since the first laparoscopic simple prosta- tectomy (LSP) described by Mariano et al., the minimally invasive approach for BPH has widely and quickly extend- ed, up to include the robotic approach, the robot-assisted simple prostatectomy (RASP) (7, 8). Minimal invasive simple prostatectomy, including laparoscopic or robot-assisted approach, presents similar efficacy and safety compared to OSP, although data are still lacking and both procedures should be considered as under investigation (9, 10). The aim of our study was to compare peri and postopera- tive outcomes of RASP and LSP in two experienced centers. Purpose: Robotic-assisted simple prostatectomy (RASP) is a novel surgical procedure for the management of obstructive symptoms caused by enlarged prostate glands. Before the introduction of minimally invasive techniques, the standard approach was the open simple prostatectomy (OSP). The aim of our study was to compare intraoperative and perioperative outcomes of robotic (RASP) and laparoscopic (LSP) simple prostatectomy. Methods: We retrospectively analyzed data from patients who underwent minimally invasive simple prostatectomy at the Urological Department of Portogruaro Hospital, Portogruaro, and at the Urological Department of “San Bassiano” Hospital, in Bassano del Grappa, from March 2015 to December 2020. Data collected from medical records included age, body mass index, prostate volume, operative time, preoperative International Prostatic Symptoms Score (IPSS), postoperative IPSS, time with drainage, blood transfusion, intraoperative complications, perioperative complications and length of hospital stay. Results: Robotic-assisted (n = 25) and laparoscopic simple prostatectomy (n = 25) were performed with a transvesical approach. No significant differences were observed regarding baseline characteristics, body mass index, prostate volume and IPSS. Operative time was lower in the laparoscopic group (122 min vs 139 min) (p = 0.024), while hospital stay was lower in the robotic group (4 days vs 6 days) (p = 0.047). Conclusions: Robotic-assisted simple prostatectomy is a safe technique with results comparable to laparoscopic simple prostatectomy, encompassing the advantage of a shorter hospitalization. Considering the costs and the limited availability of robotic-assisted simple prostatectomy, laparoscopic simple prostatectomy is a valid and safe alternative for experienced surgeons. KEY WORDS: Minimally invasive simple prostatectomy; Benign prostatic hyperplasia; Laparoscopy; Robotic-assisted surgery. Submitted 3 February 2022; Accepted 9 February 2022 Minimally invasive simple prostatectomy: Robotic-assisted versus laparoscopy. A comparative study Michele Amenta 1, Francesco Oliva 1, Biagio Barone 2, Alfio Corsaro 1, Davide Arcaniolo 3, Antonio Scarpato 2, Gennaro Mattiello 2, Lorenzo Romano 2, Carmine Sciorio 4, Tommaso Silvestri 5, Giovanni Costa 5, Felice Crocetto 2, Antonio Celia 5 1 Urology Unit, Azienda ULSS n.4 Veneto Orientale, Portogruaro, Italy; 2 Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples, Italy; 3 Department of Woman, Child and General and Specialized Surgery, Urology Unit, University of Campania Luigi Vanvitelli, Naples, Italy; 4 Unit of Urology, ASST Manzoni, Lecco, Italy; 5 Department of Urology, San Bassiano Hospital, Bassano del Grappa, Italy. DOI: 10.4081/aiua.2022.1.37 Summary Archivio Italiano di Urologia e Andrologia 2022; 94, 1 M. Amenta, F. Oliva, B. Barone, et al. 38 METHODS Consecutive patients who underwent minimally invasive prostatectomy from March 2015 to December 2020 at the Urological Department of Portogruaro Hospital, Portogruaro, and Urological Department of “San Bassiano” Hospital, Bassano del Grappa, were retrospectively analyzed. No spe- cific criteria were used to assign patients to either laparo- scopic or robotic procedures. Prostate volume was assessed by transrectal ultrasound (TRUS). All procedures, in both hospitals, were performed by an experienced sur- geon as first operator. Data collected from medical records were age, body mass index, prostate volume, surgical approach, operative time, blood loss, time with drainage, blood transfusions, intraoperative complications, pre and postoperative International Prostate Symptom Score (IPSS) (collected at least 6 months after surgery), perioperative complications and length of hospital stay. No patients underwent prior abdominal/pelvic surgery. Laparoscopic simple prostatectomy After the induction of general anesthesia, the patient was positioned supine and in slight Trendelenburg on the sur- gical table. The procedure was performed via transperi- toneal approach. A skin incision was made at the umbilical level, entering the abdominal cavity using the Hasson tech- nique and inducing the pneumoperitoneum at 20 mmHg. Five trocars were successively positioned, after the inser- tion of a 18 F urinary catheter. A 12-mm Hasson trocar for the insertion of 0° optic was placed at the umbilical inci- sion while another 12 mm trocar was positioned along the right margin of lateral rectus, a finger lower on umbilical line, for the insertion of the Harmonic, monopolar