Initial Experience on Extraperitoneal Single-Port Robotic-Assisted Radical Prostatectomy
The evolution of radical prostatectomy (RP) has transitioned from open surgery to minimally invasive techniques, with robotic-assisted radical prostatectomy (RARP) emerging as a preferred approach for localized prostate cancer (PCa). While transperitoneal RARP remains the most common route, alternative approaches such as extraperitoneal, perineal, or transvesical access have been explored. Recent advancements in robotic platforms, including the da Vinci Xi and single-port (SP) systems, have facilitated the adoption of robotic laparoendoscopic single-site surgery (R-LESS) across various specialties. Despite the initial report of single-port robotic-assisted radical prostatectomy (spRARP) in 2008, technical challenges such as limited working space, instrument collision, and prolonged operative times have hindered widespread adoption. This study introduces a novel approach—extraperitoneal single-port RARP (espRARP)—using the da Vinci Si HD system, demonstrating its feasibility and perioperative outcomes in a cohort of 19 patients.
Surgical Technique and Patient Selection
The study retrospectively analyzed 19 patients aged 57–78 years with biopsy-confirmed PCa between November 2018 and September 2019. All patients exhibited organ-confined disease on multiparametric magnetic resonance imaging and bone scintigraphy, with no indications for pelvic lymph node dissection based on Briganti nomogram assessments. Preoperative evaluations categorized one patient as low-risk and 18 as intermediate-risk according to D’Amico criteria. Nerve-sparing procedures were performed in four preoperatively potent patients. The surgeries were conducted by an experienced console surgeon with over 700 prior RARP cases, supported by a fixed team of surgical assistants and nurses.
Under general anesthesia, patients were positioned in a 15°–20° Trendelenburg tilt. A 5 cm transverse incision was made 5 cm above the pubic symphysis. After incising the anterior rectus fascia and separating the rectus abdominis, an extraperitoneal workspace was created using an inflated surgical glove as a homemade dilator. A commercial 100-mm multichannel laparoscopic port (Senscure Biotech Co., Ltd., China) was inserted beneath the rectus muscle [Figure 1A]. The da Vinci Si HD system (Intuitive Surgical, USA) was equipped with 8-mm monopolar scissors and Maryland bipolar forceps. To minimize instrument clashing, a 12-mm 30° high-definition laparoscope was positioned at the caudal port and angled 30° upward throughout the procedure [Figure 1B].
Key surgical steps included removal of anterior prostatic fat, incision of lateral endopelvic fasciae, ligation of the dorsal venous complex with 2-0 Monocryl suture, transection of the bladder neck, and dissection of seminal vesicles. The prostate was mobilized extra- or intra-fascially based on nerve-sparing eligibility. After urethral transection, the prostate was extracted in a specimen bag, followed by urethrovesical anastomosis using a 3-0 bidirectional barbed suture. A Jackson-Pratt drain was placed through the same incision before closure [Figure 1C].
Perioperative Outcomes and Complications
The median operative time was 95.0 minutes (IQR: 67.5–110.0), with a console time of 68.5 minutes (IQR: 50.75–82.25). Estimated blood loss was 50 mL (IQR: 50.0–100.0), and no cases required conversion to open surgery or additional ports. Patients were discharged after a median postoperative stay of 3 days (range: 1–4), with Foley catheters removed at 14 days. No Clavien-Dindo grade ≥III complications occurred. One patient experienced wound dehiscence 10 days post-discharge, managed conservatively without infection.
Pathologic analysis revealed locally advanced disease in 52.6% (10/19) of cases, including eight with extracapsular extension and two with seminal vesicle invasion. Positive surgical margins were observed in 15.8% (3/19). Adjuvant therapies included external beam radiation therapy (EBRT) in four patients, two of whom received combined androgen deprivation therapy.
Functional and Oncologic Outcomes
Continence recovery rates were 26.3% (5/19) immediately after catheter removal, improving to 36.8% (7/19) at 1 month, 73.7% (14/19) at 3 months, and 100% (15/15) at 6 months. Among four nerve-sparing cases, two reported spontaneous morning erections within one month without phosphodiesterase-5 (PDE5) inhibitors. Median follow-up was 7 months (range: 3–13), with no biochemical recurrences (PSA <0.2 ng/mL) observed.
Advantages and Limitations
The extraperitoneal approach offers distinct benefits, including reduced intra-abdominal adhesions, avoidance of extreme Trendelenburg positioning, and faster recovery due to minimized facial and airway edema. The single-port design further decreases abdominal trauma and cosmetic concerns. However, technical challenges persist, particularly in pelvic lymph node dissection (PLND), which remains unvalidated in the espRARP setting. Limited working space and instrument collision, though mitigated by caudal camera positioning and lower abdominal incisions, still pose hurdles for inexperienced surgeons.
Clinical Implications and Future Directions
This study validates espRARP as a safe and feasible option for localized PCa, with perioperative outcomes comparable to conventional multi-port transperitoneal RARP. The technique’s reproducibility in high-volume centers underscores its potential for broader adoption, particularly in patients with prior abdominal surgeries or contraindications to transperitoneal access. Future prospective studies with larger cohorts and extended follow-up are necessary to evaluate long-term oncologic outcomes, cost-effectiveness, and comparative advantages over existing techniques.
DOI: https://doi.org/10.1097/CM9.0000000000001145
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