Transvesical versus extraperitoneal single-port robotic radical prostatectomy: a matched-pair analysis

Single port robot-assisted radical and simple prostatectomy: a systematic review and meta-analysis

BACKGROUND

Aim of our study was to review the current evidence on single port robot-assisted radical prostatectomy (SP-RARP) and SP robot-assisted simple prostatectomy (SP-RASP) procedures.

METHODS

A comprehensive bibliographic search on multiple databases was conducted in July 2023. Studies were included if they assessed patients with non-metastatic prostate cancer or candidate for benign prostatic hyperplasia surgery (P) who underwent SP-RARP or SP-RASP, respectively, (I), compared or not with other surgical techniques (C), evaluating perioperative, oncological, or functional outcomes (O). Prospective and retrospective original articles were included (S). A meta-analysis of comparative studies between SP-RARP and MP-RARP was performed.

RESULTS

A total of 21 studies investigating 1400 patients were included in our systematic review, 18 were related to SP-RARP while 3 to SP-RASP. Only 8 comparative studies were eligible for meta-analysis. Mean follow-up was 8.1 (±5.8) months. Similar outcomes were observed for SP-RARP and MP-RARP in terms of operative time, catheterization time, pain score, complications rate, continence and potency rates, positive surgical margin, and biochemical recurrence. Length of hospital stay was shorter in the SP group after sensitivity analysis (WMD -0.58, 95% IC -1.17 to -0.9, p < 0.05). Subgroup analysis by extraperitoneal approach did not show any statistical difference, except for a lower positive margins rate in the SP extraperitoneal technique compared to MP-RARP. Overall, SP-RASP exhibited shorter hospital stay and lower rate of de novo urinary incontinence when compared to other techniques, while no differences were reported in terms of postoperative International Prostate Symptom Score, post void residual and maximum flow.

CONCLUSIONS

Overall comparable oncological, functional, and perioperative outcomes can be achieved with SP platform. Subgroup analysis by different approaches did not reveal significant variations in outcomes. However, the retrospective nature of the studies, the limited follow-up, and the relatively small sample size of selected Centers may impact these results.

Navigating Now and Next: Recent Advances and Future Horizons in Robotic Radical Prostatectomy

Robotic-assisted radical prostatectomy (RARP) has become the leading approach for radical prostatectomy driven by innovations aimed at improving functional and oncological outcomes. The initial advancement in this field was transperitoneal multiport robotics, which has since undergone numerous technical modifications. These enhancements include the development of extraperitoneal, transperineal, and transvesical approaches to radical prostatectomy, greatly facilitated by the advent of the Single Port (SP) robot. This review offers a comprehensive analysis of these evolving techniques and their impact on RARP. Additionally, we explore the transformative role of artificial intelligence (AI) in digitizing robotic prostatectomy. AI advancements, particularly in automated surgical video analysis using computer vision technology, are unprecedented in their scope. These developments hold the potential to revolutionize surgeon feedback and assessment and transform surgical documentation, and they could lay the groundwork for real-time AI decision support during surgical procedures in the future. Furthermore, we discuss future robotic platforms and their potential to further enhance the field of RARP. Overall, the field of minimally invasive radical prostatectomy for prostate cancer has been an incubator of innovation over the last two decades. This review focuses on some recent developments in robotic prostatectomy, provides an overview of the next frontier in AI innovation during prostate cancer surgery, and highlights novel robotic platforms that may play an increasing role in prostate cancer surgery in the future.

Perioperative, function, and positive surgical margin in extraperitoneal versus transperitoneal single port robot-assisted radical prostatectomy: a systematic review and meta-analysis

BACKGROUND

Extraperitoneal and transperitoneal approaches are two common modalities in single-port (SP) robot-assisted radical prostatectomy (RARP), but differences in safety and efficacy between the two remain controversial. This study aimed to compare the perioperative, function, and positive surgical margin of extraperitoneal with transperitoneal approaches SP-RARP.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, this study is registered with PROSPERO (CRD 42023409667). We systematically searched databases including PubMed, Embase, Web of Science, and Cochrane Library to identify relevant studies published up to February 2023. Stata 15.1 software was used to analyze and calculate the risk ratio (RR) and weighted mean difference (WMD).