scissors, or needle driver. A 5 mm trocar was positioned on the con- tralateral side (left margin of lateral rectus) for the insertion of a bipolar grasper or needle driver while a 12 mm trocar was placed laterally (8-10 cm from the umbilical trocar) on the right side. Finally, a 5 mm trocar for the suction device was similarly positioned, contralaterally (Figure 1). The fat covering the prostatic capsule was dissected, while bladder and prostate were identified by moving the urinary catheter. A longitudinal incision was performed approxi- mately 1cm below the bladder neck. Stay sutures were placed between the edges of the open bladder to skin on each side. Ureteral ostia were consequently identified while Harmonic was used for the exposure and development of the plane between the surgical prostate capsule and the adenomatous tissue, proceeding, bluntly, towards the pro- static apex. Using the urinary catheter to facilitate the iden- tification of nearby structures, the dissection proceeded until the whole adenomatous tissue has been freed, sepa- rating, carefully, the urethra. After the excision of the ade- noma, the specimen was temporarily placed in the lateral prostatic fossa, waiting for further removal. Trigonization was accomplished by two or four sutures of 2-0 Vycril placed posteriorly to the bladder neck and to the internal posterior prostatic fossa. The urinary bladder catheter was then replaced with a 22F irrigation catheter. Robotic-assisted simple prostatectomy Camera port (12 mm) was placed in a midline supra- umbilical position. A 12-mm assistant port was placed about 3 cm medially to the right iliac crest. On the left- hand side, an 8-mm robotic port, for the fourth arm, was inserted exactly in the corresponding position of the 12- mm assistant port on the right side. Two robotic 8-mm trocars were placed para-rectally on the left- and right- hand sides in a more caudal position, at a distance of about 10 cm from the camera port. Lastly, a 5-mm assis- tant port was placed midway between the camera port and the right robotic port. The procedure was then iden- tical to the laparoscopic one (Figure 2). Statistical analysis Descriptive statistics were reported as median and interquartile range (IQR) for continuous variables, while fre- quencies and percentages were obtained for categorical Figure 1. Trocar configuration for laparoscopic simple prostatectomy. Figure 2. Trocar configuration for robotic-assisted simple prostatectomy. 39Archivio Italiano di Urologia e Andrologia 2022; 94, 1 Minimally invasive simple prostatectomy variables. According to the non-normality of data, assessed via the Kolmogorov-Smirnov test, Mood’s Median Test was utilized, considering, as statistically significant, p < 0.05. Statistical analysis was performed using IBM SPSS Statistics® software (IBM Corp. Released 2017; IBM SPSS Statistics for Windows, Version 25.0. Armonk, NY). RESULTS 50 simple prostatectomies were performed with a minimal- ly invasive approach. 25 were performed as LSP and 25 as RASP. All cases were successfully performed without pro- ceeding to open surgery conversion and no patient reposi- tioning or change in port assignment/redocking was need- ed. Median age of patients involved was 71.5 (58-81) while median BMI was 25 (20-38) kg/m2. Both groups were com- parable in terms of age, BMI, prostate volume and preoper- ative IPSS (Table 1). Regarding operative findings, both groups were comparable in terms of blood loss, transfusion rate and complications, albeit patients who underwent RASP reported a longer operative time (139 min; IQR 108- 225) compared to patients who underwent LSP (122 min; IQR 110-150) (p = 0.024). Overall, median length of hos- pitalization was 5 days, with a slightly shorter hospitaliza- tion in RASP patients (4 days; IQR 3-6) compared to LSP patients (6 days; IQR 4-10) (p = 0.047). Median drainage time was 4 days. All patients had urinary catheter until hos- pital discharge. Five patients needed a transfusion, and four intraoperative complications were recorded. Postoperative IPSS score was comparable in both groups. DISCUSSION Our results suggest that both laparoscopic and robotic prostatectomy can be associated with limited blood loss, short postoperative recovery, and low postoperative com- plications. Compared to OSP, those characteristics repre- sent a clear advantage. OSP is indeed a demanding proce- dure, associated with significant perioperative morbidity, that correlates with prostate volume, and blood loss (6). Minimally invasive approaches as LSP and RASP allow minimizing blood losses due to different factors: the use of cauterizing instruments during the enucleation of the ade- noma from the surgical capsule; the compressive effect of insufflation gas on vessels; the better visualization of bleed- ing points provided by a better view. The increased field of view associated with both techniques permit, indeed, to manage perioperative bleeding and avoid potentially seri- ous complications as urethral injury, ostia injury or improper dissection plane. As result, the utilization of OSP is steadily decreasing, in favor of minimally