The Humanitarian Impact of Telesurgery and Remote Surgery in Global Medicine.

Telesurgery is a natural evolution of robotic surgery and has potential to address health care deficiencies in underserved areas of the globe. The same expert can reach more patients on the same day via telesurgery, and emergency procedures for neurovascular and cardiac events could be performed at the appropriate time, reducing deaths and disabilities.

A nomogram to predict pathologic T2 stage in candidates to robot-assisted radical prostatectomy with iT3 prostate cancer on preoperative multiparametric MRI: results from a multi-institutional collaboration.

In candidates to robot-assisted radical prostatectomy (RARP) for locally advanced (iT3) prostate cancer on preoperative MRI, the performance of MRI for local staging is demonstrably suboptimal, and currently no prediction tools that might help surgeons in preoperative planning are available. We analyzed data of 685 patients with iT3 prostate cancer (PCa) who received RARP at five participating institutions between 2012 and 2020. Multivariable logistic regression model investigated predictors of pT2 disease among variables available before surgery (i.e.: preoperative PSA, biopsy ISUP group, clinical T stage on digital rectal examination-DRE, prostate volume on MRI, PIRADS score of index lesion, seminal vesicles invasion on MRI, location suspicious for T3 disease on MRI). Coefficients from such model were used to build a nomogram to predict organ-confined (i.e. pT2) disease on final pathology. Internal validation was performed using the leave-one-out cross-validation. Median (interquartile range) preoperative PSA was 7.5 (5.2, 11.9) ng/mL, and 280 (41%) and 216 (32%) had biopsy ISUP group 4-5 disease and palpable disease on DRE, respectively. Preoperative MRI was suspicious for iT3 disease on the mid-posterior part of the gland in 485 (71%) men, and 527 (77%) men had a PIRADS 5 lesion. After surgery, a total of 192 (28%) patients had organ-confined disease (i.e. pT2). All variables fitted into the model and were considered to build the nomogram. After internal validation, the AUC was 73% (95% confidence interval: 69%, 77%). Awaiting external validation, we provided data that is relevant to optimize surgical strategy in men diagnosed with iT3 PCa who are scheduled for RARP.

Same-Day Discharge Protocol for Robot-Assisted Radical Prostatectomy: Experience of a High-Volume Referral Center.

Objective: As the coronavirus disease 2019 (COVID-19) global pandemic continues, there is increased value in performing same-day discharge (SDD) protocols to minimize viral exposure and maintain the appropriate surgical treatment for oncologic patients. In this scenario, we performed a prospective analysis of outcomes of our patients undergoing SDD protocol after robot-assisted radical prostatectomy (RARP). Materials and Methods: The SDD criteria included patients with no intraoperative complications, stable postoperative hemoglobin levels (compared with preoperative values), stable vital signs, normal urine output, ambulation with assistance and independently without dizziness, tolerance of clear liquids without nausea or vomiting, pain control with oral medication, and patient/family confidence with SDD. Patients older than 70 years, concomitant general surgery operations, multiple comorbidities, and complex procedures such as salvage surgery were excluded from our protocol. Results: Of the 101 patients who met the criteria for SDD, 73 (72%) had an effective SDD. All SDF (same day discharge failure) patients were discharged one day after surgery. Intraoperative characteristics were not statistically different with a median operative time of 92 (81-107) vs 103 (91-111) minutes for SDD and SDF, respectively. Of the 28 SDF patients, the most common reasons for staying were anesthesia-related factors of nausea (35%), drowsiness (7%), patient/caregiver preference (25%), pain (14%), labile blood pressure (7%), arrhythmia (7%), and dizziness (7%). There was no significant difference in readmission rates, complication rates, or postoperative pain scores between SDD and SDF patients. Conclusions: In our experience, SDD for patients undergoing RARP can be safely and feasibly incorporated into a clinical care pathway without increasing readmission rates. We were effective in 72% of cases because of coordinated care between anesthetics, nursing staff, and appropriate patient selection. We also believe that incorporating pre- and postoperative patient education and assurance is crucial to minimize their exposure to COVID-19 during the surgical treatment for prostate cancer.

