Extraperitoneal versus Transperitoneal Single Port Robotic Radical Prostatectomy: A Comparative Analysis of Perioperative Outcomes.

PURPOSE: We compared intraoperative and perioperative outcomes between extraperitoneal and transperitoneal radical prostatectomy performed using a "purpose-designed" single port robotic platform. MATERIALS AND METHODS: A total of 98 patients underwent single port robotic prostatectomy using the da Vinci SP® robotic system with extraperitoneal (group I, 52) vs transperitoneal (group II, 46) approach. Demographics and perioperative data including postoperative recovery outcomes were recorded and compared between the 2 groups. RESULTS: Groups were similar in terms of demographics and prostate cancer risk category. Mean operative time (201±37.5 vs 248.2±42.3 minutes, p <0.00001) as well as median postoperative hospital stay (4.3 vs 25.7 hours p <0.0001) was significantly shorter with the extraperitoneal approach. Overall need for pain medications or narcotics as well as the required amount of narcotics per patient (if administered) were significantly lower with the extraperitoneal approach. Extraprostatic extension was detected in 48.1% vs 41.3% of patients in groups I and II, respectively. Surgical margins were positive in 26.9% in group I vs 41.3% in group II (p=0.13). More than 80% of patients with positive surgical margins had high risk features on final surgical pathology. The 90-day continence rate was similar between the 2 groups (60% vs 62.5%, p=0.82). CONCLUSIONS: Extraperitoneal and transperitoneal single port robotic radical prostatectomy are safe and feasible approaches. The extraperitoneal approach is associated with a significantly shorter postoperative hospital stay and decreased need for postoperative narcotics. Randomized trials with adequate sample size and postoperative followup are advisable for further evaluation of the outcomes to clarify patient selection criteria for each approach.

The evolution and resurgence of perineal prostatectomy in the robotic surgical era.

PURPOSE: To review the recent advances in terms of surgical technique and new robotic platforms applied to radical perineal prostatectomy (RPP). METHODS: A literature review was performed focusing on original articles on perineal prostatectomy searching via Medline/Pubmed and Embase. The entire spectrum was covered such as development of surgical technique including pelvic lymphadenectomy, adoption of novel surgical platforms, learning curve and future directions. RESULTS: Surgical removal of the prostate plays a significant role on the treatment of localized prostate cancer (PCa). RPP was the first surgical approach described for radical prostatectomy. This technique declined in popularity secondary to the development of the retropubic approach. Recently, the appearance of novel robotic technology has generated renewed interest in the perineal approach. CONCLUSION: There has been a recent resurgence on the interest of radical perineal prostatectomy for the treatment of localized PCa driven by the advent of new robotic surgical technologies into the field. Future studies are needed to better determine the learning curve of the perineal approach and its current role in the treatment of prostate cancer.

Single-port Mini-Pfannenstiel Robotic Pyeloplasty: Establishing a Non-narcotic Pathway Along With a Same-day Discharge Protocol.

OBJECTIVE: To analyze the feasibility of a same day discharge protocol following single-port (SP) robotic pyeloplasty. MATERIALS AND METHODS: From a single institution series, 23 patients (12 multi-port, 11 SP) who underwent primary robotic dismembered pyeloplasty between February 2018 and March 2021 were analyzed. The association between baseline and perioperative characteristics with functional outcome was analyzed using, chi-square, Fisher's exact, Mann Whitney U and t tests. RESULTS: All SP cases were completed using the mini Pfannenstiel incision without the need for conversion or additional ports. Baseline characteristics were comparable. No intraoperative complications were seen. Only 1 patient in the SP group had a Clavien II complication. All patients in the multi-port group had a drain placed, whereas drain was not placed in the SP group. Length of stay was shorter in the SP group (11.4 vs 42.6 hours, P <.001). Although visual analog pain score was comparable at discharge (P = .633), the SP group had lower opioid usage (morphine milligram equivalent) in the hospital (P <.001) and a lower rate of opioid prescription during discharge (18.2% vs 91.7% P <.001). At a median follow-up of 8 months, no patients had flank pain and all patients had good kidney drainage on follow-up images. CONCLUSION: Single-port robotic dismembered pyeloplasty through a mini-Pfannenstiel access allows a same-day discharge protocol with minimal opiate use.

Robot-assisted Radical Prostatectomy Using Single-port Perineal Approach: Technique and Single-surgeon Matched-paired Comparative Outcomes.

