Simple prostatectomy has been established as a management option for lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH) with glands larger than 80 cc.<sup>1Lerner LB, McVary KT, Barry MJ, e al. Management of lower urinary tract symptoms attributed to benign prostatic hyperplasia: AUA guideline part I–initial work-up and medical management The Journal of urology 2021 ;  206 : 806-817 [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> Robotic-assisted simple prostatectomy (RASP) has been established as a safe and effective management option. This has been reported in multiple studies comparing it with the open approach where no statistically significant differences in complication rates have been found.<sup>2Sorokin I, Sundaram V, Singla N, e al. Robot-assisted versus open simple prostatectomy for benign prostatic hyperplasia in large glands: a propensity score–matched comparison of perioperative and short-term outcomes J Endourol 2017 ;  31 : 1164-1169 [cross-ref]

Cliccare qui per andare alla sezione Riferimenti</sup> The intrafascial approach is intended to add multiple benefits, such as not requiring continuous bladder irrigation and resection of a larger percentage of the adenoma, potentially leading to a lower reoperation rate and diagnosis of prostate cancer in patients in which this was missed preoperatively.<sup>3Clavijo R, Carmona O, De Andrade R, e al. Robot-assisted intrafascial simple prostatectomy: novel technique J Endourol 2013 ;  27 : 328-332 [cross-ref]

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To present the resection of a very large prostate can lead to significant intraoperative challenges. Therefore, we demosntrate our intrafascial robotic management of a 470g prostate.

A 56-year-old with LUTS (IPSS: 34) for over 6 years, complicated with multiple episodes of urinary retention. PSA: 20.6 ng/mL. MRI reported a 463 cc prostate volume without focal lesions. First, the retropubic space was developed. Cystotomy was performed at the anterior bladder neck. A plane between the prostatic capsule and the surrounding fascia was dissected while carefully preserving the neurovascular bundles. Due to its large size, the prostate was divided into segments to facilitate its extraction. Hemostatic control and vesicourethral anastomosis were performed.

Discharged on postoperative day 1 with a Jackson-Pratt drain and Foley catheter removed on days 6 and 9, respectively. Pathology was negative for malignancy. Patient-reported improvement of LUTS (IPSS: 3) and preservation of erectile function (SHIM: 23) at the 3-month follow-up.

The intrafascial technique can be useful in cases where a large-sized prostate hinders a transvesical approach. Additionally, it allows for an easier piecemeal of the gland. A larger series is needed to determine its potential benefits.