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Endourologic Society Summer Student Scholarship Project SummaryStudent: Hersh Trivedi Mentor: Dr. Ryan Steinberg, M.D, Dr. Jeff Gahan M.D. Home Institution: University of Texas Southwestern Medical CenterThe Impact of Pre-Operative Catheter Dependence on Urinary Retention and Other Lower Urinary Tract Symptoms Associated with BPH Following Robotic Assisted ProstatectomyI would like to thank the Endourologic Society for this opportunity to pursue meaningful research that has allowed me to grow both as a medical student as well as a member of the academic community. By having this opportunity to pursue research within urology, I have gained a greater insight into the variety of clinical and research opportunities that urology offers.Older men tend to develop significant lower urinary tract symptoms (LUTS) associated with benign prostatic hyperplasia (BPH). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"XEwoemFu","properties":{"formattedCitation":"\\super 1\\nosupersub{}","plainCitation":"1","noteIndex":0},"citationItems":[{"id":58,"uris":[""],"uri":[""],"itemData":{"id":58,"type":"article-journal","title":"A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update","container-title":"European Urology","page":"1066-1096","volume":"67","issue":"6","source":"ScienceDirect","abstract":"Context\nA number of transurethral ablative techniques based on the use of innovative medical devices have been introduced in the recent past for the surgical treatment of benign prostatic obstruction (BPO).\nObjective\nTo conduct a systematic review of the literature and a meta-analysis of available randomized controlled trials (RCTs), and to evaluate the efficacy and safety of transurethral ablative procedures for BPO.\nEvidence acquisition\nA systematic literature search was performed for all RCTs comparing any transurethral surgical technique for BPO to another between 1992 and 2013. Efficacy was evaluated after a minimum follow-up of 1 yr based on International Prostate Symptom Score, maximum flow rate, and postvoid residual volume. Efficacy at midterm follow-up, prostate volume, perioperative data, and short-term and long-term complications were also assessed. Data were analyzed using RevMan software.\nEvidence synthesis\nA total of 69 RCTs (8517 enrolled patients) were included. No significant difference was found in terms of short-term efficacy between bipolar transurethral resection of the prostate (B-TURP) and monopolar transurethral resection of the prostate (M-TURP). However, B-TURP was associated with a lower rate of perioperative complications. Better short-term efficacy outcomes, fewer immediate complications, and a shorter hospital stay were found after holmium laser enucleation of the prostate (HoLEP) compared with M-TURP. Compared with M-TURP, GreenLight photoselective vaporization of the prostate (PVP) was associated with a shorter hospital stay and fewer complications but no different short-term efficacy outcomes.\nConclusions\nThis meta-analysis shows that HoLEP is associated with more favorable outcomes than M-TURP in published RCTs. B-TURP and PVP have resulted in better perioperative outcomes without significant differences regarding efficacy parameters after short-term follow-up compared with M-TURP. Further studies are needed to provide long-term comparative data and head-to head comparisons of emerging techniques.\nPatient summary\nBipolar transurethral resection of the prostate, photovaporization of the prostate, and holmium laser enucleation of the prostate have shown efficacy outcomes comparable with conventional techniques yet reduce the complication rate. The respective role of these new options in the surgical armamentarium needs to be refined to propose tailored surgical treatment for benign prostatic obstruction relief.","DOI":"10.1016/j.eururo.2014.06.017","ISSN":"0302-2838","title-short":"A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction","journalAbbreviation":"European Urology","author":[{"family":"Cornu","given":"Jean-Nicolas"},{"family":"Ahyai","given":"Sascha"},{"family":"Bachmann","given":"Alexander"},{"family":"Rosette","given":"Jean","non-dropping-particle":"de la"},{"family":"Gilling","given":"Peter"},{"family":"Gratzke","given":"Christian"},{"family":"McVary","given":"Kevin"},{"family":"Novara","given":"Giacomo"},{"family":"Woo","given":"Henry"},{"family":"Madersbacher","given":"Stephan"}],"issued":{"date-parts":[["2015",6,1]]}}}],"schema":""} 1 First line treatment of BPH is lifestyle modifications and subsequent medical therapy. