65Archivio Italiano di Urologia e Andrologia 2018; 90, 1 CASE REPORT Robotic perineal radical prostatectomy with high prostate volume Volkan Tugcu, Abdulmuttalip Simsek, I • smail Yigitbasi, Mustafa Gürkan Yenice, Selcuk Sahin, Ali I • shsan Tasci Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Department of Urology, Istanbul, Turkey. Background: Minimally invasive techniques are ever improving and are preferred more. Many techniques were developed in radical prostatectomy oper- ations. Robotic radical prostatectomy with the perineal approach is a new technique. Case presentation: A 66-year-old male patient presented because of lower urinary tract symptoms, a PSA value of 5.5 ng/ml was detected, prostate biopsy was performed under tran- srectal ultrasound guide, a Gleason 3+3 adenocarcinoma on 3/12 foci was reported at pathology. Robotic perineal radical prostatectomy (r-PRP) operation was performed in the patient who had a prostate volume of 130 cc with middle lobe and a body mass index of 32 without additional disease. The duration of operation was 140 minutes in total and the duration at the console was 95 minutes, the amount of bleeding was 85 cc and no intraoperative complication was detected. Conclusion: r-PRP is a technique that can be applied safely without prolonging the operation period and without additional morbidity to the patient, preserving the oncologic and function- al outcomes in patients with surgical history and large prostate volume. KEY WORDS: Robotic perineal radical prostatectomy; High prostate volume. Submitted 15 January 2018; 20 January 2018 Summary No conflict of interest declared. (RRP) showed prolonged operation time and hospital- ization (3). Since each technique has its own difficulties and limitations, it is only when the factors of the prostate do not affect the operation and when the comorbidities of the patient are also taken into account, the situation becomes more difficult and the development of new techniques will be inevitable. Robotic perineal radical prostatectomy (r-PRP) was developed and applied by Tugcu et al to 15 patients, indicated that this technique can be safely applied in centers with advanced robotic surgery experience (4). This technique with the perineal approach, is applied to a narrow surgical field without incision of endopelvic fascia and without abdomen involvement. When evaluating the surgical steps, a ques- tion comes to mind whether this technique is applicable to large prostates. In this case report, we aimed to prove that this technique can be safely applied to prostates with a large volume. PRESENTATION OF CASE A 66-year-old male patient presented because of lower urinary tract symptoms, a PSA value of 5.5 ng/ml was detected, prostate biopsy was performed under transrec- tal ultrasound guide and a Gleason 3+3 adenocarcinoma on 3/12 foci was reported at pathology. At multiparametric magnetic resonance imaging (Figure 1a) of the patient, who had a laparotomy history due to ileus (Figure 1b), there was no extraprostatic spread when the PIRADS 3 lesion was detected, Radical-PRP DOI: 10.4081/aiua.2018.1.65 INTRODUCTION AND BACKGROUND Since description of radical prostatectomy technique which has high morbidity and mortality, many methods have been used up to that time and the results have been presented. With the acquisition experience, the morbid- ity and mortality are reduced in parallel with the devel- opment of the technology and these operations can be performed safely in experienced centers with minimally invasive techniques. Despite the introduction of many new methods, some factors of the disease may cause this surgical technique to change, to apply another surgical technique or to give up the surgeon. One of these factors is the size of the prostate and when applied with differ- ent methods, prostate size can affect the duration of operation, amount of bleeding, postoperative urinary incontinence and erectile dysfunction (1). When open radical prostatectomy (ORP) compared to other tech- niques, it has been reported that the amount of bleeding is significantly increased as a negative factor (2). According to the data of the literature, laparoscopic radi- cal prostatectomy (LRP) and robotic radical prostatectomy Figure 1a. Screening middle lobe. Figure 1b. Laparotomy incision due to ileus. Simsek_Stesura Seveso 27/03/18 09:31 Pagina 65 Archivio Italiano di Urologia e Andrologia 2018; 90, 1 V. Tugcu, A. Simsek, I • smail Yigitbasi, M. Gürkan Yenice, S. Sahin, A. I • hsan Tasci 66 operation was performed in the patient who had a prostate volume of 130 cc with middle lobe and a body mass index of 32 without additional disease. The dura- tion of operation was 140 minutes in total and the dura- tion of the console was 95 minutes, the amount of bleed- ing was 85 cc and no intraoperative complication was detected. The drainage catheter and urethral catheter of the patient with no postoperative complication were removed on 2nd and 7th postoperative day, respectively, and the patient was discharged the same day of catheter removal.The pathology score was Gleason 3 + 3 adeno- carcinoma and the surgical margin was negative. Surgical technique The patient is taken to the exaggerated lithotomy position with 15 degrees of Trendelenburg. A urethral catheter is placed and the bladder is emptied. A sterile glove is placed in the rectum and the sides of the glove are stitched to the perineal skin. Thus, we aim to avoid rectum damage by using digital rectal examination during perineal dissec- tions. A 6 cm semilunar incision is bilaterally made between tubercula ischiadica. The perineal dissection is terminated when the dissection margin reaches to the membranous urethra and the apex of the prostate is seen. Subcutaneous tissue laying under the incision borders is dissected deeply over the superficial perineal fascia to place the GelPOINT® (Applied Medical, Rancho Santa Margarita, CA, USA). Once the robotic system is docked (Figure 2), dissection is started from prostate apex and extended in to the lateral sides of the prostate and then deepened inferiorly to reveal the Denonvilliers’ fascia cov- ering the seminal vesicle compartment. Once the Denonvilliers’ fascia is incised, vasa deferentes are bilater- ally