With the increasing adoption of novel techniques, the surgical management of benign prostatic hyperplasia (BPH) provides significant benefits in terms of obstruction relief, early catheter removal and faster return to daily activities. However, the main pitfall of BPH surgery in sexually active men remains ejaculatory dysfunction (ED). In this video we described a novel technique for marking intraprostatic urethra through a retrograde injection of indocyanine green (ICG) to enhance a selective dissection of prostatic lobes during urethra-sparing robot-assisted simple prostatectomy (US-RASP) with the use of Near Infrared Fluorescence Imaging (NIFI).
Between January-September 2017, 12 consecutive patients with BPH, sexually active and motivated to preserve ejaculatory function, underwent US-RASP. The first step was a retrograde injection of 10 mL of ICG through the urethral catheter placed at navicular fossa. Once prepared the Retzius space the bladder neck was meticulously isolated in order to expose the proximal prostatic urethra. BPH dissection started from the right lobe, developing the dissection plane starting from the base and progressively moving to 12 o’clock site. Sharp and blunt dissection were progressively used to enucleate the lobe. NIFI imaging was used when dissection moved towards the median aspect of the lobe in order to improve visualization of the bladder neck and of the urethra, to avoid any unintended violation of urinary tract. Energy free dissection was used in proximity to urinary tract. Once completed the resection, a Foley catheter was introduced and the cuff inflated in the prostatic urethra with 10 mL of saline solution. Finally, the bladder was approximated to the prostatic fossa with two running monocryl sutures. Clinical data were prospectively collected into our institutional RASP dataset. Perioperative and functional outcomes of US-RASP were both graded and assessed according to Clavien Grading System and validated questionnaires postoperatively (IPSS; MSHQ-EjD Short Form) at 3,12 months.
Median preoperative prostate size was 102 cc (IQR 88-115). Median operative time was 150 minutes (IQR 145-170). Median estimated blood loss was 250 (IQR 200-350). Continuous bladder irrigation was avoided in 83,4% of patients. Median time to catheter removal was 7 days (IQR 7-7) with a median hospital stay of 3 days (IQR 2-3). At 1-yr follow-up median IPSS score, IIEF score and MSHQ-EjD Short Form were 5 (IQR 4-8), 26 IQR 26-28) and 12 (IQR 1-14), respectively. A satisfactory anterograde ejaculation was reported in 8 patients (66 %).
We first described a novel NIFI-guided technique to perform US-RASP. This technique showed promising early functional results suggesting a significant role of intraprostatic urethral integrity for the preservation of ejaculatory function.