Perioperative, Oncological, and Functional Outcomes Between Robot-Assisted Laparoscopic Prostatectomy and Open Radical Retropubic Prostatectomy: A Randomized Clinical Trial.

PURPOSE: Limited high-quality studies have compared robot-assisted laparoscopic prostatectomy (RALP) vs open retropubic radical prostatectomy. We sought to compare their postoperative outcomes in a randomized setting. MATERIALS AND METHODS: In a single center, 354 men with newly diagnosed prostate cancer were assessed for eligibility; 342 were randomized (1:1). The primary outcome was 90-day complication rates. Functional outcomes and quality of life were assessed over 18 months, and oncological outcomes, biochemical recurrence-free survival, and additional treatment over 36 months. RESULTS: From 2014 to 18, 327 patients underwent surgery (retropubic radical prostatectomy = 156, RALP = 171). Complications occurred in 27 (17.3%) vs 19 (11.1%; P = .107). Patients undergoing RALP experienced lower median bleeding (250.0 vs 719.5 mL; P < .001) and shorter hospitalization time. Urinary EPIC (Expanded Prostate Cancer Index Composite) median scores were better for RALP over 18 months, with higher continence rate at 3 months (80.5% vs 64.7%; P = .002), 6 months (90.1% vs 81.6%; P = .036) and 18 months (95.4% vs 78.8%; P < .001). Sexual EPIC and Sexual Health Inventory for Men median scores were higher with RALP up to 12 months, while the potency rate was superior at 3 months (23.9% vs 5.3%; P = .001) and 6 months (30.6% vs 6.9%; P < .001). Quality of life over the 18 months and oncological outcomes over 36 months were not significantly different between arms. CONCLUSIONS: Complications at 90 days were similar. RALP showed superior sexual outcomes at 1 year, improved urinary outcomes at 18 months, and comparable oncological outcomes at 36 months.

The IRON Study: Investigation of Robot-assisted Versus Open Nephron-sparing Surgery.

Background: Current literature does not provide large-scale data regarding clinical outcomes of robot-assisted (RAPN) versus open (OPN) partial nephrectomy. Moreover, data assessing predictors of long-term oncologic outcomes after RAPN are scarce. Objective: To compare perioperative, functional, and oncologic outcomes of RAPN versus OPN, and to investigate the predictors of oncologic outcomes after RAPN. Design setting and participants: This study included 3467 patients treated with OPN (n = 1063) or RAPN (n = 2404) for a single cT1-2N0M0 renal mass from 2004 to 2018 at nine high-volume European, North American, and Asian institutions. Outcome measurements and statistical analysis: The study outcomes were short-term postoperative, functional, and oncologic outcomes. Regression models investigated the effect of surgical approach (open vs Robot assisted) on study outcomes, and interaction tests were used for subgroup analyses. Propensity score matching for demographic and tumor characteristics was used in sensitivity analyses. Multivariable Cox-regression analyses identified predictors of oncologic outcomes after RAPN. Results and limitations: Baseline characteristics were similar between patients receiving RAPN and OPN, with only few differences. After adjusting for confounding, RAPN was associated with lower odds of intraoperative (odds ratio [OR]: 0.39, 95% confidence interval [CI]: 0.22, 0.68) and Clavien-Dindo ≥2 postoperative (OR: 0.29, 95% CI: 0.16, 0.50) complications (both p < 0.05). This association was not affected by comorbidities, tumor dimension, PADUA score, or preoperative renal function (all p > 0.05 on interaction tests). On multivariable analyses, we found no differences between the two techniques with respect to functional and oncologic outcomes (all p > 0.05). Overall, there were 63 and 92 local recurrences and systemic progressions, respectively, with a median follow-up after surgery of 32 mo (interquartile range: 18, 60). Among patients receiving RAPN, we assessed predictors of local recurrence and systemic progression with discrimination accuracy (ie, C-index) that ranged from 0.73 to 0.81. Conclusions: While cancer control and long-term renal function did not differ between RAPN and OPN, we found that the intra- and postoperative morbidity-especially in terms of complications-was lower after RAPN than after OPN. Our predictive models allow surgeons to estimate the risk of adverse oncologic outcomes after RAPN, with relevant implications for preoperative counseling and follow-up after surgery. Patient summary: In this comparative study on robotic versus open partial nephrectomy, functional and oncologic outcomes were similar between the two techniques, with lower morbidity-especially in terms of complications-for robot-assisted surgery. The assessment of prognosticators for patients receiving robot-assisted partial nephrectomy may help in preoperative counseling and provides relevant data to tailor postoperative follow-up.