Implementing the da Vinci SP Without Increasing Positive Surgical Margins: Experience and Pathologic Outcomes of a Prostate Cancer Referral Center.

Background: Different consoles have been described for the da Vinci single-port (SP) surgery since it was cleared by the FDA in November 2018. However, the literature still lacks studies identifying factors related to the SP learning curve and how to overcome the technological limitations, especially in terms of maintaining acceptable positive surgical margins (PSMs). This study describes our perioperative experience implementing a safe SP approach to radical prostatectomy (RP) while minimizing PSM, especially during the initial learning period. Materials and Methods: We performed a retrospective analysis of 100 consecutive patients with prostate cancer who underwent RP with the SP robot from June 2019 to December 2020 (IRB 237998). We accessed the perioperative data, pathology report, and short-term oncologic outcomes. We also represented our PSM trends in 100 consecutive cases, discussing potential factors for minimizing the learning curve impact on positive margins and outcomes. Medians and interquartile ranges, as well as frequencies and proportions, were reported for continuous and categorical variables, respectively. Results and Limitations: The median follow-up is 14 months (8-17). The cohort has a median age of 62 years (56-68), median prostate-specific antigen of 5.5 (4.3-7.7), median preoperative Sexual Health Inventory for Men (SHIM) of 20, median American Urological Association (AUA) of 7 (3-11), and median body mass index of 25.4 (23.4-27.4). The median total operative time was 114 minutes (104-124), the median console time was 80 minutes (75-90). No intraoperative complications were reported. The overall rate of PSMs was 15% (5% were pT2 and 10% were pT3). Conclusions: The SP approach to RP is feasible, safe, and with acceptable intraoperative performance. In this study, we have described crucial factors for considering selection criteria in candidates for SP-robot-assisted RP. We believe that with an appropriate patient selection, this robot can be safely implemented without increasing positive margins and compromising the outcomes, especially during the learning curve period.

Association Between Oncotype DX Genomic Prostate Score and Adverse Tumor Pathology After Radical Prostatectomy.

BACKGROUND: The Oncotype DX assay is a clinically validated 17-gene genomic assay that provides a genomic prostate score (GPS; scale 0-100) measuring the heterogeneous nature of prostate tumors. The test is performed on prostate tissue collected during biopsy. There is a lack of data on the association between the GPS and tumor pathology after radical prostatectomy (RP). OBJECTIVE: To investigate the association between GPS and final pathology, including extraprostatic extension (EPE), positive surgical margin (PSM), and seminal vesicle invasion (SVI). DESIGN, SETTING, AND PARTICIPANTS: Data for the 749 patients who underwent Oncotype DX assay and RP at a referral prostate cancer center between 2015 and 2019 were retrospectively assessed to evaluate the association between GPS and unfavorable pathology parameters. INTERVENTION: After a GPS genetic test, patients underwent robotic RP performed by the same surgeon. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Multivariable logistic regression analyses were performed to assess the association between GPS and EPE, PSM, and SVI. The models were adjusted for age, clinical stage, prostate-specific antigen (PSA) level, Gleason score, and time between the genomic assay and surgery. The median time between Oncotype DX assay and surgery was 176 d (interquartile range [IQR] 141-226). The median age was 63 yr (IQR 58-68), median GPS was 29 (IQR 21-39), and median PSA was 5.7 ng/ml (IQR 4.6-7.7). In multivariable analyses assessing the odds ratio (OR) per 20-point change in GPS, GPS was an independent predictor of EPE (OR 1.8, 95% confidence interval [CI] 1.4-2.3) and SVI (OR 2.1, 95% CI 1.3-3.4). In addition, when patients were grouped by GPS quartile, the percentage of cases with EPE and SVI increased with the GPS quartile. CONCLUSIONS: We provide evidence that the Oncotype DX GPS is significantly associated with adverse pathology after RP. Specifically, the risk of EPE and SVI increases with the GPS. Therefore, use of the Oncotype DX GPS may help clinicians to improve preoperative patient counseling and develop surgical strategies for patients with a higher chance of EPE or unfavorable pathological features. PATIENT SUMMARY: We studied whether the score for a prostate genetic test was associated with prostate cancer pathology findings for patients who had their prostate removed. We found that the risk of prostate cancer spread outside the gland and to the seminal vesicle increases with higher test scores. These findings may help surgeons in counseling patients on surgical options for prostate cancer.

