Although the gold standard for management of large prostate glands (>90cc) is the open simple prostatectomy, the use of a robotic assisted simple prostatectomy has emerged as a safe treatment option given shorter length of stay and reduced blood loss.  The surgical approach traditionally described is similar to that of a radical prostatectomy allowing for surgeon adaptability.  We describe an alternative via a posterior transvesicular approach to perform the robotic assisted simple prostatectomy.

The patient was placed in steep trandelenberg position.  A 12mm balloon port was used for the camera, three 8mm robotic ports, and two assistant ports (5mm and 8mm).  After insufflation, the assistant retracted bowel cephalad.  The peritoneum covering the posterior aspect of the bladder was grasped.  At this point, a conventional approach includes transecting the median umbilical ligaments at the dome of the bladder to drop the bladder posteriorly.  We instead choose to incise the peritoneum and the posterior bladder wall.  The bladder had been distended with water.  Once inside, we identified the trigone and both ureteral orifices.  Two 3-0V lock sutures were used to tack the superior aspect of the cystotomy to the peritoneum to allow for better exposure.  We scored the prostate circumferentially and continued to dissect the adenoma from the prostatic capsule and apex.  A tenaculum was used to retract the adenoma.   The adenoma was placed in an endocatch.  A 3-0V lock suture was used for retrigonalization to close the empty posterior fossa by advancing the bladder to the urethra.  A foley catheter was replaced.  The bladder cystotomy was closed in two layers using a running and an imbricating V lock.  The tacking sutures were removed and the peritoneum was closed.  The adenoma was removed through the 12mm port site by hubbing the endocatch bag to the skin opening and using a scalpel to morcellate.

We have demonstrated an alternative technique for performing a robotic assisted simple prostatectomy using an approach through the posterior bladder foregoing the need to drop the bladder posteriorly or compromise any vasculature in the anterior prostate.  We believe this technique also allowed us for better visualization and control of a very prominent intravesicular anterior component of the prostate.

In conclusion, this posterior transvesicular approach provides an alternative method to perform the robotic assisted simple prostatectomy.