Future of BPH Surgery is Urethra Preserving!

Madigan prostatectomy was published in 1990. During open prostatectomy the urethra was preserved and the prostate lobes including middle lobes were removed. At no time during surgery and postoperatively urine and blood do not mix together. Catheter time is short. Most complications of BPH surgery are avoided.

I watched video of Lap Madigan Prostatectomy in Shanghai end of 2019. The series was of about 35 patients with excellent results.
I compare Ureter to prostatic urethra. Ureteric obstruction is classified as in the lumen: stone and we get patients with stone obstructed in the prostatic urethra. Ureteric obstruction in the wall: stricture and we perform ureteroplasty(Lap BMG augment for longer stricture) and we can get prostatic  urethral stenosis usually at the beginning (BNO) or end of prostatic urethra( Trauma) and needs urethroplasty.Ureteric obstruction due to  Retro Peritoneal Fibrosis(RPF) and we do not enter the ureter, Prostatic obstruction is outside the urethra and as a urethra surgeon I would request my friends not to destroy prostatic urethra. The Future of BPH surgery is Urethra Preserving. Prof Venugopal has posted photos of 3 new procedures where the results of these techniques look promising. 

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  • Rahul Kapoor
    Rahul Kapoor
    09 Mar 2021 12:59:36 PM


     is their any video one can watch.
     Please share the link if you have.
     i couldnt find on youtube

  • Venugopal P
    Venugopal P
    15 Mar 2021 10:55:59 AM

    Dear All,

    For some time now Sanjay has been talking about Madigan’s Urethral Preserving prostatectomy as the way simple prostatectomy should be done. With the Introduction of Robotics in almost all surgeries in Urology, RASP is gaining popularity. Robot Assisted Simple Prostatectomy is being recommended as a safe alternative to other evolving techniques even, though advocates of the newer technologies are opposing it vehemently.

    Madigan Introduced his Urethral Sparing Simple Prostatectomy way back. It did not gain much acceptance then and is being revived after the introduction of Robots. The main reason for this is the Magnification and better vision available with usage of Robots which the naked eye could not discern properly. Credit for Introduction of RASP was given to Sotelo but I have read sometime in 2007 or 8 that Mihir was the first to perform a pilot study on the feasibility of RASP by Retropubic Route.

    Recently much has been talked about RASP with an article by H John* et al (2021) addressing this issue of the need for conversion from open to Robot Assisted Technique.


    I am providing a Video link which explains RASP


    As mentioned initially Madigan Technique was performed as an open procedure and did not gain much popularity because of visibility for preserving urethra while dissecting out the lobes. If the urethra got opened and damaged, the procedure was converted into conventional techniques of Open Simple Prostatectomy.

    Lu Jun* (2005) published their experience with Open Madigan Prostatectomy.


    Urethral Sparing Robotic Madigan Prostatectomy is gaining popularity of late and articles are now published on this.

    I am providing 3 articles that could be of benefit

    Urethral-sparing Robot-assisted Simple Prostatectomy: An Innovative Technique to Preserve Ejaculatory Function Overcoming the Limitation of the Standard Millin Approach

    Francesco Porpiglia* et al, 2020

    Urethra and Ejaculation Preserving Robot-assisted Simple Prostatectomy: Near-infrared Fluorescence Imaging-guided Madigan Technique

    Giuseppe Simone* et al, 2019

    Rahul Kapoor can get the Video of ‘Urethra Sparing Robot-Assisted Simple Prostatectomy: Modified Madigan Technique’. I am providing the link but the video can be obtained for only those with Access to Endourology – Videourology. Either of the links can be used.

    https://www.liebertpub.com/doi/10.1089/vid.2020.0062  or


    I hope we will continue to have discussions on Sanjay’s Post ‘Future of BPH Surgery is Urethra Preserving’. I salute Sanjay on his effort to keep us thinking and progressing.

    With warm regards,



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  • Dr Sanjay Balwant Kulkarni
    Dr Sanjay Balwant Kulkarni
    16 Mar 2021 08:16:51 AM

    Respected Venu SIr

    Thanks a lot for your thoughts and links for "Urethra sparing prostatectomy".
    The surgery is beneficial for the patient and I wish to stimulate minds of doctors and engineers who wish to invent new techniques for BPH treatment.
    The logistics and finances are also important.
    In USA 30,00,000 surgeries are performed for BPH compared to 300,000 radical prostates.(Please correct me if some one has correct and latest figures)
    Rezum was sold for 400 Million $ and Urolift for 1Billion $.
    Chinese are ahead with series of lap Madigan prostatectomies!
    We need more inventions from India to be a world leader.

  • Dr. Roy Chally
    Dr. Roy Chally
    16 Mar 2021 11:40:30 AM

    Sanjay is very logical in his argument that we should not remove the posterior urethra in surgery for obstructive with benign enlargement of Prostate. Preservation of sexual function is the main advantage of preserving the posterior urethra. We need good studies to show better preservation of sexual function with urethra sparing surgery. Cost also should be a consideration in treating this condition. Innovation is the need of the times in removing the adenoma alone without 

    injuring adjacent structures in a cost effective technique. Obviously preserving sexual function may not be an issue in a group of our patients. 

  • Venugopal P
    Venugopal P
    16 Mar 2021 11:41:02 AM

    Dear All,

    The cost of Surgical Treatments for various procedures that are recently developed for LUTS/BPH are prohibitive for most Indians if the figures shown by Sanjay is exact which I believe could be.

    Urethral sparing surgery (Madigan and its modifications) are being reinvented with Robotic Technology taking a lead.

    But the question that remains is whether this procedure is feasible for all patients needing Simple Prostatectomy. It has been well documented that Patients who have associated infections lurking in the prostate and those having large median lobe are not suitable for this procedure. Hence it should be realised that no one procedure is suitable for a single procedure and one should never have the principle ‘my way or no way’. Choosing appropriate procedure for an individual depends on various factors and not on technology alone.

    With Warm Regards,


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