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"Ri9JBqAB","properties":{"formattedCitation":"\\super 2\\nosupersub{}","plainCitation":"2","noteIndex":0},"citationItems":[{"id":68,"uris":[""],"uri":[""],"itemData":{"id":68,"type":"webpage","title":"Benign Prostatic Hyperplasia (BPH) Guideline - American Urological Association","URL":"(bph)-guideline","accessed":{"date-parts":[["2019",9,29]]}}}],"schema":""} 2 However, when BPH is refractory to medical management, surgery treatment is the next step. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"tToS3bHo","properties":{"formattedCitation":"\\super 2\\nosupersub{}","plainCitation":"2","noteIndex":0},"citationItems":[{"id":68,"uris":[""],"uri":[""],"itemData":{"id":68,"type":"webpage","title":"Benign Prostatic Hyperplasia (BPH) Guideline - American Urological Association","URL":"(bph)-guideline","accessed":{"date-parts":[["2019",9,29]]}}}],"schema":""} 2 The standard of care for large prostates is transurethral holmium laser enucleation (HoLEP), thulium laser enucleation (ThuLEP) and simple prostatectomy (SP). ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"KzIeI1xl","properties":{"formattedCitation":"\\super 2\\nosupersub{}","plainCitation":"2","noteIndex":0},"citationItems":[{"id":68,"uris":[""],"uri":[""],"itemData":{"id":68,"type":"webpage","title":"Benign Prostatic Hyperplasia (BPH) Guideline - American Urological Association","URL":"(bph)-guideline","accessed":{"date-parts":[["2019",9,29]]}}}],"schema":""} 2 Simple prostatectomy had been traditionally performed using open technique. However, with recent advances in robotic surgery, the robotic-assisted simple prostatectomy (RASP) has become much more common. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"a27Gbvxc","properties":{"formattedCitation":"\\super 3\\nosupersub{}","plainCitation":"3","noteIndex":0},"citationItems":[{"id":62,"uris":[""],"uri":[""],"itemData":{"id":62,"type":"article-journal","title":"EAU Guidelines on the Treatment and Follow-up of Non-neurogenic Male Lower Urinary Tract Symptoms Including Benign Prostatic Obstruction","container-title":"European Urology","page":"118-140","volume":"64","issue":"1","source":"ScienceDirect","abstract":"Objective\nTo present a summary of the 2013 version of the European Association of Urology guidelines on the treatment and follow-up of male lower urinary tract symptoms (LUTS).\nEvidence acquisition\nWe conducted a literature search in computer databases for relevant articles published between 1966 and 31 October 2012. The Oxford classification system (2001) was used to determine the level of evidence for each article and to assign the grade of recommendation for each treatment modality.\nEvidence synthesis\nMen with mild symptoms are suitable for watchful waiting. All men with bothersome LUTS should be offered lifestyle advice prior to or concurrent with any treatment. Men with bothersome moderate-to-severe LUTS quickly benefit from α1-blockers. Men with enlarged prostates, especially those >40ml, profit from 5α-reductase inhibitors (5-ARIs) that slowly reduce LUTS and the probability of urinary retention or the need for surgery. Antimuscarinics might be considered for patients who have predominant bladder storage symptoms. The phosphodiesterase type 5 inhibitor tadalafil can quickly reduce LUTS to a similar extent as α1-blockers, and it also improves erectile dysfunction. Desmopressin can be used in men with nocturia due to nocturnal polyuria. Treatment with an α1-blocker and 5-ARI (in men with enlarged prostates) or antimuscarinics (with persistent storage symptoms) combines the positive effects of either drug class to achieve greater efficacy. Prostate surgery is indicated in men with absolute indications or drug treatment–resistant LUTS due to benign prostatic obstruction. Transurethral resection of the prostate (TURP) is the current standard operation for men with prostates 30–80ml, whereas open surgery or transurethral holmium laser enucleation is appropriate for men with prostates >80ml. Alternatives for monopolar TURP include bipolar TURP and transurethral incision of the prostate (for glands <30ml) and laser treatments. Transurethral microwave therapy and transurethral needle ablation are effective minimally invasive treatments with higher retreatment rates compared with TURP. Prostate stents are an alternative to catheterisation for men unfit for surgery. Ethanol or botulinum toxin injections into the prostate are still experimental.