Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience

EURURO-5448; No. of Pages 9

Surgery in Motion

Transvesical Robotic Simple Prostatectomy: Initial Clinical

Experience

Scott Leslie, Andre Luis de Castro Abreu, Sameer Chopra, Patrick Ramos, Daniel Park,Andre K. Berger, Mihir M. Desai, Inderbir S. Gill, Monish Aron *

Institute of Urology, Catherine and Joseph Aresty Department of Urology, University of Southern California, Los Angeles, CA, USA

E U R O P E A N U R O L O G Y X X X ( 2 0 1 4 ) X X X – X X X

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Article info

Article history:

Accepted December 13, 2013Published online ahead ofprint on January 3, 2014

Keywords:

Benign prostatic hyperplasia

Simple prostatectomy

Robotic surgery

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Abstract

Background: Despite significant developments in transurethral surgery for benignprostatic hyperplasia (BPH), simple prostatectomy remains an excellent option forpatients with large glands.Objective: To describe our technique of transvesical robotic simple prostatectomy (RSP).Design, setting, and participants: From May 2011 to April 2013, 25 patients underwentRSP.Surgical procedure: We performed RSP using our technique.Outcome measurements and statistical analysis: Baseline demographics, pathology data,perioperative complications, 90-d complications, and functional outcomes were assessed.Results and limitations: Mean patient age was 72.9 yr (range: 54–88), baseline Inter-national Prostate Symptom Score (IPSS) was 23.9 (range: 9–35), prostate volume was149.6 ml (range: 91–260), postvoid residual (PVR) was 208.1 ml (range: 72–800),maximum flow rate (Qmax) was 11.3 ml/s, and preoperative prostate-specific antigenwas 9.4 ng/ml (range: 1.9–56.3). Eight patients were catheter dependent before surgery.Mean operative time was 214 min (range: 165–345), estimated blood loss was 143 ml(range: 50–350), and the hospital stay was 4 d (range: 2–8). There were no intraopera-tive complications and no conversions to open surgery. Five patients had a concomitantrobotic procedure performed. Early functional outcomes demonstrated significantimprovement from baseline with an 85% reduction in mean IPSS ( p < 0.0001), an82.2% reduction in mean PVR ( p = 0.014), and a 77% increase in mean Qmax

( p = 0.20). This study is limited by small sample size and short follow-up period. Onepatient had a urinary tract infection; two had recurrent hematuria, one requiringtransfusion; one patient had clot retention and extravasation, requiring reoperation.Conclusions: Our technique of RSP is safe and effective. Good functional outcomessuggest it is a viable option for BPH and larger glands and can be used for patientsrequiring concomitant procedures.Patient summary: We describe the technique and report the initial results of a series ofcases of transvesical robotic simple prostatectomy. The procedure is both feasible andsafe and a good option for benign prostatic hyperplasia with larger glands.

# 2013 European Association of Urology. Published by Elsevier B.V. All rights reserved.

* Corresponding author. 1441 Eastlake Ave., Suite 7416, Los Angeles, CA 90089, USA.Tel. +1 323 865 3700; Fax: +1 323 865 0120.E-mail addresses: [email protected], [email protected] (M. Aron).

1. Introduction

Management options for men with symptomatic benign

prostatic hyperplasia (BPH) have increased over the last 2

decades [1]. Development of newer energy sources has added

Please cite this article in press as: Leslie S, et al. Transvesical Robo(2014), http://dx.doi.org/10.1016/j.eururo.2013.12.020

0302-2838/$ – see back matter # 2013 European Association of Urology. Phttp://dx.doi.org/10.1016/j.eururo.2013.12.020

to the armamentarium available for transurethral prostate

surgery [2], and the use of lasers has gained popularity owing

to the lower morbidity compared with traditional transure-

thral resection of the prostate (TURP) [3]. However, despite

these advances, open simple prostatectomy (OSP) remains

tic Simple Prostatectomy: Initial Clinical Experience. Eur Urol

ublished by Elsevier B.V. All rights reserved.

http://dx.doi.org/10.1016/j.eururo.2013.12.020

http://www.europeanurology.com/

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Fig. 1 – Port placement for transvesical robotic simple prostatectomy. (A) Schematic view of port placement; (B) operative view of port placement.AS = assistant; Cam = camera.

Fig. 2 – Vertical cystotomy at the dome of the bladder providingtransvesical access to the adenoma.