RESULTS

A total of five studies, including 833 participants, were included in this study. The SP-TPRP group is superior to the SP-EPRP group in intraoperative blood loss (WMD: - 43.92, 95% CI - 69.81, - 18.04; p = 0.001), the incidence of postoperative Clavien-Dindo grade II and above complications (RR: 0.55, 95% CI - 0.31, 0.99; p = 0.04), and postoperative continence recovery (RR: 1.23, 95% CI 1.05, 1.45; p = 0.04). Conversely, the hospitalization stays (WMD: 7.88, 95% confidence interval: 0.65, 15.1; p = 0.03) for the SP-EPRP group was shorter than that of the SP-TPRP group. However, there was no significant difference in operation time, postoperative pain score, total incidence of postoperative complications, and positive surgical margin (PSM) rates between the two groups (p > 0.05).

CONCLUSIONS

This study demonstrates that both extraperitoneal and extraperitoneal SP-RARP approaches are safe and effective. SP-TPRP is superior to SP-EPRP in postoperative blood loss, the incidence of postoperative Clavien-Dindo grade II and above complications, and postoperative continence recovery, but it is accompanied by longer hospital stays.

The Transition Toward Opioid-sparing Outpatient Radical Prostatectomy: A Single Institution Experience With Three Contemporary Robotic Approaches

OBJECTIVE

To evaluate for differences in the perioperative and early postoperative outcomes between three different contemporary approaches of robotic radical prostatectomy (RARP), namely Single-Port (SP) Transvesical (TV), SP Extraperitoneal (EP), and Multi-Port (MP) Transperitoneal (TP).

METHODS

Retrospective review was performed on 865 consecutive patients with localized prostate cancer who underwent SP-TV, SP-EP, and MP-TP RARP. SP-TV and SP-EP RARP were performed using the purpose-built SP robotic platform. All procedures were performed by a single, experienced robotic surgeon. Demographics, perioperative, and early postoperative data were collected from the prospectively-maintained database. Statistical analysis was performed with descriptive statistics as presented.

RESULTS

All SP cases were completed without any need for conversion or additional ports. When compared with MP-TP RARP, both SP-EP and SP-TV RARP were associated with significantly reduced length of stay (median, SP-TV 5.07 vs SP-EP 5.1 vs MP-TP 26.6 hours, P = <.05) and with most patients being discharged within 24 hours (SP-TV 92.3% vs SP-EP 84.6% vs MP-TP 30.4%, P = <.05). Postoperative analgesia requirements were significantly reduced following SP-TV RARP with 95% did not require opioid analgesia after discharge, as opposed to 77.6% and 12.1% of patients in the SP-EP and MP-TP RARP cohorts, respectively (P = <.05). Additionally, SP-TV RARP demonstrated the added benefit of a shorter Foley catheter duration of 4 days with an earlier return of urinary continence.

CONCLUSION

The localization of RARP, as facilitated by the SP robotic platform, provided the opportunity for enhanced postoperative recovery resulting in decreased length of admission and postoperative pain, which allowed for increasing adoption of opioid-sparing outpatient prostatectomy.

Single-port Transvesical Robot-assisted Radical Prostatectomy: The Surgical Learning Curve of the First 100 Cases

OBJECTIVE

To determine the number of cases required to reach plateau performance.

METHODS

We performed a single-surgeon review of the first 100 consecutive procedures. All procedures were performed using the da Vinci single-port robotic system between November 2020 and March 2022. Time was used as the measure of the learning curve (LC). Relevant surgical steps were considered separately for detailed analysis. Data were collected retrospectively and analyzed through the cumulative sum method and moving average graphing. A comparative analysis was done between subgroups of 20 consecutive cases for perioperative outcomes.

