Single-port, Retzius-sparing robotic-assisted radical prostatectomy: feasibility and early outcomes

Single-port robot-assisted radical prostatectomy

PURPOSE

To provide a comprehensive update on the different techniques and outcomes of contemporary Single-Port (SP) Robotic Radical Prostatectomy (RARP) approaches.

METHODS

A literature review was performed to identify cohort studies that have utilized the purpose-built SP robotic platform (Intuitive Surgical Inc., Sunnyvale, California) for RARP. All published approaches of SP-RARP were included in our review. Baseline clinical, perioperative, and postoperative oncological and functional outcomes were collected from the included studies.

RESULTS

A total of 16 studies involving 1159 patients were identified. To date, five approaches of SP-RARP have been described, namely Transperitoneal, Extraperitoneal, Retzius-Sparing, Transperineal, and Transvesical. The surgical steps and clinical outcomes of the aforementioned approaches were discussed. While operating times were still faster in the Transperitoneal and Extraperitoneal cohorts, the novel and more regionalized Transvesical approach allowed for radical prostatectomy to be pursued in more patients with previous abdominal surgeries and contributed to significantly improved postoperative outcomes, including the earlier return of urinary continence and with most patients being discharged on the same day without any opioids.

CONCLUSION

Based on the existing literature, the introduction of SP-RARP not only enriched the repertoire of minimally-invasive surgical treatment options for prostate cancer but also provided the opportunity for urologists to develop new techniques that can improve perioperative outcomes and postoperative quality of life. Given the limited number of patients and heterogeneity in the patient selection and reporting of postoperative outcomes, further research remains necessary to better understand the different benefits and improve patient selection algorithms for the different techniques.

Predictors of Early Continence After Single-port Transvesical Robot-assisted Radical Prostatectomy

OBJECTIVE

To identify the factors associated with a short time of return to continence.

METHODS

We analyzed the first 110 SP TV RARP consecutive cases performed by one surgeon from 2020 to 2022. Continence was defined as zero to one safety pad. Two statistical analyses were done. First, patients were divided: group A (n = 62) included individuals who achieved continence within the initial week postcatheter removal; group B (n = 48) rest of the patients. Descriptive statistics were compared, followed by logistic regression for independent variables. Second, time to continence was analyzed as a continuous variable employing linear regression. The primary outcomes were the independent variables significantly associated with a short time to continence.

RESULTS

All cases were completed successfully, without additional ports or conversions. Median urinary catheter duration and time to continence were 3 and 3.5days, respectively. Patients achieving continence within 1week significantly presented with fewer preoperative urinary tract symptoms, lower prostate-specific antigen levels, and had smaller specimen weights postoperatively. Multivariable logistic regression established low specimen weight as the sole significant factor (P = .04). Furthermore, linear regression demonstrated that alterations in independent variables accounted for 12.7% of the variance in time to continence (P = .62).

CONCLUSION

The regionalization of surgery to the bladder employing a retropubic space-sparing extraperitoneal approach during SP TV RARP contributes to a fast return to continence. According to our model, the factors that significantly predict a shorter time to continence include lower preoperative International Prostate Symptom Score, prostate-specific antigen, and postoperative specimen weight.

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.

Early outcomes of single-site versus multi-port robotic-assisted radical prostatectomy: A systematic review and meta-analysis

BACKGROUND

Single-site robotic-assisted radical prostatectomy (ssRARP) has been promoted in many institutions due to its minimally invasive approach. This review aimed to investigate early outcomes of ssRARP in comparison with multi-port robotic-assisted radical prostatectomy (mpRARP).

METHODS

A systematic literature search was performed for articles related to ssRARP case series and studies that compared ssRARP with mpRARP. The primary outcomes were functional and oncological outcomes, incision length, length of hospital stay and cost.