BACKGROUND: Radical perineal prostatectomy (RPP) has been revived with the advent of single-port (SP) robotic surgery. However, its interest and precise role need to be evaluated and better defined. OBJECTIVE: To describe in detail the technique of SP-RPP and compare initial perioperative outcomes with those of multiport robot-assisted transperitoneal radical prostatectomy (MP-RARP). DESIGN, SETTING, AND PARTICIPANTS: From October 2018 to June 2020, perioperative data of 26 consecutive patients who underwent SP-RPP for localized prostate cancer (PCa) in a single institution were prospectively entered into an institutional review board-approved database. Data of 86 consecutive patients treated from September 2017 to September 2018 with MP-RARP by the same surgeon, before the beginning of the SP experience, were used as comparators. SURGICAL PROCEDURE: SP-RPP was performed using the SP robotic platform (Intuitive Surgical, Sunnyvale, CA, USA) according to the technique described in the supplementary video. MEASUREMENTS: Demographics, and intra- and postoperative data were analyzed in a matched-paired design with a 1:1 ratio on the following factors: age at surgery, prostate-specific antigen level, preoperative Gleason score, and history of abdominal surgery. RESULTS AND LIMITATIONS: After matching, baseline characteristics were comparable except for the rate of prior laparotomy, which was higher in the SP-RPP group (52% vs 8%, p < 0.001). In the SP-RPP group, 84% of the patients had a high risk and an unfavorable intermediate risk of positive surgical margins (PSMs) versus 57% in the MP-RARP group (p = 0.03). While the rate of nonlimited PSMs (ie, >3 mm) was higher in the SP-RPP group (38.5% vs 7.7%, p < 0.01), the number of patients with biochemical recurrence at 1 yr was comparable between SP-RPP and MP-RARP (1 vs 3, p = 0.3). CONCLUSIONS: SP-RPP is a complex procedure for patients with a complex surgical history and high-risk localized PCa with limited alternative therapeutic options. PATIENT SUMMARY: Our study suggests that patients with high-risk localized prostate cancer and limited treatment options due to a complex abdominal surgical history (ie, frozen pelvis) may be suitable candidates for single-port radical perineal prostatectomy.

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

BACKGROUND: Pure single-site robot-assisted extraperitoneal prostatectomy (EPP) using a single-port (SP) robotic platform has been shown to be feasible and safe in previous descriptive studies. OBJECTIVE: To compare the perioperative outcomes of patients undergoing SP-EPP versus conventional multiport (MP) transperitoneal robot-assisted radical prostatectomy (RARP). DESIGN, SETTING, AND PARTICIPANTS: From January 2019 to January 2020, data of 100 consecutive patients who underwent SP-EPP performed by the same surgeon and 110 consecutive patients who underwent MP-RARP by three surgeons from the same institution were prospectively collected. INTERVENTION: All SP-EPPs were performed in a pure single-site fashion without Trendelenburg. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Demographic characteristics as well as intra- and postoperative data of patients in both groups were analyzed. Quantitative data were described in terms of median and quartiles. RESULTS AND LIMITATIONS: After SP-EPP, the rate of patients discharged the same day was nine times higher than that after MP-RARP (p < 0.001), and the median length of postoperative hospital stay was significantly shorter: 4.3 h (interquartile range [IQR] 3.3-17.4) versus 26.1 h (IQR 21.5-44.8). The rate of opioid use in the hospital and after discharge in the SP group was at least half that in the MP group (respectively, 32% vs 64%, p < 0.001, and 35% vs 87%, p < 0.001). The overall positive surgical margin rate as well as continence rate at 12 mo (85% vs 88%, p = 0.97) and the prostate-specific antigen relapse-free survival (p = 0.09) were statistically comparable between the SP and MP groups. CONCLUSIONS: Pure single-site SP-EPP was associated with a shorter length of stay as well as a decreased need for postoperative pain medication and narcotic administration in comparison with conventional transperitoneal multiport prostatectomy, with comparable postoperative complications and readmission rate. PATIENT SUMMARY: Surgical treatment of localized prostate cancer using a single-port robotic platform allows for a shorter hospital stay, less pain, and less opioid use than conventional robotic surgery without more morbidity. TAKE HOME MESSAGE: Pure single-site single-port extraperitoneal prostatectomy was associated with a shorter length of stay as well as a decreased need for postoperative pain medication and narcotic administration in comparison with conventional transperitoneal multiport prostatectomy, with comparable postoperative complication and readmission rate.

Single-Port Robot-Assisted Dismembered Pyeloplasty With Mini-Pfannenstiel or Peri-Umbilical Access: Initial Experience in a Single Center.