\nConclusions\nThese symptom-oriented guidelines provide practical guidance for the management of men experiencing LUTS. The full version is available online (gls/pdf/12_Male_LUTS.pdf).","DOI":"10.1016/j.eururo.2013.03.004","ISSN":"0302-2838","journalAbbreviation":"European Urology","author":[{"family":"Oelke","given":"Matthias"},{"family":"Bachmann","given":"Alexander"},{"family":"Descazeaud","given":"Aurélien"},{"family":"Emberton","given":"Mark"},{"family":"Gravas","given":"Stavros"},{"family":"Michel","given":"Martin C."},{"family":"N'Dow","given":"James"},{"family":"Nordling","given":"J?rgen"},{"family":"Rosette","given":"Jean J.","non-dropping-particle":"de la"}],"issued":{"date-parts":[["2013",7,1]]}}}],"schema":""} 3 Multiple studies have shown that RASP has similar effectiveness in terms of relieving LUTS in symptomatic patients while also reducing blood loss, increasing maximum urine flow rate, and shortening length of stay, even in prostates that are above 80 grams. ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"qzFCOsfE","properties":{"formattedCitation":"\\super 4\\nosupersub{}","plainCitation":"4","noteIndex":0},"citationItems":[{"id":55,"uris":[""],"uri":[""],"itemData":{"id":55,"type":"article-journal","title":"Robot-Assisted Versus Open Simple Prostatectomy for Benign Prostatic Hyperplasia in Large Glands: A Propensity Score–Matched Comparison of Perioperative and Short-Term Outcomes","container-title":"Journal of Endourology","page":"1164-1169","volume":"31","issue":"11","source":" (Atypon)","abstract":"Objective: To report the largest comparative analysis of robotic vs open simple prostatectomy (OSP) for large-volume prostate glands.Materials and Methods: We retrospectively reviewed 103 patients that underwent open and 64 patients that underwent robotic simple prostatectomy from 2012 to 2016 at a single institution. A propensity score–matched analysis was performed with five covariates, including age, body mass index, race, Charlson comorbidity index, and prostate volume. Perioperative, postoperative, and functional outcomes were compared between groups.Results: After propensity score matching there were 59 patients in each group available for comparison. There was no statistically significant difference between groups for all preoperative demographic variables. Robotic compared with OSP demonstrated a significant shorter average length of stay (LOS) (1.5 vs 2.6 days, p?<?0.001), but longer mean operative time (161 vs 93 minutes, p?<?0.001). The robotic approach was also associated with a lower estimated blood loss (339 vs 587?mL, p?<?0.001) and lower percentage hematocrit drop (12.3% vs 19.5%, p?=?0.001). Two patients required blood transfusions in the robot group compared with four in the open group, but this was not significant (p?=?0.271). Improvements in maximal flow rate, International Prostate Symptom Score, quality of life, postvoid residual, and postoperative prostate-specific antigen levels were similar before and after surgery for both groups, but there was no difference between groups. There was no difference in complications between groups.Conclusion: Robotic simple prostatectomy is a safe and effective treatment for the surgical management of benign prostatic hyperplasia. It provides similar function outcomes to the open approach; however, offers the advantage of reduced LOS and reduced blood loss.","DOI":"10.1089/end.2017.0489","ISSN":"0892-7790","title-short":"Robot-Assisted Versus Open Simple Prostatectomy for Benign Prostatic Hyperplasia in Large Glands","journalAbbreviation":"Journal of Endourology","author":[{"family":"Sorokin","given":"Igor"},{"family":"Sundaram","given":"Varun"},{"family":"Singla","given":"Nirmish"},{"family":"Walker","given":"Jordon"},{"family":"Margulis","given":"Vitaly"},{"family":"Roehrborn","given":"Claus"},{"family":"Gahan","given":"Jeffrey C."