Single-Port Robot-Assisted Radical Prostatectomy: Comparison
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In 2018, the da Vinci Single Port (SP) robotic system was approved by the US Food and Drug Administration for urologic procedures. Available studies for the application of SP to prostate cancer surgery are limited. SP-RALP is safe and feasible, and it can offer comparable outcomes to the standard multiport RALP. Extraperitoneal and transvesical SP-RALP appear to be the two most promising approaches, as they offer decreased invasiveness, potentially shorter length of stay, and better pain control. Long-term, high-quality data are missing and further validation with prospective studies across different sites is required.

  • single port
  • radical prostatectomy
  • robotic surgery

1. The Single Port (SP) System

The da Vinci SP (Intuitive Surgical, Sunnyvale, CA, USA) is a novel surgical system with multiple innovations. It uses a single port of 27 mm that allows the introduction of an 8 mm articulating flexible camera and three articulating 6 mm instruments. The 25 mm cannula can be placed directly within the 27 mm incision, or within a GelPOINT® advanced access platform. Although it shares some common features with its predecessors—such as Endowrist manipulators, three-dimensional visualization with magnification and scaled movement, and tremor reduction—the single-port system introduces new peculiarities: a flexible camera, which can rotate in all directions and therefore different perspective angles can be achieved while the instruments maintain a fixed position. Furthermore, a specific feature of the SP called ‘‘relocation’’ allows the entire platform to be moved in any direction around its fulcrum. The camera and each instrument are positioned in the 12, 3, 6, and 9 o’clock positions within the trocar. Port placement is flexible and allows for 360° of robotic docking. Furthermore, a new visual icon, termed the ‘Navigator’, has been introduced, improving cooperation between the instruments and the camera. In doing so, all the instruments can be tracked simultaneously. Finally, the ‘Cobra Mode’ feature, essentially a centered and ~30° flexed position of the camera with optimal instruments visualization, supports the surgeon in identifying the ideal position of the camera within the various instruments during each surgical step.
These new instrument mechanics and innovative features create several specific technical adaptations from the multiport approach, including minimizing instrument clashing and maximizing workspace within the patient, additional movements, and changing angulation. On the other hand, the surgical field is reduced, as well as rotation of the instruments, thus requiring expertise and incremented coordination by the surgeon [1].

2. Transperitoneal Approach

As transperitoneal approach represented the most familiar approach for multiport RALP, it is not surprising that it was also the one initially preferred with the adoption of the SP platform. Here, the patient is placed in a 25° Trendelenburg position, an incision is made above the umbilicus, and the peritoneum is entered under direct vision via Hasson technique. An Alexis wound retractor is introduced through the incision, and a GelPOINT Access Platform is secured to the retractor. A valveless Airseal® port can be either placed through a different fascial incision (using same skin incision) or through the GelPOINT retractor. The SP robot is then docked to the SP access port, and the robotic instruments are introduced. The dissection is then handled in a similar way to a multiport transperitoneal RARP, with either a posterior or anterior approach.

3. Extraperitoneal Approach

The extraperitoneal approach for the multiport system has been described [2][3]. Albeit feasible, it is limited by a restricted working space as well as instrument clashing, which did not allow a wide adoption of this approach. The SP platform allows to overcome these limitations, making it more feasible and potentially more appealing [4]. In this case, there is no need for the Trendelenburg position as the patient can lay supine, with a remarkable advantage in terms of anesthesiology support. A single, horizontal infraumbilical incision is made; blunt finger dissection is used to develop the Retzius space to the pubic bone. Recently, a novel SP access kit has been developed, which consists of a wound retractor, an inflatable plastic sphere which provides extra space for the robotic arms—working as a “floating” platform—and an SP robotic trocar. Once the Retzius space is entered, the procedure is carried out in a similar way to the transperitoneal approach.

