Urethral-sparing Robot-assisted Simple Prostatectomy: An Innovative Technique to Preserve Ejaculatory Function Overcoming the Limitation of the Standard Millin Approach

Despite recent technical innovations in the treatment of benign prostatic hyperplasia (BPH), retrograde ejaculation is still one of the most frequent adverse effects, with a major impact on patients' quality of life.To evaluate the efficacy of our technique of urethral-sparing robotic-assisted simple prostatectomy (usRASP) in obtaining effective deobstruction and maintaining anterograde ejaculation, and secondarily, to compare these outcomes with those of a control group of patients who underwent standard robotic adenomectomy according to the Millin technique.We prospectively enrolled patients between August 2017 and July 2019 with large BPH (prostate volume >80 ml) affected by significant BPH-related lower urinary tract symptoms (LUTS) who underwent usRASP. Then, a retrospective control group treated with standard Millin robotic-assisted simple prostatectomy (RASP) was selected.The innovative aspect of our technique is the pivotal role of enucleation of the adenoma from all the anatomical structures, especially from the urethra. On the basis of the final results, the patients were divided into three groups (full, partial, or failed urethral sparing). Control group patients underwent standard Millin.All perioperative and follow-up data were collected, and descriptive, univariate, and multivariate analyses were performed.Ninety-two patients were enrolled. Full urethral-sparing adenomectomy was performed in 56 cases (60.86%). Urethral-sparing adenomectomy with minimal urethral infraction occurred in 21 cases (22.82%). In 15 patients (16.48%), the procedure was converted to standard RASP. Clavien grade ≥3 complications occurred in two patients (2%). Among the 70 patients with preoperative ejaculation, 57 (81%) maintained anterograde ejaculation at the 12th postoperative month. The maximum flow rate increased (17 m/s from baseline, p = 0.034), and International Prostate Symptom Score decreased rapidly (from 20 to 5 points; p < 0.001). With respect to the technique of the control group patients, usRASP allows the same perioperative and urinary functional outcomes, but with an improvement in terms of sexual function, especially for the ejaculation (p < 0.001 at every time point). A small sample size and short follow-up time are the major limitations of this study.Urethral-sparing RASP has been found to be a safe and effective procedure that allows resolution of LUTS in large BPH and maintaining of ejaculatory function in a high percentage of patients.Based on our findings, this technique should be considered as an option when counseling patients with large benign prostatic hyperplasia who are motivated to preserve antegrade ejaculation.