and endoscop- ic approaches, considering, in particular, comparative results in terms of functional outcomes (11-13). In addi- tion, the use of a minimally invasive approach reduces operative time and length of hospital stay, although its cost-effectiveness is still controversial (14, 15). In our study, we sought to compare operative and functional out- comes of both minimally invasive approaches, LSP and RASP. Despite both techniques could be performed via transperitoneal or extraperitoneal approach, in order to minimize potential biases and further considering our higher experience with the laparoscopic transperitoneal approach, both procedures were performed as transperi- toneal (16). In addition, we performed in both techniques (LSP and RASP) a transvesical approach. The reason is related, partly to the higher experience with this technique, partly to the possibility of directly visualizing the prostatic adenoma, exploring the bladder and, more importantly, the bladder neck. A possible limitation of this approach, however, is related to the limited visualization of the apex and the potential difficulty in controlling bleeding com- pared to the retropubic (or Millin) technique. The latter permit, indeed, to properly visualize the remnant adenoma and properly expose the prostate, allowing better control of bleeding (17). Despite those differences, however, clinical outcomes are similar (18). Although data are quite explica- tive, a few comments are interesting. As reported by our findings, LSP reported a shorter operative time compared to RASP. This could be related, however, to the time need- ed to dock and prepare the robot, consistently with data reported in the literature (19). Similarly, blood loss and transfusion rates among both approaches were compara- ble, as well as complications rates (20). Finally, the length of hospital stay was slightly favoring RASP and this could be explained by an improved field of view which permit to avoid unnecessary maneuvers on the gastrointestinal tract and, consequently, a faster recovery. Anyway, this difference was quite clinically insignificant and could be also related to differences related to non- medical factors. Lastly, although we did not mainly consider the transurethral approach, it has to be acknowledged that the use of novel and powerful lasers which permit, safely and effectively, the enucleation of large prostatic adenomas, represents an important and feasible alternative to OSP in minor centers which do not have the robotic-assisted sur- gery or enough experience with the laparoscopic approach. In particular, as reported by Schiavina et al., with the same effectiveness in clinical outcomes, Holmium laser enucle- ation of the prostate (HoLEP) yielded significantly lower costs compared to OSP (2174.15€ versus 4064.97€) (21). However, a relative limitation of HoLEP is related to the necessity of performing at least 25-50 cases to achieve a sig- nificant efficacy in this approach (22). We are conscious of several limitations afflicting our study. Firstly, the retrospective nature of our work. Secondly, the Table 1. Baseline and perioperative outcomes. LSP n = 25 RASP n = 25 P Age, years 72 (65–79) 71 (58–81) 0.572 BMI 25,5 (21–30) 25 (20–38) 0.776 Prostate volume, ml 141 (100–210) 135 (94–245) 0.777 Operative time, min 122 (110–150) 139 (108–225) 0.024 Blood loss, ml 150 (100-500) 150 (50-250) 0.753 Preop IPSS 29.5 (23–35) 29 (22–32) 0.777 Postop IPSS 7 (3–9) 3 (2–7.25) 0.396 Drainage time, days 5 (3–7) 5 (2–12) 0.396 Blood transfusion 4 (16%) 1 (4%) 0.346 Intraop complication 2 (8%) 2 (8%) 0.602 Periop complication 2 (8%) 4 (16%) 0,663 Lenght of hospital stay, days 6 (4–10) 4 (3–6) 0.047 Archivio Italiano di Urologia e Andrologia 2022; 94, 1 M. Amenta, F. Oliva, B. Barone, et al. 40 limited sample size, partly explained by the limited use of robotic-assisted surgery for non-oncologic diseases. Thirdly, the lack of a standardized follow-up and the potential dif- ferences in non-medical factors among hospitals. 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Correspondence Michele Amenta, MD michele.amenta@aulss4.veneto.it Francesco Oliva, MD francesco.oliva88@gmail.com Alfio Corsaro, MD alfio.corsaro@aulss4.veneto.it Urology Unit, Azienda ULSS n.4 Veneto Orientale, Portogruaro (Italy) Biagio Barone, MD (Corresponding Author) biagio.barone@unina.it Antonio Scarpato, MD antonioscarpato1992@gmail.com Gennaro Mattiello, MD drmattiellogennaro@gmail.com Lorenzo Romano, MD loryromano@hotmail.it Felice Crocetto, MD felice.crocetto@unina.it Department of Neuroscience, Reproductive Sciences and Dentistry, University of Naples Federico II, Naples (Italy) Davide Arcaniolo, MD davide.arcaniolo@unicampania.it Department of Woman, Child and General and Specialized Surgery, Urology Unit, University of Campania Luigi Vanvitelli, Naples (Italy) Carmine Sciorio, MD Unit of Urology, ASST Manzoni, Lecco (Italy) carmine.sciorio@gmail.com Tommaso Silvestri, MD tommaso.silve@gmail.com Giovanni Costa, MD gioc30@hotmail.it Antonio Celia, MD antoniocelia@virgilio.it Department of Urology, San Bassiano Hospital, Bassano del Grappa (Italy)