[92] Be innovative; make your incision smaller, robot-assisted transvesical prostatectomy for a very large prostate

Objective: To demonstrate robot-assisted transvesical prostatectomy for a very large prostate. The management of benign prostatic hyperplasia (BPH) has developed quickly in the last few years. Modern minimally invasive surgical methods are continuously gaining a fixed status in the therapy. The transurethral approach is currently the ‘gold standard’, but what can we do with a very large prostate? Does robot-assisted surgery play, as a minimally invasive method, any role in the treatment of BPH? Methods: An 80-year-old man with severe lower urinary tract symptoms without relevant comorbidities. His International Prostate Symptom Score (IPSS) was 21, quality of life score was 4, and his prostate-specific antigen level was 4.8 ng/mL. Transrectal ultrasonography showed a very large prostate (volume 240 mL). The residual urine volume was ∼200 mL. He had no previous abdominal surgery and the preoperative cystoscopy showed no abnormalities. Results: We performed a robot-assisted transvesical prostatectomy. We used zero optic and three robotic arms. The patient was in Trendelenburg position. The operation duration was 88 min, without significant blood loss. We used a morcellator to aid the removal of the prostate and avoid a big incision to extract the specimen. Irrigation was only required for the first 24 h after the operation. The patient was discharged on the fourth postoperative day. The transurethral catheter was removed on the sixth postoperative day and voiding was excellent. Conclusion: The management of a very large prostate remains very difficult. The robot-assisted technology allows us to perform this difficult operation in a minimally invasive way and without significant blood loss. Despite the size of the prostate, we did not need to make a big incision for extraction and the operation could be performed without any complications. Try always to be innovative and think about using some gynaecological instruments to be more minimally invasive