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 80cc (1). 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 (2). 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 (3).
The resection of a very large prostate can lead to significant intraoperative challenges. Therefore, we demonstrate our intrafascial robotic management of a 470g prostate.
56-year-old with LUTS (IPSS: 34) for over six years, complicated with multiple episodes of urinary retention. PSA: 20.6ng/ml. MRI reported a 463cc 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.

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