Surgeons: David Lee and Burak Turna

Moderators: Jeffrey Gahan, Daniel Sagalovich and Vito Pansadoro


Dr. David Lee is currently Chief of Urology at Penn Presbyterian Medical Center and an associate professor of surgery and urology at the Perelman School of Medicine at the University of Pennsylvania.

Dr. Lee graduated as part of the Alpha Omega Alpha Honor Society from Loma Linda University School of Medicine.  After completing his urology residency at Thomas Jefferson University Hospital, Dr. Lee completed an endourology fellowship with Dr. Ralph Clayman and Dr. Tom Ahlering at UCI Medical Center where he was part of one of the pioneering experiences of robotic surgery.  In his initial practice in Texas, he established the first major robot prostatectomy program in the south central United States.  He was then recruited to Penn to build a robotic program where he routinely performs more than 400 robotic cases per year and has completed more than 6000 robotic cases overall. 

Dr. Lee has published over 200 articles, abstracts and book chapters in the field of minimally invasive urologic surgery.  He is the director of the Penn robotic urologic surgery fellowship, Surgeon Champion for NSQIP, CLP for the Cancer Committee and member of the Abramson Cancer Center.  He has been recognized in Best Doctors in America, Castle Connelly Top Doctors and Top Docs in Philadelphia Magazine.

 

Webinar Transcript

Dr. Chandru Sundaram:

Hello, I'm Chandru Sundaram, welcoming you on behalf of Dr. Adrian Joyce, the Endourological Society and the Society of Urologic Robotic Surgeons to this webinar on robotic surgery. Please join us every two weeks on Friday, same time until the end of the year for exceptional technique-based webinars on various robotic surgeries. Today we have very experienced surgeons and moderators discussing robotic simple prostatectomies. CME credits will be offered, and we will give you instructions on how to get those credits later on during this webinar. I must acknowledge the generous support of Intuitive Surgical which enables us to make this happen. And I would encourage you to consider joining the Endourologic Society. I am delighted to introduce to you, Professor Jihad Kaouk, past president of the Society of Urologic Robotic Surgeons, who will moderate the rest of the webinar and introduce the surgeons as well as the moderators. Jihad.

Dr. Jihad Kaouk:

Thank you so much, Dr. Sundaram. It's a pleasure to be with all our attendees and our esteemed surgeons and moderators today for another session of the SURS endourology webinar. This is co-edited with my colleague, Chandru Sundaram. We have two very distinguished surgeons today who will share their experience with us on simple prostatectomy, of course, their robotic approach. Dr. Burak Turna is a professor of urology that practices in Izmir and Dr. David Lee is the chief of urology in Penn Presbyterian Medical Center. And they will be both presenting their techniques focusing on differences and nuances. We also have a fantastic group of moderators today. Professor Vito Pansadoro is the director of urology in Rome and for a long time, have been the chief of urology in premier hospitals in Rome, Italy, and Dr. Jeffrey Gahan, who is a urologist experienced in robotic surgery at the UT Southwestern in Texas. And also joining us is Dr. Dan Sagalovich, who is a robotic urologist also practicing in Staten Island, New York, and completed his fellowship with us here at the Cleveland Clinic some time ago.

Dr. Jihad Kaouk:

So, just quick housekeeping points here. We have three 20 minutes sessions. The first is going to be a surgery presentation by Dr. Turna, followed by Dr. David Lee, and the last 20 minutes will be an open discussion between all the moderators. During the surgery presentations, please write your questions or your comments on the Chatbox. Do not use the Q&A because we will be focusing only on the Chatbox to answer your questions throughout this session. As mentioned by Dr. Sundaram, this is a CME credit and you will have the instructions later about it. With that, I would like to invite Dr. Burak Turna to start with the first of the two presentations on robotics simple prostatectomy. Thank you. Dr. Turna.

Dr. Burak Turna:

Thank you very much, Jihad. Thank you for allowing us to share our experience with regards to robotic-assisted simple prostatectomy. And my appreciation goes to Dr. Yakup Kordan and Dr. Ali Riza Kural who supported me during this presentation. And we use Rezum for men who are concerned with regards to their sexual function, who are not fit for general anesthesia and who have an average size of prostate. And we offer HoLEP to men with prostates between 80 to 150 mL. And men who have prostates of greater than 150 mLs or if they have bladder stones or diverticula, we typically offer them robotic simple prostatectomy. So, the first report of robotic-assisted simple prostatectomy was published in 2008 by Sotelo. And with the increasing use of robotic surgery in urology, several teams have explored this option for large prostate glands. Robotic systems are widely distributed and robotic-assisted simple prostatectomy is easy to implement and perform in centers with solid robotic experience.