RESULTS

24 ssRARP case series involving 1385 cases, and 11 comparative studies involving 573 ssRARP cases and 980 mpRARP cases were included. Rate of immediate, 3-month, 6-month and 12-month recovery of continence in the ssRARP case series were 41 % [95 % CI: 0.38-0.45], 70 % [95 % CI: 0.67-0.73], 90 % [95 % CI: 0.87-0.93] and 93 % [95 % CI: 0.90-0.96]. 3-month potency recovery and positive surgical margin rate were 53 % [95 % CI: 0.46-0.60] and 21 % [95 % CI: 0.19-0.24]. No significant differences were detected between ssRARP and mpRARP in terms of 3-month (OR: 1.12; 95 % CI: 0.80-1.57) or 6-month (OR: 0.72; 95 % CI: 0.36-1.46) continence recovery rate, 3-month potency recovery rate (OR: 0.92; 95 % CI: 0.50-1.70), positive surgical margin rate (OR: 0.83; 95 % CI: 0.62-1.11), biochemical recurrence rate or total cost. Furthermore, ssRARP was associated with a significantly shorter length of incision and hospital stay.

CONCLUSION

ssRARP has significant advantages in cosmetic effect, length of incision and rapid recovery. Consequently, ssRARP is expected to become the preferred form although more evidence is needed to determine its long-term effect.

Robot-assisted Surgery in the Field of Urology: The Most Pioneering Approaches 2015-2023

Robot-assisted surgery has emerged as a transformative technology, revolutionizing surgical approaches and techniques that decades ago could barely be imagined. The field of urology has taken charge in pioneering a new era of minimally invasive surgery with the ascent of robotic systems which offer enhanced visualization, precision, dexterity, and enabling surgeons to perform intricate maneuvers with improved accuracy. This has led to improved surgical outcomes, including reduced blood loss, lower complication rates, and faster patient recovery. The aim of our review is to present an evidence-based critical analysis on the most pioneering robotic urologic approaches described over the last eight years (2015-2023).

Recent advances in single-site/incision robotic-assisted radical prostatectomy

INTRODUCTION

Single-site robotic-assisted radical prostatectomy (ssRARP) has been successfully applied to treat prostate cancer. This review aims to describe the recent advances of surgical approaches, working accesses and novel robotic platforms in ssRARP.

MATERIAL AND METHODS

A systematic literature search was performed by searching the PubMed, EMBASE, Web of Science and Scopus databases in December 2022 to identify all literature related to ssRARP.

RESULTS

A total of 48 relevant studies were found worldwide from 2008 to 2023. Since the introduction of ssRARP, various modifications of this technique in surgical approaches, working accesses and novel robotic platforms have been developed. The application of ssRARP using the da Vinci SP platform has shown great superiority with encouraging clinical outcomes.

DISCUSSION

There has been a potential shift toward ssRARP using the da Vinci SP platform due to its potential advantages in terms of lower blood loss, minimal postoperative pain, better cosmetic outcome and rapid recovery. More convincing evidence, further technical improvement and higher cost-effectiveness are needed for its widespread acceptance.

Single-Port Robot-Assisted Radical Prostatectomy: Where Do We Stand?

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. The aim of our study is to summarize the current evidence on the techniques and outcomes of SP robot-assisted radical prostatectomy (SP-RARLP) procedures. A narrative review of the literature was performed in January 2023. Preliminary results suggest that 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 Extraperitoneal and Transperitoneal Radical Prostatectomy: A Multi-Institutional Propensity-Score Matched Study

OBJECTIVE

To compare the perioperative and early postoperative outcomes between single-port (SP) extraperitoneal radical prostatectomy (EPRP) and SP transperitoneal radical prostatectomy (TPRP), in a multi-institutional setting.

METHODS

We identified all patients who underwent SP robot-assisted radical prostatectomy at 6 different institutes. Data of 650 patients were collected and divided into 2 groups based on the surgical approach: SP EPRP or SP TPRP. A Propensity-score matched-pair analysis for body mass index (BMI), prostate size, and National Comprehensive Cancer Network risk was performed with a 1:1 ratio. Analysis of perioperative and postoperative outcomes was performed using Wilcoxon signed-rank test and chi-square and Fisher's exact tests.

RESULTS

After matching, 238 patients were included in each arm. The median follow-up period was 7 and 6 months for EPRP and TPRP groups, respectively. The total operative time was longer in the EPRP group (206 vs 155 minutes, P < .001). The EPRP group had a shorter length of hospitalization and same-day discharge rate compared to the TPRP approach (P < .001). There was no difference in the overall intraoperative or postoperative complications rate between the 2 groups, nor positive surgical margin rates.