E U R O P E A N U R O L O G Y X X X ( 2 0 1 4 ) X X X – X X X2


particularly well suited for patients with large glands

(>100 g) due to the greater volume of adenoma removed

and the subsequent excellent long-term functional outcomes

[4,5]. The first laparoscopic simple prostatectomy (LSP)

was performed in 2002 [6], and subsequent series have

demonstrated functional outcomes to be equivalent to OSP

[7,8]. However, the technical difficulty and steep learning

curve of the purely laparoscopic approach has prevented

wider acceptance of LSP among urologists. The robotic

platform potentially overcomes these constraints by provid-

ing stereoscopic three-dimensional (3D) vision and excep-

tional dexterity to facilitate the more technically demanding

steps of the simple prostatectomy procedure.

We describe our technique of transvesical robotic simple

prostatectomy (RSP) in a contemporary cohort of men with

lower urinary tract symptoms (LUTS) secondary to BPH.

Perioperative and short-term functional outcomes are

described that show RSP to be feasible, safe, and effective.

2. Methods and patients

2.1. Study cohort

Between May 2011 and April 2013, 25 patients presenting

with BPH-related LUTS underwent RSP. Initial clinical work-

up included a complete history and physical examination

(including digital rectal examination), International Prostate

Symptom Score (IPSS), office uroflowmetry, urinalysis, urine

culture, serum electrolytes and creatinine, prostate-specific

antigen (PSA), renal tract ultrasound scan with postvoid

residual (PVR), and transrectal ultrasound (TRUS) with

prostate volume calculation. All patients failed medical

therapy before opting for surgical intervention. Patients were

counseled about the surgical options available including


TURP, laser prostatectomy, and photovaporization. RSP was

performed following appropriate informed consent.

2.2. Positioning

All procedures were performed with the da Vinci Si Surgical

System (Intuitive Surgical, Sunnyvale, CA, USA) with

patients positioned in lithotomy and steep Trendelenburg.

Our technique involves a transperitoneal approach with a

five- to six-port placement identical to that for robotic

radical prostatectomy (Fig. 1).

2.3. Surgical technique

The dome of the bladder is identified and a midline cystotomy

is made to gain transvesical access to the prostate (Fig. 2).



Fig. 3 – Intraoperative view of transvesical robotic simple prostatectomy.The bladder (BL) is retracted and sutured to the abdominal wall. Atransverse posterior incision is made at the junction of the trigone andadenoma (AD), and a stitch is placed through the AD allowing fordynamic retraction.

Fig. 4 – (A) Mucosal incision around the adenoma followed

E U R O P E A N U R O L O G Y X X X ( 2 0 1 4 ) X X X – X X X 3



Four stay sutures of 2-0 Vicryl on a CT-1 needle are used to

keep the edges of the cystotomy open for access to the

adenoma (Fig. 3). A traction suture (2-0 Vicryl on a CT-1

needle) is placed through the median lobe of the adenoma to

aid with dissection (Fig. 3).Starting posteriorly, an incision

is made in the mucosa overlying the adenoma. Once the

plane between the prostatic capsule and the adenoma is

identified, enucleation is performed using monopolar

scissors and blunt dissection (Fig. 4). Upon completion, the

adenoma is placed in an Endocatch bag, and hemostasis is

obtained by direct cautery and suture ligation of specific

bleeding points in the prostatic fossa. A 22F three-way

catheter is inserted with the balloon inflated to 30 ml, and the

cystotomy is closed with 2-0 V-Loc sutures (Covidien,

Norwalk, CT, USA) (Fig. 5). Finally, a Jackson-Pratt drain is

placed in the rectovesical pouch followed by extraction of

the specimen and closure of fascia and skin.

2.4. Data collection

We prospectively collected demographic and perioperative

data including age, baseline symptoms, estimated blood

loss (EBL), operative duration, length of stay (LOS), and

by (B) enucleation. AD = adenoma; PF = prostatic fossa.



Fig. 5 – (A) FloSeal (optional) applied to prostatic cavity to further ensurehemostasis, followed by (B) cystotomy closure. FL = FloSeal;PF = prostatic fossa.

