BPH and surgical thresholds: BPH affects 50% of men >50 years; severe LUTS (IPSS ≥20), refractory urinary retention, recurrent UTI, bladder calculi, hydronephrosis, or hematuria from BPH are surgical indications. Treatment selection by prostate volume - <30 g: TURP, PUL (UroLift), water vapor (Rezum); 30-80 g: TURP, HoLEP, ThuLEP, PVP (GreenLight), bipolar TURP/TUEP; 80-150 g: HoLEP/ThuLEP, simple prostatectomy (open or robotic); >150 g or median lobe-dominant adenoma: simple prostatectomy preferred. Preoperative evaluation - PSA, prostate biopsy if indicated, MRI to exclude prostate cancer (cancer detection requires radical, not simple, prostatectomy), uroflowmetry, post-void residual, cystoscopy.
Robotic technique (Millin-style transcapsular enucleation): patient in steep Trendelenburg, 6-port da Vinci configuration. Steps - 1) anterior bladder neck dissection or transverse capsulotomy; 2) identification of plane between adenoma and surgical capsule; 3) blunt and sharp enucleation of bilateral lobes and median lobe; 4) hemostasis at vascular pedicles (bilateral inferior vesical artery branches); 5) urethral mucosa incision at apex preserving external sphincter; 6) reconstruction - bladder neck advancement (trigonization) or modified Madigan technique to reduce dead space; 7) Foley catheter and pelvic drain placement. Hospital stay 2-3 days, catheter 5-10 days. Compared to open simple prostatectomy - reduced blood loss (200-400 mL vs 500-1000 mL), transfusion rate 2-5% vs 10-20%, similar functional outcomes (Qmax improvement 3-fold, IPSS reduction 70-80%).
Postoperative care and outcomes: catheter removal at 5-10 days based on cystographic anastomosis check (if extensive bladder neck reconstruction). Functional outcomes - Qmax 20-25 mL/s, IPSS <8, post-void residual <50 mL, continence preservation >95%. Complications - bleeding requiring transfusion 2-5%, urethral stricture 3-5%, bladder neck contracture 3-8%, urinary incontinence (transient stress) 5-10%, retrograde ejaculation 80-90% (counsel preoperatively), persistent storage symptoms (overactive bladder), infection 3-5%, conversion to open <2%. Long-term outcomes - 10-year reoperation rate <5%, comparable to open simple prostatectomy. RSP is increasingly preferred over open in centers with robotic expertise.