Robot-assisted Bladder Diverticulectomy Using a Transperitoneal Extravesical Approach

Background: Acquired bladder diverticula (BD) are a possible complication of blad-der outlet obstruction (BOO) due to benign prostate enlargement (BPE). Robot -assisted bladder diverticulectomy (RABD) has been proposed as an alternative to open removal; however, only a few small series have been published. Objective: To describe our surgical technique for RABD and to assess perioperative results and functional outcomes at 6-mo follow-up. Design, setting, and participants: A prospective single-centre, single-surgeon cohort of 16 consecutive men with posterior or posterolateral BD due to BOO/BPE under-going RABD between May 2017 and December 2021 was analysed. Surgical procedure: RABD was performed with a four-arm robotic system via a transperitoneal approach. BD were identified intraoperatively via bladder disten-sion with saline solution through an indwelling catheter with or without concomi-tant illumination using flexible cystoscopy and fluorescence imaging. Extravesical BD dissection and removal were performed. Outcome measurements and statistical analysis: Operating room time, estimated blood loss, intraoperative and postoperative complications, indwelling catheter time, and timing of associated procedures for BOO/BPE were assessed. The International Prostate Symptom Score (IPSS) and postvoid residual volume (PVR) were compared between baseline and 6 mo after surgery. Results and limitations: Median age and maximum BD diameter were 68 yr (in-terquartile range [IQR] 54-74) and 69 mm (IQR 51-82), respectively. The median operative time was 126 min (IQR 92-167) and the median estimated blood loss was 20 ml (IQR 15-40). No intraoperative complications were recorded. The ure-thral catheter was removed on median postoperative day 5 (IQR 5-7). Two men experienced 90-d postoperative complications (persistent urinary infection requir-ing prolonged antimicrobial therapy). Bipolar transurethral resection of the prostate was performed 3 wk before RABD in seven men and concomitant to RABD in nine men. Median IPSS significantly decreased from 25 (IQR 21-30) to 5