Table 1 – Preoperative characteristics of the patient cohort

Patient demographics Results

n 25

Age, yr, mean (range) 72.9 (54–88)

Body mass index, kg/m2, mean (range) 28.2 (19.2–41)

America Society of Anesthesiologists score,

mean (range)

3 (2–4)

International Prostate Symptom Score,

mean (range)

23.9 (9–35)

Sexual Health Inventory for Men score,

mean (range)

12.8 (0–25)

PSA, ng/ml, mean (range) 9.4 (1.9–56.3)

Prostate volume, ml, mean (range) 149.6 (91–260)

Qmax, ml/s, mean (range) 11.3 (4–20)

Postvoid residual volume, ml, mean (range) 208.1 (72–800)

BPH-related complications, no. (%)

Urinary retention 13 (52)

Catheter dependent 8 (32)

Urinary tract infection 5 (20)

Macroscopic hematuria 8 (32)

Bladder calculi 2 (8)

Bladder diverticulum 1 (4)

Prior prostate surgery, no. (%)

TURP 3 (12)

TUMT 5 (20)

PVP 1 (4)

Cystoscopic findings

Prostatic urethra length, cm, mean (range) 7.2 (6–10)

Median lobes, no. (%) 15 (60)

BPH = benign prostatic hyperplasia; PSA = prostate-specific antigen;

PVP = photovaporization of the prostate; Qmax = maximum flow rate;

TUMT = transurethral microwave thermotherapy; TURP = transurethral

resection of the prostate.

Fig. 6 – Sagittal computed tomography scan demonstrating an enlargedprostate and bladder stone (arrow).



complications. Pathologic data included specimen weight

and histologic assessment. Patients were followed with

postoperative uroflowmetry, renal tract ultrasound, and

IPSS to assess functional outcomes.

2.5. Statistical methods

Mean, range, and statistical significance were used to report

continuous and categorical data. Statistical significance

was determined based on a two-sided significance level of

0.05. Data analysis was performed using SAS v.9.2 software

(SAS Institute Inc., Cary, NC, USA).

3. Results

Table 1 presents the demographic and baseline clinical

characteristics of the cohort. Mean patient age was 72.9 yr

(range: 54–88); mean body mass index was 28.2 (range:

19.2–41). Mean IPSS was 23.9 (range: 9–35), mean PSA was

9.4 ng/ml (range: 1.9–56.3), mean maximum flow rate

(Qmax) was 11.3 ml/s (range: 4.0–20), and mean PVR was

208.1 ml (range: 72–800).

Of the 25 patients, 20 (80%) experienced a BPH-related

complication. Urinary retention occurred in 13 patients

(52%) including 8 patients who had failed their void trial and


were catheter dependent at the time of their operation. Five

patients (20%) experienced a urinary tract infection (UTI),

and 8 patients (32%) complained of macroscopic hematuria.

Two patients had bladder calculi (Fig. 6), and one patient

had a large bladder diverticulum (Fig. 7).

All patients had failed medical therapy (5a-reductase

inhibitors and/or a-blockers), and seven patients had

undergone previous surgical intervention for BPH including



Fig. 7 – Fluoroscopic images during a urodynamic study. (A) A large right-sided bladder diverticulum is demonstrated (B and C) that does not empty onvoiding.



TURP, transurethral microwave thermotherapy, and photo-

vaporization of the prostate (PVP).

Preoperative flexible cystoscopy identified mean pro-

static urethra length to be 7.2 cm (range: 6–10) with 15

patients (60%) having a prominent intravesical median lobe.

All patients successfully underwent RSP with no intrao-

perative complications or conversions to open surgery

(Table 2). The mean operative duration was 214 min (range:

165–345); mean EBL was 143 ml (range: 50–350). Average

LOS was 4 d (range: 2–8), and average length of catheter

insertion was 9 d (range: 7–23). Patients underwent a

cystogram 1 wk postoperatively prior to catheter removal

(Fig. 8). Two patients were noted to have a small leak on

initial cystogram necessitating a longer catheter insertion of

18 and 23 d, respectively.

Five patients had a concomitant procedure in addition

to the simple prostatectomy. These included a bladder

diverticulectomy, heminephrectomy for a duplex system,

inguinal hernia repair, and two cases of cystolithotomy. All

procedures were completed robotically.

We report a total of five postoperative complications

(20%) in four patients. Despite perioperative injectable

third-generation cephalosporin, one patient developed a

UTI treated with oral antibiotics (Clavien-Dindo grade 2).