OBJECTIVE: To assess the feasibility and describe the surgical technique for single-port robotic-assisted laparoscopic pyeloplasty using the new da Vinci SP surgical platform (Intuitive Surgical Inc., Sunnyvale, CA), and to describe the approach through a mini-pfannenstiel incision. METHODS: Data from a prospectively maintained single-institution database on all patients undergoing single-port robotic-assisted pyeloplasty between November 2018 and November 2019 were reviewed. Pyeloplasty was performed with the da Vinci SP system through a pure single site approach (except for the first patient). The initial procedures were performed through a midline incision and the technique evolved to a mini-pfannenstiel incision. Patient demographics, intraoperative data, post-operative data and surgical outcomes were collected. RESULTS: Overall, 10 patients were included and underwent the procedure without intraoperative complications or conversion to an alternate approach. The patients' ages ranged between 11 and 75 years. Mean operative time was 166 minutes (interquartile range [IQR] 146-181) and EBL was minimal. Pfannenstiel incision was performed for 6 patients and 4 patients had a vertical midline incision. The only complication recorded was a postoperative urinary tract infection treated with antibiotics. The median postoperative hospital stay was 21 hours (7-24). Postoperative pain management after discharge was managed exclusively with non-opioid medication. Overall success rate defined as the absence of pain and renal obstruction on post-operative imaging at 3 months after surgery was 100%. CONCLUSION: Single-port robotic-assisted laparoscopic pyeloplasty is a safe and feasible procedure through a mini-pfannenstiel incision.

Technical advancements in robotic prostatectomy: single-port extraperitoneal robotic-assisted radical prostatectomy and single-port transperineal robotic-assisted radical prostatectomy.

BACKGROUND: To describe our step-by-step techniques for single-port robotic-assisted extraperitoneal and perineal radical prostatectomy as recent technical advancements in this field. METHODS: An English-language literature review was done using search terms including extraperitoneal, transperineal, single-port, robotic surgery, prostate cancer, radical prostatectomy in various combinations. Unique features of the da Vinci SP® platform are discussed. Details of surgical techniques with single-port robotic platform are also covered. RESULTS: The relatively recent introduction of the da Vinci SP platform has led to the development of novel techniques for radical prostatectomy. Unique features of this platform including intracorporeal triangulation and double-articulating instruments will likely lead to widespread applications of this novel system. The principles of radical prostatectomy are reproducible with both extraperitoneal and perineal approaches via a single incision. CONCLUSIONS: A better cosmetic results as well as a quick recovery maybe potential advantages of single-port extraperitoneal/transperineal robotic prostatectomy. By avoiding the peritoneal cavity, a lower rate of bowel related complications and minimum systemic CO2 absorption can be expected. Adverse effects of steep Trendelenburg positioning can be avoided with these techniques. Evaluation of the oncological and functional outcomes of these techniques will be necessary. Comparative trials with standard robotic surgery and cost-analysis studies remain hot topics for research after implementation of these new platforms at any institute.

Predictors Associated with a Prolonged Hospital Stay After Single-Port Extraperitoneal Robotic Radical Prostatectomy: A Comparative Analysis of Outpatient Versus Inpatient Care.

Purpose: To compare the perioperative characteristics of patients receiving outpatient vs inpatient care and to define predictors of inpatient care after single-port extraperitoneal robotic radical prostatectomy (RRP). Patients and Methods: Data on 120 patients who underwent single-port extraperitoneal RRP were collected and categorized into two groups: Group I (n = 98) included patients who received outpatient care (i.e. discharged on postoperative day 0) and Group II (n = 22) comprised patients with inpatient care. Demographics and perioperative data were recorded and analyzed between the two groups. Multivariable binary logistic regression was used to determine factors associated with inpatient care. Results: Most patients (98/120: 81.7%) were discharged in few hours (median: 4.1 hours) after surgery (outpatient care: Group I [n = 98]), whereas others (Group II [n = 22]) received inpatient care (median hospital stay: 25.4 hours); p < 0.00001. Most patients with inpatient care (13/22, 59.1%) were among the first initial 40 cases, whereas 37 out of last 40 patients received outpatient care (p = 0.005). Operative time was significantly shorter in patients with outpatient prostatectomy (p = 0.015). The amount of narcotics per patient (if administered) was also significantly greater in Group II (p = 0.006). With regression analysis, having medical comorbidities (odds ratio [OR]: 3.41 95% confidence interval [CI]: 2.05-5.64; p = 0.014), a longer operative time (OR: 1.15 95% CI: 1.10-1.28, p = 0.017), as well as a higher dose of administered narcotics after operation (OR: 1.31 95% CI: 1.08-1.61, p = 0.005) were significant predictors of inpatient care after single-port extraperitoneal RRP. Conclusion: A safe transition to outpatient care is feasible in patients undergoing single-port extraperitoneal RRP. In addition to associated medical comorbidities, a longer operative time and the amount of received narcotic after procedure were the most significant predictors of prolong hospital stay after single-port extraperitoneal RRP. These later modifiable predictors can be optimized with improvement of surgical techniques, intraoperative and postoperative pain management protocols through quality improvement initiatives.