Dr. Burak Turna:

So in my view, robotic simple prostatectomy presents all the advantages of minimally invasive surgery and it provides shorter learning curve, especially regarding suture techniques and comfortable operating position. And it seems to have no prostate size limit in contradiction with other techniques. So, there was a multi-institutional study where American patients have contributed. And yet when you look at this graph, you can see there is a increasing use of robotic-assisted prostatectomy over time. And I would like to share some of the data with regards to the published literature. And as you can see, for example, here, the average prostate size is usually 150 grams and it goes up to 300 grams. And most operations were done transperitoneally in these cases. The average blood loss was 250 ccs and the average hospital stay was about two to three days. And the complications were minor in most of the cases.

Dr. Burak Turna:

And when you look at the difference between the pre-op and post-op IPSS score, it was quite significant as expected, and the outcome was quite rapid. You could see the rapid response to the treatment in these cases. So when you compare the robotic prostatectomy with open prostatectomy, you can see robotic prostatectomy achieves similar functional outcomes and provides significant advantages such as decreased blood loss, faster catheter removal, and a shorter hospital stay in comparison to open prostatectomy. However, when you look at the comparison of HoLEP, the literature does not provide a clear advantage of robotic prostatectomy. And I think we need more data about that results.

Dr. Burak Turna:

So, when you look at the techniques of robotic-assisted prostatectomy, the most popular approach is transperitoneal approach because of the familiarity of anatomical landmarks, the wider working space and so forth. However, Stolzenburg have described the extraperitoneal approach. So, one can enucleate the adenoma by transvesical approach, however, some surgeons also prefer the transcapsular approach, so called the Millin technique. In addition, there were some added modifications in the literature. For example, Clavijo in 2013 had described the intrafascial simple prostatectomy, which is very similar to a robotic radical prostatectomy.

Dr. Burak Turna:

So, we typically choose large prostate glands for our robotic prostatectomy cancer patients. We would like to rule out the prostate cancer looking at the PSA and the PSA density. Clearly, the anesthetic considerations are important. And it's also advisable to request a prostate MRI in order to understand the prostate anatomy and also to rule out the prostate cancer. So, positioning, ports and instruments. So, this is very similar to the typical robotic radical prostatectomy. The patient is placed in the low lithotomy position on the steep Trendelenburg. And we typically put the port configuration very similar to radical prostatectomy, and we use similar instrumentation.

Dr. Burak Turna:

So, the operative steps of a transperitoneal robotic simple prostatectomy is as follows. So, first we release the adhesions, then we drop the bladder, establish the space of Retzius, clear off the paravesical fat and identify the cystotomy site. Then we do either a vertical or a transverse cystotomy incision. Identification of the ureteral orifices are very important. Then we start with the posterior plan dissection, then extend the dissection laterally, then anteriorly. Identify the apex. Enucleation of the adenoma is followed. So you can see the MRI of this patient. You can see it's quite a big prostate, it's around 200 grams. And we use a transperitoneal approach in this case.

Dr. Burak Turna:

The first step is after grasping the [inaudible 00:10:29], we drop the bladder. You can see it here. So the first anatomical landmark is the symphysis pubis. Then when we see the symphysis pubis... This particular patient had a inguinal hernia, so clearly, we dissect the peritoneum and then open the space as wide as possible in the pelvis. We take care of the smaller bleeders, and then we fill the bladder. And then we typically like to do the incision in a longitudinal way, however, one can also use a transverse incision. So we extend the incision towards the bladder neck, as you can see here. We like to use the monopolar scissors on our right hand. And this patient had a big bladder stone, so this was a very good indication for a robotic simple prostatectomy. You can see the large stone here. Then we put the stone in the endobag.

Dr. Burak Turna:

And then we open the bladder. It's very important to identify the ureteral offices. And then once we identify the ureteral offices, we start our dissection on the posterior plane. And then in some large median lobes, as you will do in a radical prostatectomy, we clamp. In this case, once the stay suture is done, you could either give that suture to your assistant or the other option is you could lift it with your fourth arm. And then once you go in the direct plane and see the shiny surface of the prostate, you will follow that correct plan. It's very important to stay on the correct plane, as you can see here, so then you would expect less bleeding. However, if you go on the wrong plane, then there will be more bleeding in these cases. Then you extend your dissection. As you can see here in this case, we are extending our cystotomy incision.

Dr. Burak Turna:

Then the next step is the apical dissection. So this is very critical. You must have a good view here. As you may know, in open prostatectomy, you don't have a very clear view in the apical dissection. So you can see the urethra here. So urethra is usually dissected sharply. It's very important to do that apical dissection carefully. And then once you do that, you have to achieve the hemostasis. I'm sorry about that. And then after you achieve the hemostasis, you have a good view, then you need to make it to that trigonization of the urothelium here, especially on the posterior aspect of the bladder and the ureter. You see here, it's very similar to do the vesicoureteral anastomosis as one will do in a radical prostatectomy. However, we don't do the anterior portion in order to avoid the stricture or the bladder neck contracture.