Table 2 – Perioperative outcomes and complications

Results

Perioperative outcomes

Operative time, min, mean (range) 214 (165–345)

Blood loss, ml, mean (range) 143 (50–350)

Concomitant procedures, no. (%) 5 (20)

Blood transfusions, no. (%) 1 (4)

Conversions, no. (%) 0 (100)

Length of hospital stay, d, mean (range) 4.0 (2–16)

Length of catheter insertion, d, mean (range) 9.0 (7–23)

Preoperative hemoglobin, g/dl, mean (range) 14.0 (10.0–18.5)

Lowest postoperative hemoglobin, g/dl,

mean (range)

11.3 (8.4–14.6)

Clavien-Dindo complications, no. (%)

Grade 1 0 (0)

Grade 2 2 (8)

Grade 3a 2 (8)

Grade 3b 1 (4)

Grade 4 or 5 0 (0)


Two patients were readmitted following recurrent hema-

turia leading to clot retention and the need for recatheter-

ization and bladder irrigation (Clavien-Dindo grade 3a).

Both patients restarted anticoagulation therapy that was

halted for their initial surgery. In one case the hemoglobin

dropped to 8.4 g/dl requiring transfusion with a total of

3 units of packed red cells (Clavien-Dindo grade 2). In both

cases, the hematuria resolved with bladder irrigation and

cessation of the anticoagulation. The final complication

involved a blocked catheter on postoperative day 1 due to

clot retention within the bladder associated with extra-

vasation into the peritoneal cavity. The patient underwent

robotic exploration with opening of the cystotomy and clot

evacuation under general anesthesia (Clavien-Dindo grade

3b). The patient subsequently had an uneventful post-

operative recovery and was discharged on day 4.

The mean specimen weight of the resected adenoma was

88.0 g (range: 50–172). Three cases of prostate cancer were

identified including two patients with a small focus of

Gleason 6 (pT1a) who are currently on active surveillance.

The third patient was found to have Gleason 7 (3 + 4)

involving the left lobe. Follow-up TRUS biopsy demon-

strated residual Gleason 7 cancer, and the patient was

subsequently treated with focal cryotherapy.

Early functional outcomes were assessed postopera-

tively with a mean follow-up of 6 mo (Table 3). Mean

postoperative IPSS was 3.58 (range: 0–6), which repre-

sented an 85% improvement from preoperative scores

( p < 0.01). Mean postoperative PVR was 36.9 ml (range:

0–175) indicating an 82.2% reduction ( p = 0.014). Mean Qmax

increased from 11.3 ml/s preoperatively to 20 ml/s following

surgery (77.0% improvement); however, this did not reach

statistical significance ( p = 0.20). One patient was wearing

one pad per day at 5 mo postoperatively for mild urinary

incontinence. None of the other patients had any incon-

tinence or erectile dysfunction as a result of the procedure.

4. Discussion

Our series represents one of the largest RSP cohorts in the

literature, demonstrating good perioperative outcomes

with excellent short-term symptomatic and functional

improvements. TURP and OSP are traditionally the main



Fig. 8 – Anteroposterior and oblique views of a postoperative cystogram demonstrating no leak and a large prostatic fossa occupied by the catheterballoon.



surgical options for men with BPH, with the latter most

appropriate for larger glands (>100 g). Improved morbidity

profiles of newer technologies such as PVP and holmium

laser enucleation of the prostate (HoLEP) make these viable

options alongside TURP and OSP. Randomized trials

comparing these laser treatments with OSP for large glands

have demonstrated equivalent short-term outcomes in

terms of improvements in IPSS, Qmax, and PVR [9,10].

One of the concerns about OSP is the high rate of adverse

events, specifically perioperative bleeding. In a randomized

trial comparing HoLEP with OSP for glands >100 g, Kuntz

and Lehrich [11] demonstrated a higher rate of adverse

events in the OSP group (26.7% vs 15%), largely a result of

the 13.3% rate of perioperative blood transfusion. This high

transfusion rate with OSP is consistently reported in the

literature. A large series of 902 patients undergoing OSP

demonstrated an overall complication rate of 17.3% with

68 patients (7.5%) requiring a blood transfusion due to

excessive bleeding [12]. In a prospective study of 56

patients, the mean EBL was 1181.3 ml (range: 500–2020)

with 36% of patients receiving a blood transfusion [13].

