Urethra and Ejaculation Preserving Robot-assisted Simple Prostatectomy: Near-infrared Fluorescence Imaging-guided Madigan Technique

Abstract

Background: With the increasing adoption of novel technologies and anatomical techniques, surgical management of benign prostatic hyperplasia (BPH) provides significant benefits in terms of obstruction relief, early urethral catheter removal, and faster return to daily activities. However, the main pitfall of BPH surgery in sexually active men remains ejaculatory dysfunction (EjD), which permanently affects quality of life.

Objective: To detail a novel technique for marking the intraprostatic urethra through a retrograde injection of indocyanine green to enhance selective dissection of prostatic lobes during urethra-sparing robot-assisted simple prostatectomy (US-RASP) with the use of near-infrared fluorescence imaging (NIFI).

Design, setting, and participants: Between January and September 2017, 12 consecutive male patients, who had BPH, were sexually active, and were motivated to preserve ejaculatory function, underwent US-RASP.

Surgical procedure: US-RASP with NIFI to enhance the identification and preservation of the prostatic urethra.

Measurements: Clinical data were prospectively collected in 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 (International Prostate Symptom Score [IPSS]; Male Sexual Health Questionnaire on EjD [MSHQ-EjD] Short Form) at 3 and 12mo.

Results and limitations: Median preoperative prostate size was 102cc (interquartile range [IQR] 88-115). Median operative time was 150min (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 7d (IQR 7-7) with a median hospital stay of 3d (IQR 2-3). At 1-yr follow-up, median IPSS score, International Index of Erectile Function score, and MSHQ-EjD Short Form score were 5 (IQR 4-8), 26 (IQR 26-28), and 12 (IQR 1-14), respectively. Satisfactory anterograde ejaculation was reported in eight patients (66%).

Conclusions: We 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.

Patient summary: We developed a novel robotic technique to perform simple prostatectomy with integral preservation of the prostatic urethra. This technique provided a high rate of ejaculatory function preservation.

Keywords: Benign prostatic hyperplasia; Ejaculation preserving; Madigan prostatectomy; Near-infrared fluorescence imaging; Robotic; Simple prostatectomy.