}],"issued":{"date-parts":[["2017",8,30]]}}}],"schema":""} 4, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"5nrctbZx","properties":{"formattedCitation":"\\super 5\\nosupersub{}","plainCitation":"5","noteIndex":0},"citationItems":[{"id":57,"uris":[""],"uri":[""],"itemData":{"id":57,"type":"article-journal","title":"Robot-assisted Simple Prostatectomy for Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Enlargement: Surgical Technique and Outcomes in a High-volume Robotic Centre","container-title":"European Urology","page":"451-457","volume":"68","issue":"3","source":"ScienceDirect","abstract":"Background\nRobot-assisted simple prostatectomy (RASP) is a minimally invasive procedure for treatment of patients with lower urinary tract symptoms (LUTS) due to large benign prostatic enlargement (BPE).\nObjective\nTo present the perioperative and short-term functional outcomes of RASP in a large series of patients with LUTS due to BPE treated in a high-volume referral center.\nDesign, setting, and participants\nWe retrospectively collected data for 67 consecutive patients who underwent RASP from October 2008 to August 2014.\nSurgical procedure\nRASP was performed using a Da Vinci S or Si system with a transvesical approach.\nMeasurements\nComplications were graded according to the Clavien-Dindo system. Continuous variables are reported as median and interquartile range (IQR). Comparison of preoperative and postoperative outcomes was assessed by Wilcoxon test. A two-sided value of p<0.05 was considered statistically significant.\nResults and limitations\nThe median preoperative prostate volume was 129ml (IQR 104–180). For the 45 patients who did not have an indwelling catheter, the median preoperative International Prostate Symptom Score (IPSS) was 25 (20.5–28), the median maximum flow rate (Qmax) was 7ml/s (IQR 5–11), and the median post-void residual volume (PVRV) was 73ml (IQR 40–116). The median operative time was 97min (IQR 80–127) and the median estimated blood loss was 200ml (IQR 115–360). The postoperative complication rate was 30%, including three cases (4.5%) with grade 3b complications (major bleeding requiring cystoscopy and coagulation). The median catheterization time was 3 d (IQR 2–4) and the median length of stay was 4 d (IQR 3–5). The median follow-up was 6 mo (IQR 2–12). At follow-up, the median IPSS was 3 (IQR 0–8), the median Qmax was 23ml/s (IQR 16–35), and the median PVRV was 0ml (IQR 0–36) (all p<0.001 vs baseline values). The retrospective design is the major study limitation.\nConclusions\nOur data indicate good perioperative outcomes, an acceptable risk profile, and excellent improvements in patient symptoms and flow scores at short-term follow-up following RASP.\nPatient summary\nWe analyzed the perioperative and functional outcomes of robot-assisted simple prostatectomy in the treatment of male patients with lower urinary tract symptoms due to large prostatic adenoma. The procedure was associated with a relatively low risk of complications and excellent functional outcomes, including considerable improvements in symptoms and flow performance. We can conclude that the procedure is a valuable option in the treatment of such patients. However, comparative studies evaluating the efficacy of the procedure in comparison with endoscopic treatment of large prostatic adenomas are needed.","DOI":"10.1016/j.eururo.2015.03.003","ISSN":"0302-2838","title-short":"Robot-assisted Simple Prostatectomy for Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Enlargement","journalAbbreviation":"European Urology","author":[{"family":"Pokorny","given":"Morgan"},{"family":"Novara","given":"Giacomo"},{"family":"Geurts","given":"Nicolas"},{"family":"Dovey","given":"Zach"},{"family":"De Groote","given":"Ruben"},{"family":"Ploumidis","given":"Achilles"},{"family":"Schatteman","given":"Peter"},{"family":"Naeyer","given":"Geert","non-dropping-particle":"de"},{"family":"Mottrie","given":"Alexandre"}],"issued":{"date-parts":[["2015",9,1]]}}}],"schema":""} 5, ADDIN ZOTERO_ITEM CSL_CITATION {"citationID":"uzhIpduK","properties":{"formattedCitation":"\\super 6\\nosupersub{}","plainCitation":"6","noteIndex":0},"citationItems":[{"id":66,"uris":[""],"uri":[""],"itemData":{"id":66,"type":"article-journal","title":"Robot-Assisted