RESULTS

All cases were completed successfully, without extra ports or conversion. The LC for prostate excision showed initial exponential improvement and reached plateau at case 28. Vesicourethral anastomosis time gradually shortened over time, with a clear inflection point at case 10. Total operative time rapidly improved and plateaued early to 213.0 minutes. Robot-docking and undocking, achieving hemostasis, wound closure, and intraoperative idle times were consistent throughout the series. Estimated blood loss decreased significantly after the first 20 cases (from median of 135.0-88.0 mL, P = .03).

CONCLUSION

In our early experience, the LC for single-port transvesical robot-assisted radical prostatectomy suggests that performance improved after 10-30 cases in the hands of an experienced robotic surgeon.

Comparison between intra- and postoperative outcomes of the da Vinci SP and da Vinci Xi robotic platforms in patients undergoing radical prostatectomy

The new SP robot incorporates a single trocar that houses a flexible camera and three bi-articulated arms, which minimize the number of incisions needed to assess the surgical site, allowing for a less invasive procedure. To compare the postoperative pain scale and outcomes in patients with similar demographic characteristics undergoing robotic-assisted radical prostatectomy (RARP) with SP and Xi robots, One-hundred consecutive patients undergoing RARP with the SP robot were matched, using a propensity score (PS), with 100 patients from a cohort of 1757 who were operated on with the da Vinci Xi from June 2019 to January 2021. We described and compared the perioperative pain scores and outcomes of both groups. The SP group had less blood loss (50 cc vs. 62.5 cc, P < 0.001) and longer operative time (114 min. vs. 94 min, P < 0.001). The only period we could show a difference in postoperative pain scores was 6 h after surgery, with a small advantage for the SP (2 vs. 2.5, P < 0.001). Both groups had satisfactory postoperative continence recovery, 91% vs. 90% for the SP and Xi, respectively. The groups had a mean follow-up of 24.5 and 22 months for SP and Xi, respectively. The tumor stage and percentage of positive surgical margins were similar between groups (15% vs. 15%, P = 1). Patients undergoing RARP with the SP had longer operative times with less blood loss than the Xi. However, despite the lower number of abdominal incisions on the SP, the groups had similar intraoperative performance, and we were unable to demonstrate clinically significant differences in postoperative pain scores between the groups 6, 12, and 18 h after surgery.

Single-port robot-assisted perineal radical prostatectomy with the da Vinci XI system: initial experience and learning curve using the cumulative sum method

BACKGROUND

To evaluate the early functional and oncological outcomes of single-port robot-assisted perineal radical prostatectomy (sp-pRARP) using the da Vinci XI system and analyze its learning curve using the cumulative sum (CUSUM) method.

METHODS

The clinical data of 50 patients who underwent sp-pRARP for localized prostate cancer between May 2020 and May 2022 in our center by a single surgeon were analyzed retrospectively. Demographic information, preoperative and postoperative variables, complications, early functional and oncological outcomes of patients were recorded. The CUSUM method was used to illustrate the learning curve based on operation time.

RESULTS

All surgeries were completed without conversion. The median (interquartile range, IQR) operation time was 205.0 (82.5) min, whereas the median (IQR) docking time was 30.0 (15.0) min and the console time was 120.0 (80.5) min. The median (IQR) estimated blood loss (EBL) was 50.0 (137.5) mL. Positive surgical margins were detected in five patients (10.0%). The continence rate was 40.9%, 63.6%, 88.4%, and 97.7% at the 1, 3, 6, and 12 months after surgery. According to the CUSUM plot, the inflection points of the learning curve were 20 cases, splitting the case series into "early phase" and "late phase." In "late phase" cases, there was less time spent on each step of the operation and less EBL.

CONCLUSIONS

Sp-pRARP using the da Vinci XI system was verified to be a feasible and reliable surgical approach. According to the CUSUM plot, 20 cases was considered the turning point for surgeons to master the novel technique.