Outcomes of Salvage Robot-assisted Radical Prostatectomy After Focal Ablation for Prostate Cancer in Comparison to Primary Robot-assisted Radical Prostatectomy: A Matched Analysis.

BACKGROUND: Focal therapy (FT) for prostate cancer is less invasive than radical treatment but carries a risk of recurrence. Salvage robot-assisted radical prostatectomy (S-RARP) is a possible option after FT failure. OBJECTIVE: To evaluate the impact of FT on functional and oncological outcomes following S-RARP. DESIGN, SETTING, AND PARTICIPANTS: In a retrospective analysis of data from a prospectively collected institutional database, 53 patients who underwent S-RARP following failure of focal ablation were selected as group I; patients who had whole-gland ablation and external beam therapy were excluded. This group was matched to a control sample (matched at ratios of 1:1, 1:2, 1:3, 1:4) of men who had undergone primary RARP, using age, prostate-specific antigen (PSA), PSA density, body mass index, Sexual Health Inventory for Men score, American Urological Association symptom score, Charlson comorbidity index, prostate weight, preoperative Gleason score (GS), and history of smoking as variables. SURGICAL PROCEDURE: S-RARP after FT was performed using a standardized technique developed at our institute with the da Vinci Xi Surgical System. MEASUREMENTS: Oncological and functional outcomes were compared between the S-RARP and primary RARP groups. RESULTS AND LIMITATIONS: There was no difference in estimated blood loss (p = 0.8) between the 1:1 matched groups, but operating room time was significantly longer for S-RARP (p = 0.007). The primary RARP group had a higher proportion of patients who underwent a full nerve-sparing procedure. The S-RARP group had higher incidence of positive surgical margins (40% vs 15%; p = 0.008), GS ≥8 (25% vs 15%; p = 0.07), and positive lymph node status (9.4% vs 5.7%; p = 0.02). There was no significant difference in overall complications between the groups. The primary RARP group had a higher incidence of lymphocele drainage after surgery (15% vs 0%; p = 0.006). The main limitation of the study is its retrospective design. CONCLUSIONS: S-RALP after FT failure is feasible; however, surgery following FT leads to poorer oncological and functional outcomes. Despite the targeted nature of FT, significant nonfocal collateral damage is evident in tissues surrounding the prostate, which in turn translates to poorer functional outcomes after S-RARP. PATIENT SUMMARY: We studied the surgical challenges during robot-assisted removal of the prostate after previous focal treatment (FT) for prostate cancer and compared the outcomes to those for robot-assisted prostate removal in patients who had no previous FT. We found that this technique is safe and effective with a limited risk of complications, but poor urinary and sexual functional outcomes.

Da Vinci Single-Port Robotic Radical Prostatectomy.

The field of robotic surgery continues to evolve and the advent of the single-port (SP) platform is another step toward the future. The SP platform is a new technology that has promising implications for urologic surgery. Since the Food and Drug Administration (FDA) cleared this platform in 2018, multiple urologic procedures have been described, with radical prostatectomy being the most common. This article aims to describe and illustrate the step-by-step technique of SP radical prostatectomy. We have described our technique from the patient positioning and trocar placement until the anastomosis. We included in the video compilation surgical steps such as bladder dropping and anterior bladder neck dissection, posterior bladder neck and seminal vesicles, posterior prostate dissection and nerve sparing, apical dissection and dorsal venous complex control, posterior reconstruction and anastomosis, and lymph node dissection.

Stratification of Potency Outcomes Following Robot-Assisted Laparoscopic Radical Prostatectomy Based on Age, Preoperative Potency, and Nerve Sparing.

