Extraperitoneal single‐port robot‐assisted radical prostatectomy: initial experience and description of technique

Abstract

Objective To describe our technique of extraperitoneal single‐port (SP) robot‐assisted radical prostatectomy (RARP) and present our clinical experience with the first 10 cases. Patients and Methods In all, 10 consecutive patients diagnosed with localised prostate cancer underwent extraperitoneal SP‐RARP using the da Vinci SP® Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Exclusion criteria included previous surgery through an infra‐umbilical midline incision, prostate size >100 g, or preoperative evidence of extraprostatic disease. All surgeries were performed by a single surgeon with previous experience of >3000 cases in robotic surgery. Demographics and perioperative information were collected including: operative time, estimated blood loss (EBL), complications, length of stay, and days with Foley catheter. The extraperitoneal SP‐RARP is performed as follows. Firstly, a 3‐cm incision ~2 cm below the umbilicus is made. Dissection of the extraperitoneal space is achieved using a kidney shaped Spacemaker™ balloon (Covidien, Dublin, Ireland), placed through the infra‐umbilical incision caudally reaching the retropubic space. Thereafter, the balloon is deployed; the space is created and verified under direct vision with a laparoscopic endoscope. A GelPOINT® mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) is inserted and a dedicated 25‐mm multichannel port is placed with a 12‐mm accessory laparoscopic port through the gel‐seal cap into the same incision. The da Vinci SP surgical platform robot is docked with the patient in a supine position. RARP is performed replicating the technique previously described for multi‐arm platforms or transperitoneal SP‐RARP. No drain and no additional assistant ports were utilised. Results The patient's ages ranged between 48 and 70 years, and the mean preoperative prostate‐specific antigen (PSA) level was 9 ng/mL. No conversions or intraoperative complications were recorded. The median (interquartile range) operative time was 197.5 (185.5–229.7) min. EBL ranged between 50 and 400 mL, six patients were discharged on the same day as the surgery and the median time with a Foley catheter after surgery was 8 days. Conclusions Extraperitoneal SP‐RARP is a feasible and safe surgical option to treat localised prostate cancer. In our early experience, promising results and possible advantages were found such as: a small single incision, no additional ports, no Trendelenburg positioning, minimal postoperative pain and use of opioids, and same day discharge. Further investigations need to be done to validate these advantages.

Early outcomes of single‐port robot‐assisted radical prostatectomy: lessons learned from the learning‐curve experience

“…The initial clinical experience using this robot was described by Kaouk et al In one series of 19 patients who underwent RPs, pyeloplasty, radical nephrectomy, and simple nephrectomy they established feasibility and safe outcomes. All procedures described used the GelPoint technique to house the SP trocar [15][16][17][18]. Recently, Deepak et al [19] described a larger series of 49 cases performed by three different surgeons who performed anterior and Retzius-sparing RPs with some technical modifications, such as the lack of GelPoint and the use of frozen-section analysis.…”

Pure Single-site Robot-assisted Radical Prostatectomy Using Single-port Versus Multiport Robotic Radical Prostatectomy: A Single-institution Comparative Study

“…SP-EPP was performed for all patients in the SP group. Details of the SP-EPP surgical technique and conventional MP-RARP have been described elsewhere [10,13]. Bilateral obturator lymphadenectomy (LND) was planned for all patients regardless of surgical approach unless technically prohibited due to prior LND in a previous surgical procedure or due to extensive scarring in the iliac fossa after vascular surgery or hernia repair with mesh implants…”

“…Most importantly, the double articulating design (ie, wrist and elbow) of all SP robotic instruments and the camera make intracorporeal triangulation possible. SP extraperitoneal prostatectomy has been shown to be feasible [8,9], and the technique has been described previously [10,11].…”

The role of robotic surgery for endometriosis

“…Another novel single port robotic platform, the da Vinci ® SP Surgical System (Intuitive Surgical, Sunnyvale, CA, USA) uses a single robotic arm that contains an articulating camera and instruments docked from a single laparoscopic trocar. Initial reports on this system were published in other fields, such as urologic surgery, and they suggested that this new technology is a safe and feasible surgical option compared with prior procedures [31,32]. However, no report has yet been published about the use of this platform for endometriosis.…”