Editorial Comment for Coelho et al.

L arge median lobes can pose a unique set of challenges during robot-assisted prostatectomy because they frequently distort the trigonal anatomy and the ureteral orifices can be very close to the bladder neck. In addition, the presence of a large median lobe usually results in a wide bladder neck necessitating bladder neck reconstruction.

In this article, the authors retrospectively evaluate the impact of a median lobe on both surgical margins and continence after robot-assisted prostatectomy. Data were analyzed on 1693 patients undergoing robot-assisted prostatectomy of which 323 (19%) patients had a median lobe. The authors, however, did not really quantify the size of the median lobe. One would not expect the smaller median lobes to have any significant impact on the outcomes, and therefore quantifying them would have been helpful.

The authors and others ^1,2 have previously reported that median lobes do not result in higher positive surgical margins. In the current study, the authors noted a slightly higher operative time in patients with a median lobe but no significant difference in return of continence between groups. They report a median time to continence of 5 weeks. Notably, the authors report a 65% bladder neck reconstruction rate even in patients who did not have a median lobe.

Overall, these are excellent results in experienced hands and should not be generalized. Median lobes can be particularly challenging to tackle in the beginning of one's learning curve, and patient selection is very vital for optimal results.