Impact of Prostate-Specific Membrane Antigen Positron Emission Tomography/Computed Tomography on the Therapeutic Decision of Prostate Carcinoma Primary Staging: A Retrospective Analysis at the Brazilian National Public Health System.

BACKGROUND: Prostate cancer (PCa) is the most common malignant tumor in males and conventional imaging does not provide accurate primary staging. Prostate-specific membrane antigen (PSMA) positron emission tomography (PET) presents superior performance and strongly affects therapeutic choice. OBJECTIVE: The aim of this study was to evaluate the impact of PSMA PET, compared with conventional imaging methods, on the therapeutic approach in primary staging scenarios in patients with PCa treated at the Brazilian National Public Health System. METHODS: Overall, 35 patients diagnosed with PCa were evaluated using PSMA after conventional staging imaging with multiparametric magnetic resonance (MMR) and/or total abdominal computed tomography (CT) scan and bone scintigraphy (BS). The PCa extension identified by PET was compared with conventional imaging; staging changes and the management impact were then determined. PET comparison with conventional imaging, staging, and decision-making changes was analyzed using descriptive statistics. RESULTS: PET revealed local disease (LD) in 15 (42.9%) patients, seminal vesicle invasion (SVI) in 5 (14.3%) patients, pelvic nodal impairment (PNI) in 7 (20%) patients, pelvic and distant nodes in 3 (8.6%) patients, pelvic nodes and bone metastasis in 4 (11.4%) patients, and pelvic and distant nodes and bone metastasis in 1 (2.8%) patient. Staging changes were observed in 60% of patients, with downstaging predominance (76.2%). Volume increase was identified in 11 (31.4%) patients (only 4 related to upstaging, 36.4%). The board changed management decisions for 60% of the patients. The main limitations of this study were the sample size and its retrospective nature. CONCLUSIONS: PSMA findings changed the management decisions in more than half of the patients, which made the majority eligible for locoregional treatment and avoided unnecessary procedures in the systemic disease scenario.

A Prospective, Randomized Trial Comparing the Outcomes of Open vs Laparoscopic Partial Nephrectomy.

PURPOSE: Partial nephrectomy is the standard treatment for renal tumors <7 cm, and the trend toward minimally invasive surgery has increased. However, data that could support its use and benefits are still lacking. MATERIALS AND METHODS: We conducted a prospective, randomized controlled trial comparing surgical, functional and oncologic outcomes in patients undergoing open partial nephrectomy (OPN) or laparoscopic partial nephrectomy (LPN). Randomization was 1:1 to OPN or LPN for the treatment of renal tumors <7 cm. The primary endpoint was surgical complications up to 90 days after surgery. Secondary outcomes were comparison of surgical, oncologic and functional results. RESULTS: We randomized 208 patients between 2012 and 2020 (110 with OPN vs 98 with LPN). Operative data showed no differences in operative time, warm ischemia time, estimated blood loss, transfusions or length of hospital stay. Zero ischemia was more frequent in the OPN (35.4% vs 15.5%, p=0.02). OPN was associated with more abdominal wall complications (31.2% vs 13.1%, p=0.004). Regarding oncologic outcomes, no differences were noted. The LPN group had less kidney function reduction at 3 (-5.2% vs -10%, p=0.04; CI 0.09 to 9.46) and 12 months after surgery (-0.8% vs -6.3%, p=0.02; CI 1.18 to 12.95), and a lower rate of downstaging on the chronic kidney disease classification at 12 months (14.1% vs 32.6%, p=0.006). CONCLUSIONS: Surgical and oncologic outcomes of LPN were similar to OPN. Minimally invasive surgery may provide better preservation of kidney function. More studies, especially those involving robotic surgery, are necessary to confirm our findings.

Robot-assisted simple prostatectomy: the evolution of a surgical technique

ABSTRACT Purpose: Enucleation of a large prostate is the best surgical choice for patients refractory to clinical treatment (1,2). Since the first robot-assisted simple prostatectomy (RASP) was described (3,4), some technical modifications (5-7) and different approaches to reach the adenoma have been proposed (8,9). The aim of this video is to demonstrate three different techniques of RASP. Materials and Methods: The first procedure begins with a transversal incision over the bladder neck, the second is a transvesical approach and the last one is a Retzius-sparing RASP. All techniques were performed with a vesico-urethral anastomosis. Results: Three patients underwent RASP, each one with a different approach. Patients presented mean age of 66±4.4 years, PSA baseline level of 7.8±3ng/mL, IPSS score of 17.7±4.5, maximum urine flow of 8.3±1.5mL/seg and 122.3±11.2cm3 of prostate volume. The mean operative time was 63±8 minutes, estimated blood loss of 106.7±11.5mL, prostate weight of the surgical specimen of 106.3±8 grams and 1 day of length of stay. No continuous bladder irrigation was required and there was no complication. The mean postoperative PSA and IPSS were 0.7±0.3ng/mL, 4.7±1.5. The maximum urine flow raised to 20±4.4mL/seg. Conclusions: RASP with vesico-urethral anastomosis allowed minimal blood loss, short length of stay and great functional outcomes. All the three approaches allowed to perform this technique in a safe way, while showing different alternatives to reach the adenoma.