Introduction: To identify factors affecting potency and to predict ideal patient subgroups who will have the highest chance of being potent after robot-assisted laparoscopic prostatectomy (RALP) based on nerve sparing (NS). Materials and Methods: Analysis of 7268 patients who underwent RALP between 2008 and 2018 with a minimum of 12 months of follow-up was performed. The patients were then categorized into four separate neurovascular bundle-sparing groups (NVB 1-4). A Cox regression analysis was used to determine the independent factors predicting potency outcomes. Cumulative incidence functions were used to depict the probability and time to potency between the NS groups stratified by age and preoperative sexual health inventory in men (SHIM). Results: Cox regression analysis of age, preoperative SHIM score, and grades of NS significantly predicted potency outcomes post-RALP. Patients with SHIM score ≥22 had a better chance of potency vs patients with SHIM <17 (odds ratio [OR]: 1.69, confidence interval [CI]: 1.47-1.79). NVB1 had better potency vs NVB4 (OR: 3.1, CI: 2.51-3.83). Patients <55 years with NVB1 and no preoperative erectile dysfunction had the best potency rates of 92.5%. However, we did not see any statistical difference between NVB2 and NVB3 in this group, implying that in patient groups with SHIM ≥22 and age <55, NVB1 provided the best chance of potency recovery. As age increased and preoperative SHIM worsened, the curves corresponding to NVB 2 and 3 showed significant differences, suggesting that NVB 2 and 3 may be predictive in unfavorable age and preoperative SHIM groups, especially NVB 2 > NVB 3. Conclusions: Preoperative SHIM, age, and NS are the most influential factors for potency recovery following RALP. Patients with good baseline sexual function had similar postoperative potency, irrespective of their grades of partial NS. In patients with decreased baseline SHIM and older age, a higher grade of partial NS resulted in a significantly better potency compared with a lower grade of partial nerve spare.

A Predictive Preoperative and Postoperative Nomogram for Postoperative Potency Recovery after Robot-Assisted Radical Prostatectomy.

PURPOSE: Prediction of potency recovery following robot-assisted radical prostatectomy (RARP) is useful for better patient counseling and postoperative treatment strategies. In this study we propose a preoperative and postoperative nomogram to predict postoperative potency recovery following RARP. MATERIALS AND METHODS: Patients from development set (6,502) were selected to develop the nomograms, and patients in validation set (2,706) were used for validation. Cox regression models were fitted on the development cohort to predict potency recovery after RARP using as prognostic factors the covariates selected. Two nomograms were drawn using the regression coefficients of the preoperative and postoperative Cox models. RESULTS: The discrimination ability of the preoperative model was evaluated on the development cohort using the receiver operator curves estimated at 3, 6, 12 and 24 months. The AUC at these time points was 0.726, 0.734, 0.754, and 0.778, respectively. The areas under the curve of the postoperative model at 3, 6, 12 and 24 months were 0.746, 0.756 and 0.777, and 0.801, respectively. Preoperative and postoperative predictive models were validated using a separate set of 2,706 patients. The AUCs of the preoperative model at 3, 6, 12 and 24 months were 0.789, 0.772, 0.768, and 0.778, respectively. The ROC curves of the postoperative model at 3, 6, 12 and 24 months with AUCs of 0.807, 0.797, 0.793 and 0.798, respectively. Along with age and preoperative sexual function, nerve-sparing technique determines the potency outcomes justifying better AUC for postoperative model vs the preoperative model. CONCLUSIONS: The above nomograms help us to predict with good accuracy the probability of potency recovery within 3, 6, 12 and 24 months following surgery taking into consideration preoperative and postoperative factors. This is a novel tool for the care giver to predict realistic expectation of potency outcomes to the patients, while preoperative and immediate postoperative counseling.

Minimally Invasive Lymphocele Drainage Using the Da Vinci Single-Port Platform: Step-By-Step Technique of a Prostate Cancer Referral Center.

