Prof. Doutor Tiago S. Rodrigues

Urologist

Robotic surgery in benign prostate hyperplasia

Another national innovation by the HPA Health Group

HPA Magazine 19

The prostate is a chestnut-sized gland that is part of the male reproductive system, located in front of the rectum and below the bladder.
Benign prostatic hyperplasia (BPH) is an enlarged prostate resulting in the gradual compression of the urethra. 
The incidence of BPH increases with age, symptomatically affecting approximately 25% of men over 40 years of age and approximately 75% over 65 years of age.
The importance of this disease is due to its symptoms which affect the quality of life of men. The prostate surrounds the urethra and when it increases in size,  it may lead to compression of the urethra and consequently obstruction of the bladder. 

The symptoms caused by BPH are increased urinary frequency, both during the day and at night, the sudden and unavoidable urge to urinate, incontinence, dribbling at the end of urination, difficulty in starting and maintaining the flow of urine, and abdominal pressure to urinate. 
These symptoms worsen over time and affect daily activity and sleep patterns, drastically altering the quality of life of these patients. 
If left untreated, it can also cause irreversible changes in the functioning of the bladder as well as the kidneys, even leading to kidney failure.
Size is not a reliable indicator of severity, and there is not a good correlation between symptoms and the size of the prostate.  
Some men with large prostates (over 100g) may have few symptoms that do not interfere with their quality of life, while there are other men with smaller prostates (30-40g) with severe urinary symptoms.

It is therefore mandatory to carry out an assessment of the level of obstruction and the severity of its symptoms. 
Therapeutic options for the treatment of BPH include medication and surgery.
Medication includes several groups of drugs, of which two stand out. A group of drugs (α1-adrenergic receptor blockers) that relax the muscles of the prostate gland, neck of the bladder and proximal urethra, which are the quickest to reduce symptoms. Those in the second group (5α-reductase inhibitors) block the transformation of the male hormone testosterone into dihydrotestosterone in the prostate, which partially reduces the volume of this organ and subsequently urinary symptoms. 
They take a few weeks to act and are only effective in the larger prostates. 
Recently, a drug (tadalafil) used to treat erectile dysfunction has been shown to have advantages when taken daily in patients who have symptoms of BPH associated with erection problems.
Classically, when medical treatment fails, surgical treatment is necessary. 
The surgical technique is determined by the size of the prostate, medical equipment available and the surgeons experience. 
For prostates up to 80 grams, transurethral procedures are performed, preferably with bipolar energy or laser. For prostates over 100 grams open surgery or laparoscopy.
The objective is the same with all these surgical procedures: the removal of the central hypertrophied and obstructive tissue responsible for the symptoms, although there may be a risk of urinary incontinence, erectile dysfunction or ejaculatory dysfunction.
Robotic Technology Treats Benign Prostate Hyperplasia in Six Minutes
Aquabeam, as this new technology is called, for the treatment of BPH, can be used in all prostate sizes, with the substantial advantage of preserving sex life and continence.
This robot uses a high-pressure water jet - 10,000 PSI - to clear the urethra and improve urinary symptoms. Unlike classic endoscopic or laser surgeries, the Aquabeam Robotic System permits ablation of hypertrophied prostatic tissue, without using any type of thermal energy.
The surgeon controls the entire procedure in real time through ultrasound and cystoscopy image, planning the treatment in a personalized way, delimiting the prostatic tissue to be removed by the robot. Once all parameters are integrated, the robot performs the procedure quickly, predictably and accurately (in about 6 minutes). 
Once the procedure is complete, a catheter is placed in the bladder which is usually removed the following day, allowing the patient to be discharged after 24 hours.
In addition to a shorter hospital stay, the preservation of sexual life, namely ejaculation, and less blood loss are important benefits.

AQUABEAM ROBOTIC HYDRO ABLATION 
ALSO ALLOWS:

> Possibility to treat any prostate size with or without medial lobe
> Reproducibility as it is a robotic system, where the resection to be performed is planned by software and controlled in real time by ultrasound vision
> The learning curve for the Urologist is considered small
> Much shorter resection time and surgical time than any other technique
> Very low rate of urethral strictures
> Very low percentage of retreatments

So far, approximately 130 robots have been installed around the world, the first one to be installed in Portugal was at the HPA Gambelas.
This technological innovation comes in addition to prostatic biopsy by microechography, high-definition transrectal prostatic microechography and low-intensity shock waves for erectile dysfunction, making the HPA Urology Group a national benchmark.