CONCLUSION

The SP extraperitoneal approach is associated with a shorter hospital stay and higher rate of same-day discharge, with no difference in the surgical margin, or complication rates.

Comparison of Three Approaches to Single-Port Robot-Assisted Radical Prostatectomy: Our Institution's Initial Experience

Background: We aimed to compare three robot-assisted radical prostatectomy (RARP) approaches-Retzius sparing (RS), extraperitoneal (EP), and transperitoneal (TP)-performed at our institution using the da Vinci® single-port (SP) platform (Intuitive Surgical, Sunnyvale, CA). Materials and Methods: We retrospectively reviewed the records of 101 patients who underwent SP-RARP at our institution and stratified them into three cohorts based on the RARP approach: RS (n = 32), EP (n = 30), and TP (n = 39). Data regarding preoperative patient characteristics, perioperative characteristics, oncologic outcomes, and early functional outcomes were collected. The Fisher's exact test and chi-square tests were utilized for categorical variables, and the Kruskal-Wallis test was utilized for numerical variables. Wilcoxon rank-sum tests were utilized for pairwise comparisons. A two-tailed p < 0.05 was considered significant. Results: All three cohorts were largely similar in terms of preoperative patient characteristics. Operative time was significantly different between cohorts (p < 0.001), with the RS approach having a faster mean operating time than the TP approach (208 ± 40 minutes vs 248 ± 36 minutes, p < 0.001). Clinically significant margin rates did not differ significantly between cohorts (p = 0.861). Postoperative continence differed significantly between cohorts (p < 0.001); higher continence rates were observed in RS vs EP-94% (30/32) vs 52% (15/29), respectively, p < 0.001. Return of erectile function also differed significantly between cohorts (p = <0.001); higher erectile function recovery rates were observed in RS vs EP-88% (28/32) vs 41% (11/27), respectively, p < 0.001-and in RS vs TP-88% (28/32) vs 60% (22/37), respectively, p = 0.014. Median (IQR) follow-up time was 150 (88-377) days. Conclusions: RS SP-RARP is associated with improved early functional outcomes when compared with both EP and TP approaches. These benefits are achieved while maintaining equivalent oncologic outcomes. Further research is needed to optimize the patient selection paradigm for the SP-RARP approach.

Robot-assisted radical prostatectomy: Advancements in surgical technique and perioperative care

We reviewed the evolving strategies, practice patterns, and recent advancements aimed at improving the perioperative and surgical outcomes in patients undergoing robot-assisted radical prostatectomy for the management of localized prostate cancer.

Da Vinci SP radical prostatectomy: a multicentric collaboration and step-by-step techniques

INTRODUCTION

Several techniques of robotic-assisted radical prostatectomy (RARP) using the da Vinci SP (SP) have been described since its clearance by the FDA (Food and Drug Administration) in 2018 (1, 2). Even with the expanding literature about this robot, the SP technology has been restricted to a few centers in the US and Asia due to the recent release of this robot in the marked.3 In this scenario, we provided, in this video compilation, a consensus of SP referral centers describing the current approaches and techniques of da Vinci SP Radical prostatectomy (SP-RARP).

SURGICAL TECHNIQUE

We have illustrated five different techniques, including transperitoneal, extraperitoneal, Retzius-sparing, transvesical, and transperineal (4-6). Each surgery demonstrated crucial steps from the trocar placement until anastomosis. All approaches follow anatomic concepts and landmarks to minimize positive surgical margins, optimize oncological outcomes and promote optimal functional recovery. The trocar placement and the use of an assistant port were selected according to the operative technique of each institution. None of these surgeries had intra- or postoperative complications, and the pain management until discharge was controlled without using narcotics. All patients were discharged in less than 16 hours of surgery.

CONCLUSION

Robotic-assisted radical prostatectomy performed with the da Vinci SP is feasible and safe with optimal perioperative outcomes. Five different approaches were described in this video compilation, and we believe that the technical details provided by this multicentric collaboration are crucial for centers willing to initiate the SP approach to radical prostatectomy.