Dr. Burak Turna:

Once that's complete, then we start closing the bladder after we insert a 22 three-way catheter. As you can see, we typically like to use a 2-0 V-Loc suture. And once that's over, we, of course, test the leak. And when you are sure there is no leak, then you place a drain. Okay. So, some people also prefer not to drop the bladder. So they typically want to go directly to the bladder during a transperitoneal approach. You can see it here. You enter transperitoneally, you lift the bladder, and then at the dome of the bladder, you can make either a transverse or a longitudinal incision, as you can see it here. Of course, the first step is to clear all the fat so that you have a clear understanding of the bladder here. You will see, we open the peritoneum here then we are now clearing the fat in the bladder and then we will incise the bladder. Okay.

Dr. Burak Turna:

So, once the cystotomy incision is made, then we will enter the bladder. You will see. And similarly, we typically use the monopolar scissors on our right hand and on the left hand, different instruments. We may use a bipolar, of course. Okay now, we enter the bladder. And this incision was a transverse incision. And then you need to have enough opening in the... Understanding of the prostate and the urethra offices. Okay. Now, the incision is extended, and then you can see the catheter here. Quite enlarged median lobe, as you can see from here. So, some people, after doing this incision, prefer to use a Keith needle in order to keep the opening. We typically don't use that. Now, I will show you the right and the left ureteric offices. And then we lift the median lobe and then the posterior dissection started in a similar fashion like the previous video.

Dr. Burak Turna:

So, the other alternative is the extraperitoneal approach. I know most people like to do the transperitoneal approach, but in some patients, extraperitoneal approach could be an advantage, such as patients with scars in their abdomen or in some patients where you can't give an extended Trendelenburg position. As you may know, in the extraperitoneal approach, usually 10 to 15 degrees of Trendelenburg is sufficient whereas in the transperitoneal approach, you typically need at least 30 degree. So, with regards to steps, the first step is development of the extraperitoneal space. This may require some learning curve. And then trocar placement follows, then afterwards, you don't see the bowel, then you do your cystotomy incision. It could be, again, vertical or transverse. Then enucleation of the adenoma, then hemostasis and then specimen retrieval.

Dr. Burak Turna:

So, I will show a little video clip again with regards to extraperitoneal approach. So, again, we start with clearing of the fat in order to understand the anatomy, the relationship of the prostate. But you can't see it here. And then afterwards, the bladder is filled again. I typically like to use 150 mLs of saline. And then once you do that, I like to do the incision about two to three centimeters close to the vesical junction. And then the catheter is lifted up with the fourth arm. And as you can see, the mucosal incision is done circumferentially. At the anterior part, as you may know, there is less tissue, so one has to be careful. And again, you can see it here, once the correct plane is entered, you can see the shiny surface of the prostatic adenoma. And then you can follow an extended incision laterally. This is the lateral extension, as you can see. And you can do that extension on a sharp and in a blunt basis.

Dr. Burak Turna:

And if there is a bit of bleeding, you can use your bipolar to stop the little bleeders. And then once the posterior and lateral aspect is done, then now we focus on the anterior aspect. So anterior aspect, you need more clear vision, typically less tissue is encountered there. And then these are the final attachments of the prostatic adenoma, as you can see here. And then the final step, you can see the urethra here. It's important to see the urethra at the apex. And then one of the important things is, if possible, to see the verumontanum. So, the verumontanum has to stay with the patient. So, that's a tip. So, verumontanum has to stay with the patient and then the adenoma is removed. There will be always a bit of bleeding. So, with regards to that bleeding, you can use some bipolar, you can use 4-0 Vicryl in order to achieve good hemostasis.

Dr. Burak Turna:

Then once that is achieved, we then focus on the reconstruction of the bladder neck and also the reconstruction of the prostatic capsular. So here, we haven't done the trigonization. This depends on the surgeon's discretion. Some prefer to do the trigonization and some don't. And in my opinion, there isn't much difference. You can see the catheter, again, is a 22 French three-way. And then the next step is the bladder neck, cystotomy closure. So I quite like to use a two-layer closure, but some people like to do a one-layer closure with the V-Loc. Once the closure is complete, it's important to do, definitely, a leak test to make sure it's a watertight closure. And once that's done, definitely, a drain is left in place. Okay.

Dr. Burak Turna:

So, with regards to postoperative course, in most cases, a bladder irrigation overnight is required. Hospital stay is typically two to three days and then the catheter removal is seven days. And antibiotics is required during the course of the catheter period. So, ladies and gentlemen and my dear colleagues, in conclusion, robotic simple prostatectomy is a safe, effective and reproducible minimally invasive treatment for large BPH. And RASP has the advantage of a short learning curve for surgeons with experience in robotics. I, all, thank you very much for your great attention. Thank you.