Background: Some reports in the literature describe lymphocele formation in as much as half of patients after pelvic lymph node dissection (PLND) in robot-assisted radical prostatectomy (RARP), with 1%-2% requiring intervention. Several treatment modalities for symptomatic lymphoceles are available, including percutaneous drainage, sclerosing agents, and surgical marsupialization, typically performed by laparoscopy or with a multiport robotic platform. The advantage of surgical approach is permanent excision of the lymphocele capsule and fewer days with pelvic drains compared to percutaneous drainage. This study aims to describe and illustrate, for the first time, the step-by-step surgical management of symptomatic lymphoceles using a less invasive robotic platform, the da Vinci® Single Port (SP). Materials and Methods: We describe the outcomes of three patients who underwent lymphocelectomy and marsupialization with the da Vinci SP for symptomatic lymphoceles after RARP and PLND with the da Vinci Xi. Results: Operative time for cases 1, 2, and 3 was 84, 80, and 79 minutes. The blood loss for each surgery was 25 mL. Patient 2 was discharged in 3 days, whereas patients 1 and 3 were discharged in 4 days. No intraoperative or postoperative complications were reported. All patients had their drain removed in under 24 hours after surgery. The mean follow-up period was 7.7 months (3.5-15.8). No patients were readmitted or had lymphocele recurrence. Conclusion: Da Vinci SP lymphocelectomy is safe and feasible with satisfactory outcomes. The SP enables definitive treatment of the lymphocele sac, reducing the number of days with abdominal drains, and allows further decrease in surgical invasiveness with fewer incisions and better cosmesis.

Robot-assisted radical cystectomy with intracorporeal urinary diversion decreases postoperative complications only in highly comorbid patients: findings that rely on a standardized methodology recommended by the European Association of Urology Guidelines.

INTRODUCTION: The available studies comparing robot-assisted radical cystectomy (RARC) with intracorporeal (ICUD) vs. extracorporeal (ECUD) urinary diversion have not relied on a standardized methodology to report complications and did not assess the effect of different approaches on postoperative outcomes. MATERIALS: Two hundred and sixty seven patients treated with RARC at a single center were assessed. A retrospective analysis of data prospectively collected according to a standardized methodology was performed. Multivariable logistic regression models (MVA) assessed the impact of ICUD vs. ECUD on intraoperative complications, prolonged length of stay (LOS), 30-day Clavien Dindo (CD) ≥ 2 complications and readmission rate. Interaction terms tested the impact of the approach on different patient subgroups. Lowess graphically depicted the probability of CD ≥ 2 after ICUD or ECUD according to patient baseline characteristics. RESULTS: Overall, 162 ICUD vs 105 ECUD (61 vs. 39%) were performed. Intraoperative complications were recorded in 24 patients. The median LOS and readmission rate were 11 vs. 13 (p = 0.02) and 24 vs. 22% (p = 0.7) in ICUD vs. ECUD, respectively. Overall, 227 postoperative complications were recorded. The overall rate of CD ≥ 2 was 35 and 43% in patients with ICUD vs. ECUD, respectively (p = 0.2). At MVA, the approach type was not an independent predictor of any postoperative outcomes (all p ≥ 0.4). Age-adjusted Charlson Comorbidity Index (ACCI) was associated with an increased risk of CD ≥ 2 (OR: 1.2, p = 0.006). We identified a significant interaction term between ACCI and approach type (p = 0.04), where patients with ICUD had lower risk of CD ≥ 2 relative to those with ECUD with increasing ACCI. CONCLUSIONS: Relying on a standardized methodology to report complications, we observed that highly comorbid patients who undergo ICUD have lower risk of postoperative complications relative to those patients who received ECUD.

Applications of the da Vinci single port (SP) robotic platform in urology: a systematic literature review.

INTRODUCTION: Robotic surgical technology has evolved to include a new platform specifically designed for the single-port (SP) approach. Benefits of the da Vinci SP are still under investigation. This study aimed to review the urological literature since the first report of the use of the platform. EVIDENCE ACQUISITION: We performed a systematic literature review of PubMed, Medline, and Web of Science databases on June 15, 2020 searching for all available articles of da Vinci SP use from December 2014 (date of the first clinical report of da Vinci SP in the urology) until June 1, 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines. EVIDENCE SYNTHESIS: A total of 43 articles were eligible for inclusion. Ten studies reported different surgeries and techniques on cadavers while the rest described the clinical experience of different groups. We divided our article and tables into preclinical experience with surgery on cadavers, radical prostatectomy (RP) approach, and multiple types of procedures described in the same study. CONCLUSIONS: The application of da Vinci SP in urologic procedures after five years of the first clinical investigation is feasible and safe. Radical prostatectomy is the most common intervention performed with this robot. Some groups described benefits in terms of less postoperative pain and early discharge, especially with the extraperitoneal approach. However, further studies with larger sample sizes and longer follow-up are awaited.