Mariano et al. [6] first demonstrated the benefits of the

minimally invasive approach in terms of less pain and shorter

convalescence compared with OSP [7]. However, in a study

comparing the morbidity of LSP and OSP, bleeding was still

noted to be significant in both groups with a transfusion rate

Table 3 – Prostate-specific antigen and functional outcomes onfollow-up

Preoperative Postoperative Percent change p value

Mean (range) Mean (range)

PSA 9.4 (1.9–56.3) 1.48 (0.06–4.0) �84.3 0.012

IPSS 23.9 (9–35) 3.58 (0–6) �85.0 <0.0001

Qmax 11.3 (4–20) 20 (12–35) +77.0 0.20

PVR 208.1 (72–800) 36.9 (0–175) �82.2 0.014

IPSS = International Prostate Symptom Score; PSA = prostate-specific

antigen; PVR = postvoid residual; Qmax = maximum flow rate.


of 15.8% in the LSP group and 10.2% in the OSP group [8]. This

is likely related to the demanding ergonomics of pure

laparoscopy when operating within the narrow confines of

the pelvis and the subsequent difficulty of dissection and

intracorporeal suturing of bleeding vessels.

The adoption of the robotic platform to simple prosta-

tectomy largely overcomes these issues with our series

demonstrating a mean EBL of only 143 ml (range: 50–350)

and only one patient requiring a perioperative blood

transfusion (4%). These excellent results are consistently

seen in published reports of RSP (Table 4). Apart from the

first series by Sotelo et al., perioperative transfusion

rates following RSP have been consistently reported as

0% [14–19]. Contributing factors for this minimal blood loss

include the pneumoperitoneum resulting in tamponade of

open venous channels within the prostatic fossa during

dissection; the excellent 3D stereoscopic vision and

articulation of the robotic instruments allowing for accurate

control of specific bleeding vessels both within the fossa as

well as at the bladder neck; and the transvesical approach

used in our cohort that provides direct access to the

adenoma via the dome of the bladder, thus allowing optimal

visualization into the prostatic fossa from base to apex such

that individual bleeders can be easily seen and controlled

with electrocautery or suture ligation. These factors

combined resulted in minimal blood loss, and our 4%

transfusion rate is comparable with that seen for both PVP

and HoLEP in similar size glands [9,11].

The mean hospital LOS for our cohort was 4 d (range:

2–8). This is significantly shorter than four contemporary

OSP series where the mean LOS ranged from 6 to 11.9 d

[4,5,12,13]. The advantages of a minimally invasive

approach most likely explain this difference. Furthermore,

the reduced bleeding as discussed previously may play a

role because it potentially allows for an earlier cessation of

bladder irrigation and thus an earlier discharge from the

hospital. A low rate of early postoperative complications

(20%) was demonstrated in our series. Although the average

length of postoperative catheterization of 9 d in our cohort



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was longer than transurethral techniques, only one patient

developed a postoperative UTI.

Functional outcomes in our cohort were excellent and

comparable with those reported for other RSP series and for

HoLEP and PVP [9,11]. Currently, there is no long-term data

on functional outcomes following RSP; however, extra-

polation from OSP series would indicate that IPSS, Qmax,

and PVR improvements are longstanding with a low

reoperation rate between 2% and 5% [4,5]. This durability

is in part related to the amount of adenoma removed

because the robot allows complete enucleation of the

adenoma with the angles of dissection easily conforming to

the contours of the gland. The mean pathology specimen

weight in our series was 88 g, with other published RSP

series reporting a mean specimen weight between 46.4 g

and 145 g [14–19]. The amount of tissue removed by PVP is

typically less than for surgical enucleation. This explains

why a higher proportion of these treatments may fail over

time. In a prospective randomized study comparing PVP

with OSP, postoperative prostate volume had decreased less

in the PVP cohort and was associated with inferior IPSS

quality-of-life scores at 18 mo [20].

An advantage of performing RSP is the ability to treat

coexistent pathology, which occurred in five patients in our

series (20%). Concomitant procedures included cystolithot-

omy in two patients where the calculi were extracted from

the bladder following the vertical cystotomy (Fig. 9). One

patient had an inguinal hernia, and following the prosta-

tectomy a Prolene mesh was anchored in place over the

hernia defect (Fig. 10). One patient had a right-sided bladder

diverticulum. Following the vertical cystotomy in the dome

of the bladder, the neck of the diverticulum was identified

(Fig. 11), and it was dissected from the perivesical tissue

until it was completely free. The bladder defect was closed

with 3-0 Vicryl in a running fashion after excising the

diverticulum. Enucleation of the prostatic adenoma was

then performed. The last concomitant procedure was a

left robotic heminephrectomy for a duplex system. The

patient had a duplicated left collecting system with a

nonfunctioning upper pole moiety. The patient was placed

in the lateral position and the robot docked as standard for

renal surgery. Following the heminephrectomy, the robot

was undocked, the patient repositioned in lithotomy, and

the RSP continued as usual. All procedures were performed

successfully without complications, although as expected,

the operative time was longer for these five cases with a

mean duration of 243 min.