Dr. Jihad Kaouk:

Thank you so much, Professor Turna. This is fantastic demonstration. My favorite part is showing the verumontanum. That gives a lot of confidence there. Interesting to see that from the poll question during your presentation, the majority of the attendees do open prostate. So, that's great. Let them share with us their opinion on the Chatbox while we listen to the second part of this surgery demonstration by another very elegant surgeon that I've seen him in action many times, Dr. David Lee. Dr. Lee, we're eager to listen to you please.

Dr. David Lee:

Thank you so much, Jihad. Thank you, Chandru and everybody who planned this meeting to allow me the chance to present our work with this approach. So I do mostly prostate cancer. So I've done over 6200 robot prostate cases now. And as I was getting more referrals for this simple prostatectomy for guys with really big prostates, what I wanted to do was develop a technique that was very familiar to me. And obviously, that meant to mirror what I do with robotic radical prostatectomy. And so, that was the goal that we were going after. But then, comparing it to what some of my partners still did with open simple prostatectomy, I thought, "Well, we have all of these advantages during radical prostatectomy for the robotic approach, why not try to develop this technique for BPH?"

Dr. David Lee:

And Dr. Turna, that was a wonderful presentation. It helped me to feel a little bit more comfortable thinking about going through the bladder. But that's not what I typically do, obviously, during a robotic radical. And so I thought, "Well, why don't we try to develop a technique that mirrors the robotic radical approach?" So, we avoid that using those stay sutures, going through the bladder. When I first started doing this, I would leave that defect or that prostate fossa open. And we had a few patients who needed catheters back in and then that was really difficult, required cystoscopy and a lot of patient discomfort. So I thought, "There must be a better way to do this."

Dr. David Lee:

So then this is the technique that we've developed. So I use an anterior transperitoneal approach. We position the patients exactly the same as our robotic radical prostate cases, we use the same port placement. So we try to make everything very user friendly. We drop the bladder as per normal. I take time to defat that bladder as it can help to show that there are lymph nodes that live here and these are important to know as far as for staging purposes. But I think this gives us really good vision on our prostate or vesical junction, which I think is critical to the approach that I use here for even simple prostatectomy. So then we defat the bladder, I try to send this all as one specimen, and then we send that to pathology. Then I make a very limited incision in the endopelvic fascia. This helps me to get a feel for how big the prostate is. Without doing this sometime early on in my experience, I've gotten a little bit fooled as to the contour of the prostate and how deep the prostate would really go, and so this helps me.

Dr. David Lee:

Next, we'll throw a suture on the anterior part of the prostate. This helps to decrease the bleeding from the venous plexus, the run off of the DVC. So again, it gives us really clear vision around the prostatovesical junction as we're doing the rest of that dissection. So I use a running 3-0 V-Loc, just four or five sutures through there, and it really helps to decrease that venous bleeding. So, a very limited endopelvic fascia incision, run that little stitch across the top of the DVC and then go on to the next part of our technique. So, the bladder neck dissection. Again, this is exactly how I do it for a robotic radical prostatectomy. I start in a very lateral place. And so this is demonstrating, again, exactly what I do. I lift the bladder fat off the lateral edges of the bladder, sorry. And then I go straight lateral so that I can get a good feel for where I feel like the lateral edge of my bladder is.

Dr. David Lee:

Then I follow that up towards the prostate. And in guys with really large prostates, it doesn't take very long until you get the feel for where that contour is, of the prostate. And then once I do that on both sides, then I carry that incision straight across the middle. But again, we try to do this in a very bloodless fashion, placing that stitch earlier really helps. But then I'm coming right down on the adenoma. And then I go back and I... For me, this is very critical where I try to get a really good dropping of that lateral aspect of the bladder down. By doing this, it really helps us to keep a small bladder neck. So, very rarely do I ever have to reconstruct the bladder neck, even for a 200 gram prostate, whether it's a simple or a radical prostatectomy.

Dr. David Lee:

And then by taking those lateral bladder edges down, then you see as we enter the bladder here and lift our Foley catheter up, our opening is really small. And so this helps us to avoid bladder neck reconstruction. I don't think it's a big deal if you have to do that, but if you don't have to, then I think that saves a little bit of time. As I start this posterior bladder neck approach, and I'm just going to pause this video here for just a second, we see that that median lobe popped out. And so in order to do this, we have to take down these pillars of the lateral edge of the bladder neck in order to let that median lobe pop up.

Dr. David Lee:

But still, even when we do that, as long as we drop this lateral aspect of the bladder well, this bladder neck stay small. And I think it's because we're really saving this lateral muscle wall of the bladder. If you can save a good thickness of bladder muscle, the bladder neck will tailor down really well at the end and you won't have to reconstruct very often. But then, again, by establishing these lateral bladder planes, then as you thin it out, so to speak, from lateral to medial on both sides, then you come up, again, with a really nice, tailored bladder neck even with a large prostate, and it also gives me a lot of confidence to know that I'm in the right planes here between the bladder and the prostate.