Simple Prostatectomy: Multi-Institutional Outcomes for Glands Larger Than 100 Grams","container-title":"Journal of Endourology","page":"499-502","volume":"26","issue":"5","source":" (Atypon)","abstract":"Purpose: To present our experience with robot-assisted simple prostatectomy in patients with large gland adenoma (>100?g) that would not be amenable to transurethral treatments.Patients and Methods: From August 2009 to May 2011, 13 robot-assisted simple suprapubic prostatectomies were performed in patients with symptomatic large gland (>100?g) prostatomegaly on transrectal ultrasonography (mean 163?cc). Essential aspects of our technique include a transverse cystotomy just proximal to the prostatovesical junction and use of a robotic tenotomy grasper to aid in adenoma dissection.Results: Mean operative time was 179 minutes (range 90–270?min), and mean estimated blood loss was 219?mL (range 50–500?mL). Mean hospital stay was 2.7 days (range 1–8 d), and the mean urethral catheterization time was 8.8 days (range 5–14 d). None of the patients needed blood transfusion. One patient had an intraoperative urinary leak after bladder closure that was managed with prolonged urethral catheterization (14 d). Histopathologic analysis confirmed benign prostatic hyperplasia (BPH) in all patients, and mean specimen weight on pathologic examination was 127?g (range 100–165?g). Mean follow-up duration was 7.2 months with all patients having a minimum of a 4-month follow-up. Significant improvements were noted in the International Prostate Symptom Score (preoperative vs postoperative 18.1 vs 5.3, p<0.001) and the maximum urine flow rate (preoperative vs postoperative 4.3 vs 19.1?mL/min, P<0.001).Conclusions: Minimally invasive robot-assisted simple prostatectomy is techincally feasible in patients with large volume (>100?g) BPH and is associated with significant improvements in obstructive urinary symptoms. Surgeons with robotic expertise may consider using this approach for treatment of their patients with large volume BPH.","DOI":"10.1089/end.2011.0562","ISSN":"0892-7790","title-short":"Robot-Assisted Simple Prostatectomy","journalAbbreviation":"Journal of Endourology","author":[{"family":"Vora","given":"Anup"},{"family":"Mittal","given":"Sameer"},{"family":"Hwang","given":"Jonathan"},{"family":"Bandi","given":"Gaurav"}],"issued":{"date-parts":[["2012",2,18]]}}}],"schema":""} 6 Many urologists may be hesitant on offering surgical management to patients who are catheter dependent, due to perceived lower rates of post-operative success. However, it is currently unknown whether pre-operative catheter dependence results in worse functional urinary outcomes post-RASP. We sought to compare the post-operative functional outcomes in men with and without pre-operative catheter dependence, who underwent RASP. We performed a retrospective chart review of all patients who underwent RASP at a single institution in Dallas, Texas. We reviewed the electronic medical records of patients who underwent RASP procedures, performed by 2 surgeons, between 12/14 and 10/18. We collected and analyzed baseline patient demographics and compared outcomes such as OR time, estimated blood loss, length of stay, percent change in hematocrit and PSA, percent of tissue removed, and post-operative urinary retention rates, Statistical analyses were performed using SPSS. Tests were two tailed and significance set at p<0.05.In total 231 men underwent RASP during the study period. Of those, fifty-nine [26%] were catheter dependent pre-operatively. We additionally collected demographics and some pre-operative parameters, such as baseline prostate volume, baseline PSA, and baseline IPSS (Table 1). We found men who were catheter dependent did not have significantly different post-RASP catheter dependence from men who were not catheter dependent pre-operatively (1% catheter dependence post-RASP in pre-operative catheter dependent group vs 2% catheter dependence post-RASP in pre-operative catheter independent group: p=0.826) (Table 2). Catheter dependent patients had longer operative times, but all other peri-operative and post-operative measures were not significantly different between the catheter dependent and non-catheter dependent populations (170±49 minutes in the