Traditionally, large-gland benign prostatic hyperplasia (LGBPH)—defined as gland size > 80 to 100 mL—has been a particularly vexing problem for the practicing urologist. The gold standard surgical approach, open simple prostatectomy (OSP), is associated with significant blood loss and complication rates.¹ Robotic simple prostatectomy (RSP) has been a clinically relevant solution for LGBPH for over 15 years.¹ As techniques have evolved, complication rates and recovery times have improved, and perioperative outcomes of the modern RSP can be considered similar to other minimally invasive prostate procedures.²

The improvement in recovery time may be partially attributed to the use of a complete anastomotic realignment of the bladder neck and urethra. Traditional OSP typically involved only a few “re-trigonizing” sutures to assist the reepithelialization of the urethra, which could only occur by secondary intent.³ However, with the advent of robotic technology—which allows better access to the pelvis and improved visualization—a full anastomosis can now be a routine step in the operation.

First described by Coelho et al in 2012,³ a complete anastomosis allows complete mucosa-to-mucosa apposition. The original description described a retropubic approach, which had been developed from the most popular approach for OSP. However, this technique can prove difficult at times, and a full anastomosis is not always possible. The posterior transvesical approach to RSP provides better visualization of the associated anatomy and better facilitates full anastomosis.⁴

The posterior transvesical approach commonly involves a linear incision in the posterior wall of the bladder, with or without use of stay sutures to keep the bladder open (Figure 1). After extirpation of the adenoma, the urethral stump and the bladder neck mucosa are well visualized (Figure 2). The complete anastomosis is thus easily completed, most commonly with a barbed suture (Figure 3). Once the cystotomy is closed, the prostatic fossa is essentially retroperitonealized, and any bleeding or minor urine leaks are thus contained within the prostatic capsule.

Figure 1. View of prostate adenoma prior to resection, with intravesical median lobe.

Figure 2. Prostatic fossa after resection of adenoma, prior to anastomosis.

Figure 3. Prostatic urethra after complete anastomotic realignment.

Perhaps the most important benefit of a full anastomosis is the reduction in postoperative hematuria. The most significant limiting factor in a patient’s recovery from OSP is postoperative hematuria, which may require continuous bladder irrigation (CBI) for several days. In the era of RSP with complete anastomosis, CBI is rarely required, which makes the hospital stay shorter and potentially allows the procedure to be outpatient.

The improvements in perioperative outcomes have recently drawn multiple comparisons between RSP and transurethral laser therapy for LGBPH, especially holmium laser enucleation of the prostate (HoLEP). For many years, HoLEP has boasted better catheter duration, blood loss, and complication rates when compared to RSP.⁵ However, more recent reports have indicated a closure of the gap in perioperative outcomes. A prospective trial by Fuschi et al (2021) reported similar rates of hemoglobin drop, complications, and operative time between RSP and HoLEP.^2,7 A report by Kim and Byun (2022) indicated similar operative time and resected volume, with a lower rate of early incontinence after RSP.⁶ Most studies continue to indicate shorter catheter duration and hospital stay in the HoLEP group.^2,5,6

Further improvement in perioperative outcomes is expected with the growing popularity of single-port (SP) RSP. The da Vinci SP robot was first Food and Drug Administration approved in 2018 and is not yet as widely available as the da Vinci Xi, a multiport alternative. However, a growing number of centers are utilizing SP for RSP and reporting significant improvements in outcomes. The most commonly described technique avoids pneumoperitoneum by allowing transvesical access and insufflation of the bladder only, and yet still allows for a complete anastomosis. A recent retrospective study showed significant improvements in catheter duration, hospital stay, and opioid use when compared to traditional multiport RSP.⁷

In my experience, the full anastomosis has allowed me to convert RSP to a completely outpatient procedure. In early 2021, I began discharging patients same day, and I have now done over 400 multiport RSPs as outpatient, without a significant increase in complications or readmission rates. The improvements in cost, bed utilization, and patient satisfaction have been remarkable.

RSP has become a widely available, safe, and efficacious treatment for what was historically a very difficult patient. As anyone who does this surgery knows, the patient satisfaction is spectacular and is its own motivation for continued upgrades in technique. The advent of the complete anastomosis has allowed for improvements in perioperative outcomes through reduction in postoperative bleeding and avoidance of CBI. Further innovations such as SP technology will continue to fine-tune the perioperative outcomes. These updates, coupled with advantages in learning curve and incontinence rates, may eventually make this procedure the most desirable option for LGBPH.