Dr. David Lee:

And this applies, again, for robotic radical prostatectomies, even when somebody's got a significant cancer at the base, by dropping this bladder first, I know that I'm not going to get into the prostate inadvertently. We're using the fourth arm now to lift up on our median lobe. And again, carrying these dissections from lateral to medial really helps us to maintain that nice, small bladder neck. And then we're getting down on to the portion where we need to be to do our adenoma dissection. But again, here, just diagrammatically, I'm lifting that lateral bladder fat off the bladder wall, finding our dissection plane here between the bladder and the prostate and just taking that straight across, then we thin out these lateral bladder wall fibers down, let the bladder neck pop up, and then pull that up with our fourth arm.

Dr. David Lee:

Next, we'll go to our adenoma enucleation. So then, I'm, again, lifting up on the median lobe with my fourth arm. And then, yeah, this is very similar to what Dr. Turna was showing. You have to get right on the proper plane. But then once you do that, you will have a very, relatively speaking, avascular plane that you will not have too much bleeding in. And then by lifting up and then going from side to side, rocking the prostate back and forth, you're able to continue this plane. And I try to take this, again, as far underneath the prostate as I can. But then once you get to a point where it's difficult to reach, then you can pull it to the other side, left side, right side, and then you keep making your way down towards the apex.

Dr. David Lee:

And then the instrument that I'm using here, it's a spatula cautery. I find that this is a really nice tool here, especially when you're getting more distal on the prostate, and it has a nice rounded tip to it, that the energy won't shot out on the tissue that's close by. And then it gives really nice control of your energy while not tearing the tissue. As we approach the anterior portion now and we get closer to the apex, I had some difficulty, again, figuring out how distal that goes. So then as we get more distal, identifying the apex, again, what Dr. Turna was saying, is crucial. So then I split the anterior commissure until we can see the veru. And again, totally agree with Dr. Turna, you have to leave the veru intact with the patient. But then by visualizing that, then it gives me a good feel, again, on how distal to go. I try to leave a little bit of apical tissue just right around the veru.

Dr. David Lee:

If the prostates are very large, say, over 200 grams, then I'll even split the posterior commissure, and then I take each lobe out left and right separately. But then, yeah, just rocking the prostate back and forth, from side to side, maintaining that veru in the middle, I think gives you a lot of safety as to not getting too distal to avoid injuring your neurovascular bundle outside. The prostate goes into a bag and then we'll extract that just the same way as our robotic radicals. But yeah, I think this is a key step. You can see that veru very well. And then we'll try to just shave our way down around the bottom here.

Dr. David Lee:

And then our anastomosis is just the same way that I do for a robotic radical. It's a Quill suture, 2-0, Van Velthoven anastomosis. I started at four and five o'clock on the bladder neck side, and then these first two stitches go into what's left of the prostate just on the right side of the veru. And so both of those sutures will come out there. And then I'll run my back-wall around six o'clock. And you see the catheter coming in and out there. And then I just run it all the way around. I think the advantages of doing this are, your anastomosis is really watertight, just like when you do a robotic radical. I put a stitch into each point along the clock face. So it's the usual 12, 13 stitches that we do. I don't typically leave a drain. Our catheters come out in four days afterwards. We don't have to use CBI. The urine is really nice and clear. And we haven't had any bladder neck contractures that we've seen so far by doing this. So I think there are a lot of advantages.

Dr. David Lee:

So here we see a really nice watertight... We put the bladder catheter in, fill it up, I usually push on that bladder in order to make sure that we're not expressing any fluid. And then I take another V-Loc and just close that top side of the lateral bladder fat to the bladder detrusor on the outside. And then after we're all done, you can barely tell that we've done anything. Again, this is a second layer, so I don't feel like we need to use a drain. And then yeah, I think this is the key, starting your anastomosis here, so the veru is right down at the bottom, getting a nice back-wall here. Once you do that, I feel like you have a really nice approximation. And it's really easy to do.

Dr. David Lee:

So then this is a way of doing a regional block. You take your 22 French butterfly needle with some IV tubing attached to it, and then we inject 10 ccs of Marcaine onto either side, just posterior here to our lateral ports. We can place that needle in so that you're getting just below the transversus abdominis and just above the internal oblique. And so, this reapproximates really well, doing a top block percutaneously that your block team would do. We worked hard with our anesthesiologists to develop a really reliable technique for this. And under ultrasound guidance, we can do exactly the same thing that the anesthesiologists can do. But you can see that it's very quick. It takes about two minutes. I think this really helps us with our ERAS protocol. Since the COVID thing started, we've been sending 60% of the guys home the same day after surgery. And I think the TAP block really helps us doing this along with our other ERAS techniques.