Floating docking technique: a simple modification to improve the working space of the instruments during single-port robotic surgery.

OBJECTIVE: To compare the range of motion and ergonomic characteristics of single-port robotic instruments in the setting of the "floating" versus "flat" docking technique using the GelPOINT® system. MATERIAL AND METHODS: The basic principle of the floating docking technique resides in the GelSeal cap and trocar (s) being 8 cm off the skin level with the Alexis® acting as a conduit between the trocar (s) and the body while preserving insufflation. In the setting of a dry lab study, we measured the range of motion of one robotic instrument with the "floating" and the "flat" docking technique in two different situations depending on whether the distance between the incision and the target was more or less than 10 cm. RESULTS: The minimum required distances between the target and the tip of the cannula for activation of the wrist and elbow were 5 and 10 cm, respectively. When the target was near to the cannula (i.e., less than 10 cm), the floating technique was associated with a significant increase in the range of motion of the instrument in all directions. The working space volume of the instrument was increased by more than 390% (from 101 to 497 cm3) when the surgeon switched from flat (standard) to the floating technique in the setting of a target close (i.e., less than 10 cm) to the cannula CONCLUSION: The floating docking technique is a simple and effective way to increase the working surgical space, especially in confined and narrow surgical fields with a target closer than 10 cm from the skin.

Single-institution Cost Comparison: Single-port Versus Multiport Robotic Prostatectomy.

BACKGROUND: In the era of efficient value-based health care, each surgical innovation should be proven to be cost-effective for the patient and the hospital administration. OBJECTIVE: To compare the costs associated with robot-assisted prostatectomy using a single-port (SP) or multiport (MP) robotic platform. DESIGN, SETTING, AND PARTICIPANTS: Costs for surgical care for consecutive patients with localized prostate cancer treated from November 2018 to November 2019 were itemized and evaluated. INTERVENTION: Patients were treated using either the SP (n = 78) or MP (n = 97) platform. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Demographics, perioperative data, and costs for surgical care of patients in both groups were analyzed. RESULTS AND LIMITATION: The mean cost for prostatectomy was comparable between SP ($13 512 ± $1615) and MP ($13 284 ± $1360; p = 0.32). The main cost differences between the groups were the cost of hospitalization, which was lower in the SP group (p < 0.001), offset by the cost of disposables in the operating room, which was higher in the SP group (p < 0.001). The mean length of stay was significantly shorter in the SP group (9.84 ± 11.3 vs 35.5 ± 29.1 h; p < 0.001) and the proportion of patients discharged home on the day of surgery was higher in the SP group (70% vs 5%; p < 0.001). The main limitation of this study is its retrospective design. CONCLUSIONS: Overall, the costs for SP and MP prostatectomy are comparable. The higher SP cost for consumable surgical materials is offset by the lower cost associated with hospitalization, which was largely due to a shorter hospital stay after SP surgery. PATIENT SUMMARY: In this report, we found that implementation of the new single-port robotic platform for radical prostatectomy was not associated with higher surgical care costs compared to conventional multiport surgery.

Predictive factors for opioid-free management after robotic radical prostatectomy: the value of the SP® robotic platform.

BACKGROUND: The aim of this study was to evaluate perioperative factors associated with opioid-free management after robotic radical prostatectomy in a single institution. METHODS: From January 2019 to January 2020, data from patients who underwent robotic radical prostatectomy was retrospectively entered in a preapproved IRB database. Data were analyzed according to the postoperative opioid administration in hospital and/or after discharge. Robotic radical prostatectomy was performed using either the standard multi-port Da Vinci Si robotic platform with a transperitoneal approach (MP-RALP) or the novel DaVinci SP® robotic platform (Intuitive Surgical, Inc., Sunnyvale, CA, USA) with an extraperitoneal approach (SP-EPP). Patients undergoing minimally invasive surgery were included in the "enhanced recovery after surgery" (ERAS) protocol regardless of the surgery approach. RESULTS: During the study period, 210 patients matched the selection criteria. Of those, 158(75%) patients received opioids during the hospital stay or after discharge and 52(25%) patients never received opioids. SP-EPP surgical approach and shorter LOS were predictors of never receiving opioids (Odds Ratio [OR]=4.97, (95% CI 1.81-14.77, P=0.002 and OR=0.56, CI 95% 0.35-0.86, P=0.011, respectively). SP-EPP surgical approach was increasing the odds of remaining opioid free whether in-hospital or after discharge (OR= 11.97, 95% CI 4.8-32, P<0.0001 and OR=11.6, 95% CI 4.6-31, P<0.0001, respectively). Finally, a high BMI increased the odds of receiving opioid in hospital or after discharge (OR=0.89, 95% CI 0.82-0.96, P=0.003 and OR=0.89, 95% CI 0.82-0.96, P=0.002, respectively). CONCLUSIONS: In this series, after robotic radical prostatectomy the use of a less invasive approach (SP-EPP), a shorter LOS and a lower BMI, were predictive of opioid-free status.