4. Extraperitoneal versus Transperitoneal Approach

As of the date of publication, there are only two studies comparing extraperitoneal to transperitoneal SP-RALP. The first experience was described by Kaouk et al. [5], demonstrating a significantly shorter postoperative hospital stay and decreased need for postoperative narcotics, as well as shorter operative time for the extraperitoneal cohort. Later, the first and largest multi-institutional propensity score-matched study comparing the two approaches was reported [6]. Results largely echoed findings from the previous study, with exception of the operative time, which was longer in the extraperitoneal group (median 206 vs. 155 min, p < 0.001). The authors justified this finding by the different surgeon experience, additional operative time required for creating the extraperitoneal space, and more frequent lymph node dissection cases in the extraperitoneal cohort [6].
In summary, the extraperitoneal approach appears to be a less invasive approach, consequently resulting in less operative time and fewer days of hospitalization, with possible same-day discharge (SDD) in most cases. The possibility of avoiding the peritoneum, thus avoiding peritoneal irritation and postoperative ileus, also allows to perform cases with extensive previous abdominal surgery, and to minimize the postoperative use of narcotics. Furthermore, lack of steep Trendelenburg and pneumoperitoneum may also expedite postoperative recovery and facilitate anesthesia. All these factors may be responsible for shortening hospitalization length [2][7]. On the other hand, the extraperitoneal approach is potentially associated with increased CO2 absorption, resulting in hypercapnia and, possibly, systemic acidosis [8]. Although these complications appear to be rare, surgeons must be aware of this problem, and pneumo pressure should be kept at lower levels compared to what is usually used in transperitoneal cases. A history of prior laparoscopic extraperitoneal mesh herniorrhaphy or kidney transplantation might represent another relative contraindication to the extraperitoneal approach, as access to the retropubic space would be limited due to adhesions and scar fibrosis. In this case, the transperitoneal approach may be more feasible [2]. The learning curve for extraperitoneal radical prostatectomy (EPRP) might be a steep one due to restricted working space, therefore young or less-experienced surgeons may prefer starting with the transperitoneal approach to achieve more confidence and dexterity with the single-port platform. Regarding oncological and functional outcomes, there appear to be no significant differences between the two approaches. Positive surgical margins were comparable, and the stress incontinence rate was similar at 3 and 6 months [3][9].

5. Perineal Approach

First described by Young in 1905, perineal radical prostatectomy was the most common access for surgical treatment of prostate cancer for almost seven decades. However, this technique became less favored due to technical complexity and the narrow operative space. Robotic-assisted perineal radical prostatectomy was shown to be feasible, despite some technical challenges. However, limited clinical series exist to date [10].
The Cleveland Clinic group recently reported the only clinical series on SP robotic perineal radical prostatectomy [11]. Briefly, the patient is placed in the lithotomy position and a 4–5 cm perineal incision is made. After dissecting the subcutaneous tissue and dividing the central tendon, the external sphincter muscle is retracted superiorly. Then, the GelPOINT device is placed, and the robot is docked. The posterior prostatic space is developed, levator ani fibers are split along the lateral aspects of the prostate, and the Denonvilliers fascia is opened to find the plane of seminal vesicles and vasa deferens; bilateral vascular pedicles are identified and ligated followed by prostatic apex and urethra dissection; the bladder neck is identified and opened and vesicourethral anastomosis is performed according to the habitual technique. When lymphadenectomy is indicated, the access to bilateral pelvic lymph nodes is achieved with the same incision and does not require another access as previously described. The inferior lateral perivesical space, that was initially prepared after the splitting of the levator ani muscle, is now utilized for gaining exposure to the obturator fossa and the inferior edge of the external iliac vein. To note, the anatomy is reversed from the typical retropubic approach: the obturator structures will be encountered before the external iliac vein. Kaouk et al. compared SP transperineal radical prostatectomy to standard multiport transperitoneal RALP performed by the same surgeon at the beginning of the SP experience. Overall, the study showed equivalent functional and oncological outcomes at 12 months, but a higher complication rate and a higher positive surgical margin detection was recorded in the SP group (38.5% vs. 7.7%, p < 0.01) [11].
In conclusion, robotic SP perineal radical prostatectomy is a feasible but challenging procedure. Its role is limited to very selected cases and in centers with enough expertise to perform this procedure.