In an attempt to amplify the benefits seen with

minimally invasive surgery, Fareed et al. reported the first

series of single-port RSP in nine patients [21]. Their

technique involves a single GelPort (Applied Medical, Santa

Margarita, CA, USA) positioned at the bladder dome through

which the robot was docked to perform the enucleation.

Despite improvements in uroflowmetry parameters, peri-

operative complications were significant with two patients

requiring a blood transfusion due to excessive intraopera-

tive blood loss (>1000 ml) and two patients developing

significant postoperative hematuria requiring cystoscopic

clot evacuation and coagulation of bleeding tissue within



Fig. 9 – (A) Robotic cystolithotomy with concomitant simple prostatectomy; (B) respective specimen weighting 155 g.



the prostatic fossa. Although single-port RSP is feasible, the

high complications rate indicates further refinement of

ports, instrumentation, and robotics is necessary before it

can be more widely endorsed.

Never before have we been presented with such a wide

array of treatment options for men with BPH. Newer laser

techniques have been increasingly utilized, offering an

improved morbidity profile over traditional options such as

TURP and OSP. The purely laparoscopic approach to simple

prostatectomy has been explored over the last decade but

has not been embraced enthusiastically owing to its

technical difficulty and reports indicating no improvement

in adverse events when compared with conventional OSP.

The unmatched dexterity and vision afforded by the robotic

platform allows a more precise anatomic dissection of the

adenoma and facilitates accurate and swift intracorporeal

suturing to control bleeding. These factors combined offer

Fig. 10 – Concomitant robotic mesh repair of inguinal hernia.


excellent short-term perioperative outcomes as well as

durable functional improvements. This series adds to the

growing evidence that RSP not only confers the benefits of

minimally invasive surgery but is also associated with low

rates of postoperative complications comparable with that

of transurethral laser techniques.

Our report is still limited by a small sample size. A future

study with a larger patient cohort would be beneficial to

determine the reproducibility of this study’s results. In

addition, some patients currently have a short postopera-

tive follow-up. Long-term outcomes are beneficial for this

type of study. Finally, we did not address the costs of using

the robot for the procedure. However, in a RSP series by

Matei et al. [22], the overall costs of RSP were less than for

OSP and equivalent to TURP. Although initial operative costs

were higher for RSP, they identified lower hospitalization

costs when compared with both OSP and TURP [22].

Fig. 11 – Bladder diverticulum. Neck of diverticulum scored withelectrocautery. Note ureteral catheter in right ureteric orifice and tip ofurethral catheter advanced into neck of diverticulum. AD = adenoma;DN = diverticulum neck; FC = Foley catheter; UC = ureteral catheter.





5. Conclusions

Our technique of transvesical RSP in men with BPH from

large glands demonstrates excellent improvements in

functional outcomes with an acceptable perioperative

morbidity profile. It is of particular benefit in those patients

with associated pathology requiring a concomitant proce-

dure. Prospective studies comparing RSP with endoscopic

laser options are required to further define their respective

roles for men with BPH.

Author contributions: Monish Aron had full access to all the data in the

study and takes responsibility for the integrity of the data and the

accuracy of the data analysis.

Study concept and design: Leslie, Abreu, Aron.

Acquisition of data: Chopra, Ramos.

Analysis and interpretation of data: Park.

Drafting of the manuscript: Leslie, Abreu, Chopra, Aron.

Critical revision of the manuscript for important intellectual content: Gill,

Desai, Aron.

Statistical analysis: Chopra.

Obtaining funding: None.

Administrative, technical, or material support: Park, Berger.

Supervision: Aron, Gill, Desai.

Other (specify): Video compilation: Berger, Chopra, Abreu.

Financial disclosures: Monish Aron certifies that all conflicts of interest,

including specific financial interests and relationships and affiliations

relevant to the subject matter or materials discussed in the manuscript

(eg, employment/affiliation, grants or funding, consultancies, honoraria,

stock ownership or options, expert testimony, royalties, or patents filed,

received, or pending), are the following: None.

Funding/Support and role of the sponsor: None.

Appendix A. Supplementary data

The Surgery in Motion video accompanying this article can

be found in the online version at http://dx.doi.org/10.1016/

j.eururo.2013.12.020 and via www.europeanurology.com.

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Transvesical Robotic Simple Prostatectomy: Initial Clinical Experience

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