Robot-Assisted Radical Prostatectomy in a Post-Enucleation Gland

Holmium laser enucleation of the prostate (HoLEP) is an established treatment for benign prostatic obstruction, and some patients subsequently prove to have prostate cancer (1-3). Enucleation leaves fibrosis that displaces the anatomical landmarks relevant to radical prostatectomy (4, 5). We present a robot-assisted radical prostatectomy (RARP) performed after HoLEP.

A 64-year-old man underwent HoLEP; biopsy subsequently showed adenocarcinoma of the right lobe, ISUP grade 3. PSA was 0.51 ng/mL; MRI demonstrated a 0.4 cm PI-RADS 4 lesion at the right mid-base. RARP was performed 29 months later on a da Vinci Xi system. Without the adenoma, the capsule is flaccid and offers no counter-resistance; without haptic feedback, the planes of the bladder neck (6) and neurovascular bundle (7) become indistinct. A wide bladder neck may admit the balloon into the fossa; overinflating it to 40 mL or tracing extravesical landmarks restores the anatomical reference. Retzius-sparing and transvesical approaches are recognized alternatives (8, 9). The video demonstrates a thickened Denonvilliers fascia and the use of the 30-degree lens rotated 180 degrees to open the posterior plane.

Six ports were used (four robotic, two assistant); console time was 90 minutes with an estimated blood loss of 75 mL. Nerve-sparing was bilateral, and bladder neck reconstruction was not required. The patient was discharged on postoperative day 1; the catheter was removed on day 5. Pathology revealed adenocarcinoma of both lobes, Gleason 7 (4+3), pT2c, with negative surgical margins. At six weeks, the patient was continent without pads and had an undetectable PSA.

RARP after HoLEP is feasible. To our knowledge, this is the first video article dedicated to this operation, demonstrating each post-enucleation anatomical obstacle and a practical surgical response. The bladder neck and posterior plane warrant particular caution.