To present a novel surgical concept by using the trans-Douglas approach to perform a robotic-assisted simple prostatectomy (RASP) for high-volume benign prostate hyperplasia. This transposition from oncological surgery enables performance of a better bladder neck sparing adenomectomy with good functional results.

The index patient is a 67-year-old man with a history of severe urinary flow outlet obstruction. Combination medical therapy is not effective. Transrectal ultrasound scan detected a 130-cm³ enlarged prostate with middle lobe. The International Prostate Symptoms Score (IPSS) was 30. The patient was scheduled for a RASP with a trans-Douglas approach to preserve the bladder neck. The patient was put in 30° Trendelenburg position. Six ports were placed across the lower abdomen: four 8-mm robotic trocars and 2 assistant trocars (12 and 5 mm). The parietal peritoneum was incised at the anterior surface of the Douglas space, according to the access to the prostate described by Bocciardi. The Denonvillier fascia was opened, seminal vesicles were exposed, and above the vesicles, the prostatic capsule was incised. The adenoma, together with the middle lobe, was split by the capsule from the base to the verumontanum. The bladder neck was advanced and remodeled to the distal urethral mucosa and then closed to the prostatic capsule by a double-layer suture. The peritoneal breach was closed.

The operation time was 120 minutes. Blood loss was 80 cc. There was no perioperative or postoperative complication. The catheter was removed after 4 days. Uroflowmetry showed a peak flow of 30 mL/s. Pathologic examination was negative for tumor. After 60 days, the IPSS score was 8.

Trans-Douglas-RASP is a safe and effective minimally invasive treatment for benign prostate hyperplasia. It is a novel technique to perform bladder neck sparing prostatic adenomectomy and could be 1 more field of application of robotic technology.