revealed, dissected and cut. Seminal vesicles are com- pletely dissected and revealed. Then the membranous ure- thra is dissected and cut. The lateral prostatic pedicles are dissected and controlled using Hem-o-Lock® clips. After completing the lateral dissections of prostate bilaterally, the bladder neck is identified and incised with monopolar scissors, sparing and leaving intact the dorsal vein com- plex. Dissection was extended towards the bladder neck. Anterior bladder neck was incised using monopolar scis- sors. After dissection the bladder neck, the middle lobe of the prostate was observed and a vicryl suture was placed for traction of the middle lobe of the prostate (Figure 3a). With proper resection margin, posterior border of the bladder neck was cut and prostate fully dissected from the bladder (Figure 3b). Two of 4/0 V-Loc™ (Covidien, Mansfield, MA, USA) sutures are used in a run- ning fashion starting from the Retzius side to rectal side of the bladder neck. The first suture is started at 12 o'clock on the bladder neck from outside to inside and then continued the urethra from inside to outside clockwise down to 6 o’clock. A second barbed suture is used in the same setting but in reverse clockwise. Once the anastomosis is com- pleted a 22 Ch urethral catheter is replaced. The bladder is filled by 200 cc saline to test the anastomosis for leak- age. After observing the anastomosis is water tight, robot- ic system is undocked and a Jackson Pratt drain is placed. Specimen was sent to the pathology laboratory for exami- nation (Figure 4). DISCUSSION Today, despite the large prostate volumes, in the experi- enced centers, radical prostatectomy has been success- fully applied with many techniques. When we look at risk factors for prostate cancer, obesity and hypertension are at the forefront, therefore radical prostatectomy for large prostate volumes often is accom- panied by obesity, hypertension and other comorbid fac- tors. Consequently it is necessary to cope with the addi- tional comorbidities and the negative factors related to previous abdominal surgery. Sarle et al. reported that with retropubic approach the posterior border of the prostate base is very difficult to view, especially in patients with large median lobes, ureteral orifices are almost impossible to view and the risk of injury is high, especially in the antegrade approach, and seminal vesicle dissection prolonged the duration of the operation (5). Despite the narrow surgical field with perineal approach, in our technique, large prostate was easily dissected with appropriate surgical margins on the apex, base and later- al planes, even if a large median lobe was present. Approaching the posterior borders of the prostate from the inferior side allows to safely dissect them by using used strap vicryl suture without affecting the operation time with the ureters protected by direct vision. Figure 2. Docking of the robotic system. Figure 3a. Strap vicryl suture. Figure 3b. Dissection from the bladder neck. Figure 4. Specimen. Simsek_Stesura Seveso 27/03/18 09:31 Pagina 66 When large prostates are dissected from the bladder, large defects may form in the bladder neck and require addi- tional reconstructive intervention to anastomose bladder neck to the urethra and can adversely affect continence (6). Eden et al. have proposed 60 cc as the highest prostate volume for open perineal radical prostatectomy (7). Regardless of how large the prostate, in our technique the anterior and posterior borders of the bladder can be easily visualized from perineal approach and the prostate can be easily dissected without creating large defects in the bladder neck. Our technique allows to visualize the trigone and bilat- erally the ureteral orifices. In patients who have large prostate, orifices can be protected by direct vision and bladder neck resection can be safely performed. At the same time, the endopelvic fascia is completely preserved, the bladder neck defect is optimal for anasto- mosis and is not dissected from the surrounding tissues. All these advantages facilitate radical prostatectomy of large prostates in order to preserve the anatomic struc- ture at the maximum extent and contribute to function- al outcomes. This technique is safely applied to large prostates with maximum respect for anatomy with its advantages. CONCLUSION Robotic-PRP is a technique that can be applied safely without prolonging the operation period and without additional morbidity to the patient, preserving the onco- logic and functional outcomes in patients with previous surgical history and large prostate volume. REFERENCES 1. Smith JA Jr, Chan RC, Chang SS, Herrell SD, et al. A compari- son of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retrop- ubic radical prostatectomy. J Urol. 2007; 178:2385-2389. 2. Hsu EI, Hong EK, Lepor H. Influence of body weight and prostate volume on intraoperative, perioperative, and postoperative outcomes after radical retropubic prostatectomy. Urology. 2003; 61:60-1. 3. Link BA, Nelson R, Josephson DY, et al. The impact of prostate gland weight in robot assisted laparoscopic radical prostatectomy. J Urol. 2008; 180:928. 4. Tugcu V. Akca O, Simsek A, Yigitbasi I, et al. Robot-assisted rad- ical perineal prostatectomy: first experience of 15 cases. Turk J Urol, 2017; 43:476-83. 5. Sarle R, Tewari A, Hemal AK, Menon M, Robotic-assisted anatomic radical prostatectomy: technical difficulties due to a large median lobe. Urol Int. 2005; 74:92-94. 6. Zorn KC, Orvieto MA, Mikhail AA, et al. Effect of prostate weight on operative and postoperative outcomes of robotic-assisted laparo- scopic prostatectomy. Urology. 2007; 69:300-305. 7. Eden CG. Minimal access radical prostatectomy: how is it shap- ing up? BJU Int. 2008; 101:791-792. 67Archivio Italiano di Urologia e Andrologia 2018; 90, 1 Robotic perineal radical prostatectomy Correspondence Volkan Tugcu, MD Abdulmuttalip Simsek, MD (Corresponding Author) simsek76@yahoo.com I • smail Yigitbasi, MD Mustafa Gürkan Yenice, MD Selcuk Sahin, MD Ali I • hsan Tasci, MD Bakirkoy Dr. Sadi Konuk Research and Training Hospital, Department of Urology Zuhuratbaba, Tevfik Saglam Cad. NO:11, Bakirkoy, Istanbul, Turkey Simsek_Stesura Seveso 27/03/18 09:31 Pagina 67