Dr. David Lee:

So again, not all the guys are staying overnight anymore. Standard 18 French Foley catheter, no CBI. The guys are very comfortable. No bladder spasms. We haven't had any changes that guys have noted to us as far as erectile function. 25% of guys have even maintained ejaculation, which I was very surprised about when we started asking guys about this. And yeah, so far, no readmissions, reinterventions and no urine leaks. And I think that's all I have. Thanks, again, so much for your attention. And yeah, happy to continue this discussion.

Dr. Jihad Kaouk:

This was a wonderful, enjoyable to watch, actually, presentation. I would like to highlight the excellent mucosal approximation that you did. I think that is key if you're not going to use CBI. And we share the same experience. And that can lead to less and less duration of Foley catheter post-op. At this point, I will give the podium to our moderators. And we have three esteemed moderators on the panel today: Dr. Pansadoro, Gahan and Sagalovich. Vito, are you there?

Dr. Vito Pansadoro:

Yes, I am here.

Dr. Jihad Kaouk:

We would like to hear your thoughts, so we'll start with you.

Dr. Vito Pansadoro:

I'm very happy to be here. Thank you for the invitation. I must say I was really enjoying the presentations because it is completely different what we do here in Italy. We mainly do the Millin approach. We don't go to the bladder, except if we have a median lobe. In that case, we do the technique that I've seen done by Burak and Dr. Lee, and I agree. But if there is not a median lobe, we prefer a Millin approach. And another question that, in Italy, we try as much as we can to save the urethra. So if we can save the urethra, which is more easily done on a 100 and 110 grams plus adenoma than in a 200 and 220. In that case, I agree with Dr. Lee, the best thing is to do the approximation of the bladder neck to the verumontanum. But in the other case, when we have a small prostate, we like to do the enucleation through the Millin approach with the same technique.

Dr. Vito Pansadoro:

We use a lot of tenaculum forceps, which Intuitive is doing for the gynecologist, because it helps a lot to pull the prostate in different directions and to do enucleation. And the other thing that we do, we use a morcellator, always from the gynecologist, the LiNA morcellator, to extract the adenoma without doing an incision, which also helps a lot. We keep the catheter six days, and the patient goes home in two or three days the same. So, there are no big difference in what I've seen, just the approach, if there is not the median lobe.

Dr. Jihad Kaouk:

These are excellent comments, Professor Pansadoro. And I wish we had more time on this session to show more techniques, like the urethra sparing that you just mentioned. It's really nice, the limitation is that it's only for smaller prostates. There's one other way that we do also is the single port approach, where we don't enter the abdomen at all. We do a suprapubic incision, same as you would put a suprapubic tube and put the single port robot straight into the bladder. And then from there, do the same as you saw today, and we close the mucosa circumferentially. I think approximating the mucosa is the key for getting this Foley catheter clear urine from immediately post-op and may decrease the time to Foley need and hospital stay.

Dr. Daniel Sagalovich:

There was a lot of activity in the chat about the anastomosis. So Jihad, do you think there's a difference between just doing a posterior plate, trigonization, versus a 360 degree reapproximation?

Dr. Jihad Kaouk:

I think the posterior plate is a must. You can't always circumferentially approximate it. If the prostate is very big, you may have a big gap. So you try to go circumferentially, if possible, but the posterior plate is a must.

Dr. David Lee:

Yeah, no, I would agree. I don't think it is absolutely necessary to do the anterior side, but if you can do it, it's what we usually do, so it feels really incomplete to me just to leave that anterior side open, because we're always closing it. But now I've had a couple cases where we were doing prostates that were above 250 and then that anterior surface, especially the bladder, just doesn't want to come down really well. I struggled my way through and got it closed. But yeah, no, I agree. You don't have to do it that way. And then Jihad, your transvesical, percutaneous, single port, you air dock for that then? Because I would think that you don't have that much distance then from the prostate all the way through because of the angle. You must come pretty acutely downward then.

Dr. Jihad Kaouk:

Yes. So, you have your incision just above the pubic bone, same as you would do for a suprapubic catheter insertion. So, the space becomes short, and you need about 12 centimeters to be able to clear the instruments from the canula to spread them. So, we do the air docking. The air docking, for those who are not familiar with it, is to pull the robot out to the level of the skin. And you can do that by having the GelPort unfolded, so you don't fold the plastic and that gives you a nice conduit to work within. I would like to hear from Dr. Gahan about his opinion for these 200 plus prostates Dr. Lee was talking about. What would you do differently?

Dr. Jeffrey Gahan:

I mean, I think I'd take a different approach, obviously. I think we were chatting that. I actually don't drop the bladder. And one of the things that I've tried to do as I've progressed through when we first started doing until now, over hundreds of cases, is continually to reduce steps that I don't think are necessary. And so within the chat, you saw me comment, I actually don't even use stay sutures in the bladder anymore. I've found that making a transverse incision, and if you make it in the right spot, you can actually do most of the surgery without having to put in any stay sutures at all.

