Robotic Freyer’s Prostatectomy: Point of technique

This was a 2020 KS National Robotic Surgery Awards entry: Robotic Freyer’s Prostatectomy: Point of technique

Dr Arvind Ganpule, Dr Abhijit Patil, Dr Abhishek Singh, Dr Ravindra Sabnis, Dr Mahesh Desai

Introduction: Open Freyer’s procedure had long been used large prostate treatment in the past. The transurethral endoscopic approach for larger prostate has the problem of being time-consuming and transurethral resection syndrome complications. Robotic Freyer’s Prostatectomy has again brought back the traditional transvesical Freyer’s approach to mitigate such problem with the added benefit of being precise and minimal invasive. So, we present this video of point of technique and tips and tricks of Robotic Freyer’s prostatectomy.

Material and methods: We had selected this case of 73 years old male with failed catheter-free trial for making out point. He has large prostate of volume around 150 grams with median lobe.

Point of technique: Patient is placed in Trendelenburg position with a camera, 2 robotic and 2 assistant ports in an inverted fan shaped manner. The robot was docked between the legs. First step starts with midline cystotomy with four-point fixation of bladder and visualisation of prostatic lobes. The next step is incising bladder neck with taking care of ureteric orifices. The key if to enter proper plane between the prostatic capsule and adenoma. The proper plane ensure easy pealing off of the adenoma with minimal bleeding. The median lobe should be hitched with a dynamic stay suture which helps in traction-countertraction. The dissection continues 3600 – median, left lateral, right lateral lobe and anteriorly till apex. If prostate is large, removal of two lobes at a time followed by other can be performed. The prostatic fossa is then sutured with V-Loc suture for haemostasis and re-trigonization. The final step if cystotomy closure in two layers with removal of prostatic lobes.

Conclusion: This procedure offers excellent duplication of open Freyer’s principle with potential for “Gold standard” results. It mitigates the problems faced by conventional endoscopic approach especially for large prostate. The robotic approach provides magnification for precise dissection in proper plane and apical dissection for good functional outcomes.

Robotic Surgery, with PPT’s, CT Scans, Narrated, 08:01