6. Transvescical Approach

After describing the single-port transvescical approach for simple prostatectomy [12][13], Kaouk et al. reported an initial clinical experience for SP transvescical radical prostatectomy. The oncological and functional outcomes were comparable with other approaches, although the sample size was limited [14]. In this procedure, the patient is placed in a supine position and an incision is made 4 cm above the pubic symphysis; after distension of the bladder, a GelPOINT trocar is percutaneously inserted into the bladder and the multichannel SP cannula is inserted through the GelPOINT GelSeal cap. The pneumo-vesicum is then created with carbon dioxide insufflation and is robot docked. Access to the prostate is gained by incising the bladder neck distal to the trigone and ureteral orifices, thus enabling immediate clear visualization of the peripheral zone of the prostate. The dissection continues toward the apex and then the plane of seminal vesicles is identified; the infratrigonal intravesical incision is then extended circumferentially to complete the bladder neck dissection; the anterior plane of the prostate is then prepared, and anastomosis completed. The benefits of this approach include avoiding unnecessary dissection and mobilization of bladder, bowel mobilization, any need for lysis of adhesions in patients with previous surgery, and Trendelenburg positioning [14]. Moreover, CO2 is minimally absorbed; consequently, patients with significant cardiopulmonary comorbidities may profit an epidural anesthesia rather than general anesthesia. On the other hand, limitations of this approach are mostly related to bladder diseases, such as diverticula, trabeculation, and augmented bladder capacity. Above all, a large volume of the prostate might render this procedure more complex [14].

7. Retzius-Sparing Approach

A Retzius-sparing approach was first described by Bocciardi’s group in Milan [15]. The main goal of this technique is to leave the bladder in its native anatomical position, sparing Santorini’s plexus, endopelvic fascia, puboprostatic ligaments, and the other anterior compartment structures that in robotic radical prostatectomy have been associated with improved urinary continence rates compared with anterior approaches [16][17][18]. In fact, early continence upon catheter removal has been reported in up to 92% of patients [19]. Patient positioning is the same as extra or transperitoneal approach. A 2.5 cm vertical incision is made superior to the umbilicus with the peritoneum. The GelPOINT® Advanced Access Platform is then assembled. Prostatectomy is then performed as described previously by Galfano et al. [15]. Several notable modifications of surgical technique are facilitated by the SP platform. Firstly, the bladder is lifted by the Cadiere forceps at the 12 o’clock position to develop the interfascial or intrafascial plane between the prostatic and Denonvilliers’ fascia. “Cobra” mode camera allows to reach the apices without requiring suspension sutures through the abdominal wall as described in the multiport technique. The dissection of the ventral aspect of the gland is facilitated by the increased degrees of camera articulation provided by the flexible scope.
SP Retzius-sparing radical prostatectomy (SP-rsRALP) has been described in the past three years by initial experience with the cadaveric model and afterward with few series of patients [20][21][22][23]. The largest cohort of SP-rsRALP was presented by Balasubramanian S. et al. who compared this approach to extraperitoneal and transperitoneal ones. The three SP-RALP approaches appear to be safe and feasible, with similarity in terms of perioperative outcomes, oncologic outcomes, and postoperative pain control. Faster and improved returns of both continence and erection were associated with this technique [20]. However, this surgical procedure presents a steep learning curve and potential complications when compared to other accesses [22]. Moreover, working in a smaller operative space makes SP-rsRALP on larger glands technically challenging according to several reports [24]. In fact, other studies reported that rsRALP offers a higher positive surgical margin (53% rate) than classic RALP, especially for anterior tumors [25]. Other limitations may include no lateral aiming point when dissecting the lateral pedicles of the prostate, a poor vision of the bladder neck during dissection and consequently of the position of the ureteric orifices.