Dr. Jeffrey Gahan:

Now, for the very large prostates and maybe some of the bladders that are blown out or very thickened, and sometimes you'll find the anatomy tends to draw the prostate down into the pelvis deeply and then those get very difficult without proper stay sutures, but 90% of the time, 95% of the time, I don't have to use a stay suture, so I'm not wasting time, not that it's wasting time, I don't spend time dropping the bladder, I don't spend time placing stay sutures. I make an incision and begin the dissection right away. And that just continues to reduce our operative time. And so I've continually tried to reduce steps that I find that maybe are somewhat helpful, but overall, I don't think they're necessary. Our approach now is pretty minimalistic, actually. Certainly, we've had more experience, but I don't find that we're struggling anymore by omitting these steps.

Dr. Jihad Kaouk:

Dr. Turna, what would you do differently? Obviously, when you're very experienced, you don't need the retraction sutures, as Dr. Gahan was saying. But for somebody who's starting or when you anticipate you might fall into a bleeder or so, the more exposure, the more comfortable and the more the comfort zone would be.

Dr. Burak Turna:

Yeah, certainly, I agree. I think when you are starting out, it's advisable to use stay sutures, I agree, to keep everything open, a wider space and clear identification of the urethral orifice. I watched a video once, we haven't mentioned about it, sometimes it could be quite tricky to identify the urethral offices when you have that very large middle lobe. So, one can use that small five French feeding tube and put a Weck clip at the tail end, so it's quite cheap, and then you can identify the urethral orifices nicely. I agree, totally.

Dr. Jihad Kaouk:

What's the opinion of the panel here about the urodynamics? Do you do that routinely? Is it important? What's your opinion about that?

Dr. Jeffrey Gahan:

So I'll take it and then... I'm sure there's controversial or different opinions. We actually did in the beginning, on any of these patients who had an indwelling catheter, perhaps perform a CIC. And if they have 120 plus gram prostate, 150, what we found was the vast majority, we're talking greater than 99% of these patients, still void when you take out the catheter. Because the problem is the obstruction. Even if they don't have a true good contraction generated, they still are able to void and empty their bladder. And so we've actually gone almost completely away from it. Now of course, there's rare patients who have a very complicated neurologic history and maybe then we'll do it. But by and large, just because they're catheter-dependent or perform CIC, we almost never do it anymore. It just didn't change our management.

Dr. Daniel Sagalovich:

I think I agree. I don't think it's necessary, rarely changes management, obviously, neurogenic case. I find it really helpful for counseling, especially if you see detrusor overactivity with leakage, that's good for counseling. You're going to tell the patient that, "Listen, you might have some incontinence afterwards, most likely, it's overactivity, should get better." So I think for patient expectations, it's good to do urodynamics.

Dr. Vito Pansadoro:

For us in Italy, in Rome, at least in my group, the urodynamic evaluation is a must. We do it on all the patients. And this is due to two purposes: one, to understand if the patient needs surgery or there is still a place for some medical treatment and the other thing is to know how to handle the patient after the surgery. If you have a patient who has a bladder of 150, 170 cc and is hyperactive, and you know up front this problem, you can speak with the patient before the surgery. And when he's complaining that he's passing urine every half an hour, you know why, and you can calm him down and do the proper treatment. I think it's a very nice tool for two reasons, if the patient needs to have surgery and how to handle afterwards. Of course, can be done without but it's helpful.

Dr. David Lee:

Yeah, I think what we do is... Yeah, anybody with a prostate that's over 100 ccs and then also has obstructive symptoms, I don't really get urodynamics on those guys. If there is more of an overactivity component, then it'll make me think about maybe getting it, but if they're primarily having obstructive symptoms and a prostate that's that big, I think the answer really, like Jeff says, 99% of the time it's going to be obstruction. And then if somebody's got a prostate that's smaller than 100, usually I'll just send them to my voiding dysfunction partners because I think GreenLight's a great option for those guys, bipolar TURP, my partners have had great success with that. It's just that with these really big prostates, I think what we really need to do with these patients is just get all of that tissue out of the way.

Dr. Jihad Kaouk:

David and Jeff, I hear you, and I don't routinely do the urodynamics, but these are really words of wisdom that Vito is mentioning. Because remember, this is still an evolving field. And anytime there's an evolving procedure, the more documentation we put, the more clear it would be to guide us if we're doing the right thing and what we can modify and so on. So, if I can and have the resources and the patient would come in, I would try always to do the urodynamics, but there are ramifications for that.

