Anterograde ejaculation preservation after endoscopic treatments in patients with bladder outlet obstruction: systematic review and pooled-analysis of randomized clinical trials.

INTRODUCTION: Despite the high rate of resolution, ejaculatory dysfunction still is the most common side effect related to surgical treatment of bladder outlet obstruction (BOO). The aim of the present systematic review was to compare several technological treatment modalities for the management of lower urinary tract symptoms/BOO in terms of functional and sexual outcomes. EVIDENCE ACQUISITION: All English language randomized controlled trials assessing the impact of different endoscopic treatments for BOO were evaluated. We followed the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) statement to evaluate PubMed®, Scopus®, and Web of Science™ databases (up to June 2019). EVIDENCE SYNTHESIS: Our electronic search identified a total of 2221 papers in PubMed, Scopus, and Web of Science. Of these, 142 publications were identified for detailed review, which yielded 21 included in the present systematic review. All groups appeared similar with regards to preoperative IPSS/AUA Score, Qmax, and prostate volume (cc). Patients undergoing endoscopic treatments using ThuLEP, Greenlight or Prostate Artery Embolization techniques had lower-but not statistically significant- relative risk (RR) of retrograde ejaculation compared with conventional transurethral resection of the prostate (TURP) (RR: 0.90; P=0.35; RR: 0.71; P=0.1; RR0.73; P=0.11). Efficacy of those techniques was equal to TURP. CONCLUSIONS: Data reporting anterograde ejaculation preservation after endoscopic treatment in patients with benign prostatic enlargement are sparse and heterogeneous. Pooled analyses suggest that new technological alternatives to conventional TURP might improve sexual outcomes, especially for non-ablative treatments.

Robotic simple prostatectomy plus panniculectomy and Giant umbilical hernia repair.

INTRODUCTION: Simple prostatectomy is the gold standard for prostates >80 grams, robotic system has proven to help into speed the recovery of the patient and in morbid obesity the advantages of the robotic system can help to perform a successful surgery. CASE: 80 years old male with morbid obesity (BMI 45) and several other comorbidities, with history of an umbilical hernia and obstructive lower urinary tract symptoms in acute urinary retention. PSA was 7 ng/dl, DRE demonstrates a >100gr prostate gland. A robotic simple prostatectomy, urethropexy, umbilical hernia repair and panniculectomy in Fleur-de-Lis was performed. RESULTS: Operative time (OT) and estimated blood loss (EBL) were 438 min and 160 ml respectively. A JP drain was placed in the pelvis and 2 additional were left in the abdominal cavity with several Penrose drains. No immediate or intraoperative complications were observed. The length of stay (LOS) was 6 days without complications. Pathology report showed prostate of 304gr and benign prostatic tissue. DISCUSSION: In patients with multiple comorbidities robot-assisted surgery provides advantages of shorter LOS, EBL, less transfusion and lower rate of complications. In patients with morbid obesity where the increased girth makes difficult the open approach, robotic surgery is an ideal way to provide definitive treatment; concomitant, Fleur-de-Lis panniculectomy can correct the abdominal contour in both vertical and horizontal orientation at the same time that provides a better plane for trocar insertion, an accurate location of the needle tip and a proper position of the remote center decreasing the possible complication of port placement.