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.

Contemporary Techniques of Prostate Dissection for Robot-assisted Prostatectomy.

BACKGROUND: Over the years, several techniques for performing robot-assisted prostatectomy have been implemented in an effort to achieve optimal oncological and functional outcomes. OBJECTIVE: To provide an evidence-based description and video-based illustration of currently available dissection techniques for robotic prostatectomy. DESIGN, SETTING, AND PARTICIPANTS: A literature search was performed to retrieve articles describing different surgical approaches and techniques for robot-assisted radical prostatectomy (RARP) and to analyze data supporting their use. Video material was provided by experts in the field to illustrate these approaches and techniques. SURGICAL PROCEDURE: Multiple surgical approaches are available: extraperitoneal, transvesical, transperitoneal posterior, transperitoneal anterior, Retzius sparing, and transperineal. Surgical techniques for prostatic dissection sensu strictu are the following: omission of the endopelvic fascia dissection, bladder neck preservation, incremental nerve sparing by means of an antegrade or retrograde approach, and preservation of the puboprostatic ligaments and dorsal venous complex. Recently, techniques for total or partial prostatectomy have been described. MEASUREMENTS: Different surgical approaches and techniques for robotic prostatectomy have been analyzed. RESULTS AND LIMITATIONS: Two randomized controlled trials evaluating the extraperitoneal versus the transperitoneal approach have demonstrated similar results. Level I evidence on the Retzius-sparing approach demonstrated earlier return to continence than the traditional anterior approach. The question whether Retzius-sparing RARP is associated with a higher rate of positive surgical margins is still open due to the intrinsic bias in terms of surgical expertise in the available comparative studies. This technique also offers an advantage in patients who have received kidney transplantation. Retrospective evidence suggests that the more the anatomical dissection (eg., more periprostatic tissue is preserved), the better the functional outcome in terms of continence. Yet, two randomized controlled trials evaluating the different techniques of dissection have so far been produced. Partial prostatectomies should not be offered outside clinical trials. CONCLUSIONS: Several techniques and approaches are available for prostate dissection during RARP. While the Retzius-sparing approach seems to provide earlier return to continence than the traditional anterior transperitoneal approach, no technique has been proved to be superior to other(s) in terms of long-term outcomes in randomized studies. PATIENT SUMMARY: We have summarized available approaches for the surgical treatment of prostate cancer. Specifically, we described the different techniques that can be adopted for the surgical removal of the prostate using robotic 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.

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.

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.

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.

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.

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

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.

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.

Risk factors for mortality in blunt abdominal trauma with surgical approach.

OBJECTIVE: identify risk factors for mortality in patients who underwent laparotomy after blunt abdominal trauma. METHODS: retrospective study, case-control, which were reviewed medical records of blunt trauma victims patients undergoing laparotomy, from March 2013 to January 2015, and compared the result of the deaths group with the group healed. RESULTS: of 86 patients, 63% were healed, 36% died, and one patient was excluded from the study. Both groups had similar epidemiology and trauma mechanism, predominantly young adults males, automobilistic accident. Most cases that evolved to death had hemodynamic instability as laparotomy indication - 61% against 38% in the other group (p=0.02). The presence of solid organ injury was larger in the group of deaths - 80% versus 48% (p=0.001) and 61% of them had other associated abdominal injury compared to 25% in the other group (p=0.01). Of the patients who died 96% had other serious injuries associated (p=0.0003). Patients requiring damage control surgery had a higher mortality rate (p=0.0099). Only one of 18 patients with isolated hollow organ lesion evolved to death (p=0.0001). The mean injury score of TRISS of cured (91.70%) was significantly higher than that of deaths (46.3%) (p=0.002). CONCLUSION: the risk factors for mortality were hemodynamic instability as an indication for laparotomy, presence of solid organ injury, multiple intra-abdominal injuries, need for damage control surgery, serious injury association and low index of trauma score.