References

  1. Garbens, A.; Morgan, T.; Cadeddu, J.A. Single Port Robotic Surgery in Urology. Curr. Urol. Rep. 2021, 22, 1–8.
  2. Kaouk, J.; Valero, R.; Sawczyn, G.; Garisto, J. Extraperitoneal single-port robot-assisted radical prostatectomy: Initial experience and description of technique. BJU Int. 2019, 125, 182–189.
  3. Wilson, C.A.; Aminsharifi, A.; Sawczyn, G.; Garisto, J.D.; Yau, R.; Eltemamy, M.; Kim, S.; Lenfant, L.; Kaouk, J. Outpatient Extraperitoneal Single-Port Robotic Radical Prostatectomy. Urology 2020, 144, 142–146.
  4. Crivellaro, S. In Favor of Extraperitoneal Robotic Radical Prostatectomy: Back to the Future Through a Single-Port Approach. J. Endourol. 2021, 35, 1121–1122.
  5. Kaouk, J.; Aminsharifi, A.; Wilson, C.A.; Sawczyn, G.; Garisto, J.; Francavilla, S.; Abern, M.; Crivellaro, S. Extraperitoneal versus Transperitoneal Single Port Robotic Radical Prostatectomy: A Comparative Analysis of Perioperative Outcomes. J. Urol. 2020, 203, 1135–1140.
  6. Zeinab, M.A.; Beksac, A.T.; Ferguson, E.; Kaviani, A.; Moschovas, M.C.; Joseph, J.; Kim, M.; Crivellaro, S.; Nix, J.; Patel, V.; et al. Single-port Extraperitoneal and Transperitoneal Radical Prostatectomy: A Multi-Institutional Propensity-Score Matched Study. Urology 2023, 171, 140–145.
  7. Congnard, D.; Vincendeau, S.; Lahjaouzi, A.; Neau, A.-C.; Chaize, C.; Estèbe, J.-P.; Mathieu, R.; Beloeil, H. Outpatient Robot-assisted Radical Prostatectomy: A Feasibility Study. Urology 2019, 128, 16–22.
  8. Glascock, J.M.; Winfield, H.N.; Lund, G.O.; Donovan, J.F.; Ping, S.T.S.; Griffiths, D.L. Carbon Dioxide Homeostasis During Transperitoneal or Extraperitoneal Laparoscopic Pelvic Lymphadenectomy: A Real-Time Intraoperative Comparison. J. Endourol. 1996, 10, 319–323.
  9. Checcucci, E.; De Cillis, S.; Pecoraro, A.; Peretti, D.; Volpi, G.; Amparore, D.; Piramide, F.; Piana, A.; Manfredi, M.; Fiori, C.; et al. Single-port robot-assisted radical prostatectomy: A systematic review and pooled analysis of the preliminary experiences. BJU Int. 2020, 126, 55–64.
  10. Garisto, J.; Bertolo, R.; Wilson, C.A.; Kaouk, J. The evolution and resurgence of perineal prostatectomy in the robotic surgical era. World J. Urol. 2019, 38, 821–828.
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  12. Kaouk, J.; Sawczyn, G.; Wilson, C.; Aminsharifi, A.; Fareed, K.; Garisto, J.; Lenfant, L. Single-Port Percutaneous Transvesical Simple Prostatectomy Using the SP Robotic System: Initial Clinical Experience. Urology 2020, 141, 173–177.
  13. Zeinab, M.A.; Kaviani, A.; Ferguson, E.; Beksac, A.T.; Schwen, Z.; Gill, B.; Bajic, P.; Ulchaker, J.; Eltemamy, M.; Kaouk, J. Single-port transvesical versus open simple prostatectomy: A perioperative comparative study. Prostate Cancer Prostatic Dis. 2022, 1–5.
  14. Kaouk, J.; Beksac, A.T.; Zeinab, M.A.; Duncan, A.; Schwen, Z.R.; Eltemamy, M. Single Port Transvesical Robotic Radical Prostatectomy: Initial Clinical Experience and Description of Technique. Urology 2021, 155, 130–137.