pre-RASP catheter dependent group vs 144±32 minutes in the pre-RASP catheter independent group: p<0.001) (Table 2). Specific peri-operative outcomes, such as percent-change in hematocrit, complications, and length of stay, were not significantly different between groups (p=0.769; p=0.267; p=0.205; respectively) (Table 2). Similarly, post-operative urinary retention rates, maximum flow rate, post void residual, and post-operative IPSS scores were not significantly different between the two populations (p=0.826; p=0.202; p=0.916; 0.156; respectively) (Table 2). This study has several limitations that must be addressed in the future. This population is all from a single center with surgeries conducted by two surgeons and the study itself has the inherent shortcomings of any retrospective study. In the future, we hope to increase the sample size as well as diversify the source of the patient population. Our retrospective chart review found that continued post-RASP urinary retention is low for both catheter dependent and non-catheter dependent patient population and pre-operative catheter dependency was not associated with any significant functional impairments (1% vs 2%; p=0.862; respectively) (Table 2). Our study provides evidence to support the role for RASP in alleviating refractory LUTS, even in men who are catheter depended. Further studies should be performed to confirm our results. This data will provide the basis of an abstract submission to an upcoming urologic conference as well as become incorporated into a larger manuscript early next year. Personally, this project has allowed me to explore Urology early in my medical school career and further understand the intersection of clinical practice and academic research. The direct and immediate impact translational research has on clinical practice and direct patient care is inspiring and I am humbled and grateful at this opportunity. I wish to once again thank the Endourologic Society for this opportunity.Sincerely,Hersh TrivediUT Southwestern Medical CenterMD Candidate, Class of 2022 Table 1. Catheter Dependent (n=59)Non-Catheter Dependent (n=154)p-valueMean Baseline Prostate Volume (g)149 ± 58134 ± 460.064Mean Baseline PSA (ng/mL)7.9 ± 5.07.1 ± 5.20.372Mean Baseline IPSS17.8 ± 7.818.0 ± 7.90.924Table 2.Catheter Dependent (n=59)Non-Catheter Dependent (n=154)p-valueOR Time (minutes)170 ± 49144 ± 32<0.001%? HCT -10.0 ± 9.6-9.6 ± 8.50.769Post Op Retention Yes No1 (1.7%)58 (98.3%)2 (1.3%)152 (98.7%)0.826Complications Yes No8 (13.6%)51 (86.4%)31 (20.1%)123 (79.9%)0.267Length of Stay (days)2.0 ± 2.81.5 ± 1.40.205Post Op Catheter Time (days)5.3 ± 2.24.9 ± 5.00.205Post Op Qmax (mL/sec)21.3 ± 10.218.9 ± 11.10.202Post Op PVR (mL)46.5 ± 66.745.1 ± 84.30.916Post Op IPSS4.8 ± 4.76.5 ± 6.60.156Bibliography: ADDIN ZOTERO_BIBL {"uncited":[],"omitted":[],"custom":[]} CSL_BIBLIOGRAPHY 1. Cornu J-N, Ahyai S, Bachmann A, et al. A Systematic Review and Meta-analysis of Functional Outcomes and Complications Following Transurethral Procedures for Lower Urinary Tract Symptoms Resulting from Benign Prostatic Obstruction: An Update. European Urology. 2015;67(6):1066-1096. doi:10.1016/j.eururo.2014.06.0172. Benign Prostatic Hyperplasia (BPH) Guideline - American Urological Association. (bph)-guideline. Accessed September 29, 2019.3. Oelke M, Bachmann A, Descazeaud A, et al. EAU Guidelines on the Treatment and Follow-up of Non-neurogenic Male Lower Urinary Tract Symptoms Including Benign Prostatic Obstruction. European Urology. 2013;64(1):118-140. doi:10.1016/j.eururo.2013.03.0044. Sorokin I, Sundaram V, Singla N, et 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. Journal of Endourology. 2017;31(11):1164-1169. doi:10.1089/end.2017.04895. Pokorny M, Novara G, Geurts N, et al. Robot-assisted Simple Prostatectomy for Treatment of Lower Urinary Tract Symptoms Secondary to Benign Prostatic Enlargement: Surgical Technique and Outcomes in a High-volume Robotic Centre. European Urology. 2015;68(3):451-457. doi:10.1016/j.eururo.2015.03.0036. Vora A, Mittal S, Hwang J, Bandi G. Robot-Assisted Simple Prostatectomy: Multi-Institutional Outcomes for Glands Larger Than 100 Grams. Journal of Endourology. 2012;26(5):499-502. doi:10.1089/end.2011.0562 ................
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