Single-Port Robotic Urological Surgery Using Purpose-Built Single-Port Surgical System: Single-Institutional Experience With the First 100 Cases.

OBJECTIVES: To present a comprehensive report regarding our experience with single-port robotic surgery in our first 100 consecutive patients. We describe the diversity of procedures that can be performed with this platform as well as the challenges and complications we had with the application of this novel technology. METHODS: Between September 2018 and August 2019, data on 100 patients who underwent single-port robotic surgery were consecutively collected. Preoperative, intraoperative and early postoperative outcomes after various urologic procedures were recorded and analyzed. RESULTS: During the study period, 100 patients (age [range] 35-84 years; 88 [88%] Male) underwent various single-port robotic surgeries for different indications (Retroperitoneal [n = 14], Pelvic surgeries [n = 86]). Transperitoneal (n = 37), extraperitoneal (n = 53) and transvesical (n = 10) approaches have been used to access the target organs. Of these procedures, 73 (73%) were for different oncological indications: Radical prostatectomy (n = 60), Partial nephrectomy (n = 6), Retroperitoneal lymph node dissection (n = 1) and Radical cystectomy with intracorporeal diversion (n = 6). Surgery was successfully completed in all but 1 patient, in whom the surgery was converted to open surgery due to dense adhesions and failure to progress. Grades II-III postoperative complications were detected in (n = 9) patients. CONCLUSION: The purpose-built single-port robotic platform can be safely incorporated into the minimally invasive armamentarium. A wide range of pelvic and retroperitoneal urological procedures can be done with different approaches using this platform. Randomized trials with adequate sample size and postoperative follow up period is advisable for further evaluation of the outcomes and to determine the added value of this emerging technology.

Outpatient Extraperitoneal Single-Port Robotic Radical Prostatectomy.

OBJECTIVE: To assess the safety and feasibility of extraperitoneal single-port robotic assisted laparoscopic radical prostatectomy using the da Vinci SP robotic platform for same-day surgery. METHODS: Extraperitoneal single-port robotic prostatectomy (ESRP) using the da Vinci SP platform was performed on 60 patients with clinically localized prostate cancer and no prior definitive therapy. An enhanced recovery protocol was used in the perioperative period and minimal to no opiates were used in these patients. Preoperative, perioperative, and postoperative data were collected in a prospectively maintained institutional review board approved database and evaluated in a retrospective fashion. RESULTS: Mean operative time was 198 minutes and mean estimated blood loss was 179 mL. No patients required blood transfusion and there were no intraoperative complications. Pain at discharge was 0-1 in 37% of patients. Forty-five patients (75%) were discharged home the day of surgery, including patients with all surgical start times. When excluding patients that were planned for an overnight stay preoperatively or patients whose surgery finished after 6 PM, 88% of patients were discharged home the day of surgery and 96% were discharged within 24 hours of surgery. Median length of stay was 4.2 hours. Fourty-eight percent of patients required 0-1 pads at 30 days postoperatively in patients with 30 day follow data (n = 58) and 76% of patients reported requiring 0-1 pads per day by 90 days postoperatively (n = 37). CONCLUSION: ESRP using the da Vinci SP platform can be performed safely and reproducibly as a same-day outpatient surgery with minimal to no opiate use, excellent pain control, and acceptable short term functional and oncological outcomes.

Intravesical tumor involvement of the trigone is associated with nodal metastasis in patients undergoing radical cystectomy.

OBJECTIVE: To evaluate the influence of intravesical tumor location on nodal metastasis and mortality after cystectomy. The microvascular anatomy of the urinary bladder is variable in distinct regions of the bladder and thus tumor location may influence the tumors' ability to access lymphatic and vascular structures. MATERIALS AND METHODS: An observational cohort study was conducted of all patients undergoing radical cystectomy at a single institution between January 2000 and July 2008. Tumor location was classified into the following 6 locations: lateral wall, posterior wall, anterior wall, trigone, dome, and bladder neck. The association between tumor location with nodal metastasis and cancer-specific mortality was assessed. RESULTS: A total of 545 patients were identified in this cohort. Location of tumor at the bladder trigone was associated with an increased likelihood of nodal metastasis on univariate (odds ratio, 1.63; 95% confidence interval [CI], 1.01-2.62) and multivariate (odds ratio, 1.83; 95% CI 1.11-2.99) analysis. In addition, trigone location was associated with a decreased cancer-specific survival on univariate (hazard ratio, 1.49; 95% CI, 1.03-2.16) and multivariate (hazard ratio, 1.68; 95% CI, 1.11-2.55) analysis. CONCLUSION: Patients with bladder tumor in the trigone have a greater risk of lymph node metastasis at cystectomy and decreased cancer-specific survival. Tumor location may be a useful prognostic factor in risk stratification of patients with invasive bladder cancer.