Robot-assisted laparoscopic enucleation of prostate with early catheter removal: A case report

Introduction: Current American Urological Association guidelines on surgical management of benign prostatic hyperplasia (BPH) recommend either laser enucleation techniques or minimally invasive simple prostatectomy for prostates exceeding 150 g. Robot-assisted simple prostatectomy (RASP) has emerged as a safe and effective option to address the anatomical challenges, particularly in centers with established robotic expertise. Case Report: A 63-year-old Thai male with essential hypertension and chronic kidney disease presented with progressive lower urinary tract symptoms and a rising serum creatinine level. Imaging revealed a markedly enlarged prostate (213 g) with intravesical protrusion and severe bilateral hydronephrosis. Magnetic resonance imaging was further requested to exclude malignancy, as his initial prostate-specific antigen (PSA) level was 13.13 ng/mL. After confirmation of a PI-RADS 2 lesion and discussion of surgical options, patient accepted to undergo RASP. Due to unexpected intraoperative findings of trilobar prostatic enlargement obscuring both ureteric orifices and distorting normal anatomy, our team was forced to switch from conventional simple prostatectomy to enucleation. Each lobe was removed separately as en bloc dissection was impossible. Total operative time was approximately 3 hours with an estimated blood loss of 400 mL. The urethral catheter was retained for four days and removed before discharge. The pathological report confirmed benign prostatic hyperplasia with 168 g of prostatic tissue removed. At one month, the patient was satisfied with lower urinary tract symptom improvement. Uroflowmetry verified a maximal urinary flow rate of 28 mL/s with a post-void residual urine of 10 mL. Conclusion: Our case confirmed the safety and practicality of robot-assisted laparoscopic enucleation in extremely large prostates with abnormal configuration. This operation serves as another surgical option for patients who desire excellent functional outcomes with minimal urethral stricture and incontinence rates. However, surgeon experience and the learning curve should also be considered as they directly affect postoperative outcomes.