  15. Galfano, A.; Ascione, A.; Grimaldi, S.; Petralia, G.; Strada, E.; Bocciardi, A.M. A New Anatomic Approach for Robot-Assisted Laparoscopic Prostatectomy: A Feasibility Study for Completely Intrafascial Surgery. Eur. Urol. 2010, 58, 457–461.
  16. Menon, M.; Dalela, D.; Jamil, M.; Diaz, M.; Tallman, C.; Abdollah, F.; Sood, A.; Lehtola, L.; Miller, D.; Jeong, W. Functional Recovery, Oncologic Outcomes and Postoperative Complications after Robot-Assisted Radical Prostatectomy: An Evidence-Based Analysis Comparing the Retzius Sparing and Standard Approaches. J. Urol. 2018, 199, 1210–1217.
  17. Dalela, D.; Jeong, W.; Prasad, M.-A.; Sood, A.; Abdollah, F.; Diaz, M.; Karabon, P.; Sammon, J.; Jamil, M.; Baize, B.; et al. A Pragmatic Randomized Controlled Trial Examining the Impact of the Retzius-sparing Approach on Early Urinary Continence Recovery After Robot-assisted Radical Prostatectomy. Eur. Urol. 2017, 72, 677–685.
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  19. Galfano, A.; Di Trapani, D.; Sozzi, F.; Strada, E.; Petralia, G.; Bramerio, M.; Ascione, A.; Gambacorta, M.; Bocciardi, A.M. Beyond the Learning Curve of the Retzius-sparing Approach for Robot-assisted Laparoscopic Radical Prostatectomy: Oncologic and Functional Results of the First 200 Patients with ≥1 Year of Follow-up. Eur. Urol. 2013, 64, 974–980.
  20. Balasubramanian, S.; Shiang, A.; Vetter, J.M.; Henning, G.M.; Figenshau, R.S.; Kim, E.H. Comparison of Three Approaches to Single-Port Robot-Assisted Radical Prostatectomy: Our Institution’s Initial Experience. J. Endourol. 2022, 36, 1551–1558.
  21. Koukourikis, P.; Alqahtani, A.A.; Han, W.K.; Rha, K.H. Pure single-port retzius-sparing robot-assisted radical prostatectomy with the da Vinci SP: Initial experience and technique description. BJUI Compass 2022, 3, 251–256.
  22. Bassett, J.C.; Salibian, S.; Crivellaro, S. Single-Port Retzius-Sparing Robot-Assisted Radical Prostatectomy: Feasibility and Early Outcomes. J. Endourol. 2022, 36, 620–625.
  23. Agarwal, D.K.; Sharma, V.; Toussi, A.; Viers, B.R.; Tollefson, M.K.; Gettman, M.T.; Frank, I. Initial Experience with da Vinci Single-port Robot-assisted Radical Prostatectomies. Eur. Urol. 2019, 77, 373–379.
  24. Ficarra, V.; Rossanese, M.; Gilante, M.; Foti, M.; Macchione, L.; Mucciardi, G.; Martini, M.; Giannarini, G. Retzius-sparing vs. standard robot-assisted radical prostatectomy for clinically localised prostate cancer: A comparative study. Prostate Cancer Prostatic Dis. 2022, 1–7.
  25. Oshima, M.; Washino, S.; Nakamura, Y.; Konishi, T.; Saito, K.; Miyagawa, T. Retzius-sparing robotic prostatectomy is associated with higher positive surgical margin rate in anterior tumors, but not in posterior tumors, compared to conventional anterior robotic prostatectomy. Prostate Int. 2023, 11, 13–19.
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