Dr. Jeffrey Gahan:

So, what I would say is, we still have non invasive urodynamics in every patient, flow rate PVR and AUA score on every patient. And so we do have a significant amount of documentation, and we can show improvements in almost all parameters postoperatively. So we do have that. And what, actually, we're looking at right now is trying to look at our data and try to really tease out, can we determine, for patient counseling purposes, without going to urodynamics, with the AUA symptom score and a combination of the way that the flow rate and PVR look, can we actually predict the patients who aren't going to recover completely from the surgery and still have overactive symptoms? And so we're trying to figure out if we can actually gain that knowledge without going to the urodynamics. But I do agree, it's nice to be able to tell a patient, "Hey, this is most likely where you're going to end up." Because then their expectations are maybe more in line with what's going to actually happen.

Dr. Vito Pansadoro:

I say that by sparing the urethra, Francesco Porpiglia just published that in 83% of the cases, he has an ejaculation and the normal amount of sperm, which makes nice. Of course, some of these patients are not sexually active, but when they are slightly younger, with a small prostate, then you can offer a nice adenomectomy without any loss of ejaculation, which is quite well appreciated.

Dr. Jihad Kaouk:

That's a very good point. We'd like to raise one more topic in the last five minutes here that always come up in such discussions, and that's the comparison to the HoLEP or the THoLEP procedure. So how does this compare between these two procedures? We'd like to hear from the panel and the surgeons, their opinion quickly on the two.

Dr. Jeffrey Gahan:

So we've published on this. We show that the learning curve for robotic simple is quite quick. We showed our learning curve, and that we were granted both in our series, we're experienced robotic surgeons, but we subtract our experience from the beginning to the first 100 cases, and we found our learning curve to be about 10 or 12 cases. HoLEP has never been shown to have anywhere near that kind of quick adoption, the best series I see is probably somewhere around 45 all the way up to 60 or 100 cases.

Dr. Jeffrey Gahan:

And so I think that's one significant advantage to the robotic simple. And if you make a mistake in the robotic simple and you perforate the capsule, for example, which is a big problem in HoLEP, it's a pretty easy fix. You get out of and you got into the right tissue plane, you simply sew it up later on. And so I think there are some significant advantages to the initial implementation of this approach. And the outcomes are probably no different. The patients do exceedingly well. There's just no way you can do much better than how well our patients do postoperatively.

Dr. Jihad Kaouk:

Yeah, Burak.

Dr. Burak Turna:

I started doing HoLEP, and HoLEP, I think, is a nice procedure, but it's difficult to learn. It takes a long time to learn it. When you already have a good robotic experience, and if the prostate size is over 150 grams, I think robotic prostatectomy is nice. My argument will be if I have a patient with a prostate of 100 grams, I would not hesitate to do a robotic simple prostatectomy where HoLEP is available, if you see what I mean.

Dr. Jihad Kaouk:

Yeah. Usually it's 100 gram and above to start with the simple prostate, but even with these bigger ones, there's the discussion about the HoLEP. So, David.

Dr. David Lee:

Oh, yeah. So I think I would just echo the comments of the faculty. HoLEP is difficult. We actually don't have anybody at Penn who does a lot of it. The technology, it requires that high powered holmium laser. Once you get on your learning curve, I think it's fine. But yeah, again, it's a long learning curve. We have three different surgeons who are doing robotic simple prostatectomies. It's a really reliable approach. And yeah, no, I agree with what Jeff says, the results are really good. Patients are very happy with the approach. So, at Penn, this is how we're doing these large prostates.

Dr. Jihad Kaouk:

Great, David. Dan, comments.

Dr. Daniel Sagalovich:

Yes, I agree. I think reproducibility is as critical in surgery, and learning curve. And so that's an important factor. I think these are probably my happiest patients that I have. So I think that if we get the hospital stays to less than one day, like you're doing, Dr. Lee, I think the cost can at least get close, the cost-effectiveness. And so that's why the robotic simple prostatectomy in America is very popular as opposed to HoLEP.

Dr. Jihad Kaouk:

Yeah, great comments. I would like to add also that if there was an intrabladder pathology, like diverticulum or a stone or so, it's very easy to take care of it during the robotic approach. And also don't forget all the passing in and out through the urethra, and what some have described as a temporary incontinence with also the risk of stricture. So all these are potentials going from the urethra in and out so many times in a prostate that's 200 grams. But that's my opinion. The jury, I think, is still out to define the exact role and comparison between the HoLEP and the RASP. We only have maybe a minute.

Dr. Jihad Kaouk:

I would like to thank Michele Paoli from the Endourology Society for all her hard work to put all the work together and invite and do the pretest runs to make this program possible, to thank also the Endourology Society, Dr. Adrian Joyce and Chandra Sundaram, the Intuitive Surgery for their educational grant that helped make this work possible. And of course, thanks to the panelists and the surgeons today for a wonderful presentation. Thank you, Dr. Pansadoro for joining with the time difference from Italy today. You always have the words of wisdom there, so we listen. And again, thanks to our attendees who've been joining in for the last four months now. We are very humbled by the attendees and the level of audience that we have. And the Endourology Society is trying to be always the society for all robotic surgeons in urology. Thank you everyone. Have a wonderful weekend.