Establishing a successful robotic surgery program and improving operating room efficiency: literature review and our experience report.

The benefits and outcomes of robotic surgery are well established in the literature across multiple specialties. The increasing need for and dissemination of this technology associated with high costs, demand adequate planning during its implementation. Therefore, after years of training several robotic surgeons and establishing multiple robotic programs worldwide, the purpose of this article is to focus on the necessary elements in the initial phase of establishing a robotics program. We summarized in our article crucial factors when implementing a robotic program. Therefore, we explained in detail the critical aspects of the program design, implementation, marketing, research and outcomes, and ultimately improving efficiency. The creation of a robotics planning committee composed of several hospital individuals contributes in different lines of work such as cost evaluation, staff training, and OR modifications. A multidisciplinary approach and a robotic lead surgeon are also recommended to guarantee surgical volume and satisfactory outcomes. Furthermore, market analysis should evaluate the competition with other centres and potential surgical candidates in that area. Data collection should also be considered a vital element of the program organization, which assures quality control and helps to diagnose any program deficiency. We believe that the robotic program should be individualized according to the economy and reality of each centre. The success and duration of a robotic surgery program depend on long-term results. Therefore, careful planning with a robotic committee defining the types of procedures to be performed and appropriate multidisciplinary training to avoid surgery cancelations are crucial factors in establishing a successful program.

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

OBJECTIVE: To describe the crucial factors related to the implementation of the da Vinci single-port (SP) system (Intuitive Surgical Inc., Sunnyvale, CA, USA), and the early outcomes after the introduction of this robot for robot-assisted radical prostatectomy (RARP). PATIENTS AND METHODS: We prospectively collected data from 50 consecutive patients with prostate adenocarcinoma who underwent RARP using this robot. The median follow-up was 53 days. We performed a transperitoneal technique. The robotic (multiport) trocar was placed on the supra-umbilical midline 20 cm from the pubis and an assistant trocar placed in the right lower quadrant. We report our initial experience describing the intra- and postoperative outcomes associated with this new robot. Also, we report the early functional and oncological outcomes in the follow-up period considered. Continuous variables were described as medians and interquartile ranges, while categorical variables as frequencies and proportions. RESULTS: The median total operative time was 118 min, median console time was 80 min, and median estimated blood loss was 50 mL. There were no intraoperative complications or blood transfusions. The final pathology reported 18% Grade Group (GrGp)1, 58% GrGp2, 18% GrGp3, 2% GrGp4, and 4% GrGp5. In all, 40 patients (80%) were pT2 and 20% were ≥pT3a. The overall positive surgical margin rate was 14%. In all, 39 patients (78%) achieved full continence at median of 21 days after RARP. The median pain scale (0-10) score at 8, 12 and 16 h after RARP was 2, 2, and 0, respectively. CONCLUSION: The use of the da Vinci SP robot with an additional assistant port for RARP is technically safe and feasible, with acceptable short-term functional and oncological outcomes. However, there is a technical learning curve for this new platform due to the smaller scope of the operative field and the decreased flexibility and strength of the surgical instruments.

Modified Apical Dissection and Lateral Prostatic Fascia Preservation Improves Early Postoperative Functional Recovery in Robotic-assisted Laparoscopic Radical Prostatectomy: Results from a Propensity Score-matched Analysis.

BACKGROUND: Early recovery of continence and potency after robotic-assisted laparoscopic prostatectomy (RALP) still remains a challenge. OBJECTIVE: To assess the effect of our modified apical dissection and lateral prostatic fascia preservation (mod-RALP) technique on early functional outcomes. DESIGN, SETTING, AND PARTICIPANTS: Among 2168 patients who underwent RALP between 2017 and 2019, 104 received a mod-RALP, and for the purposes of this study they were propensity score (PS) matched with a control group of conventional RALP cases based on preoperative and histological characteristics. SURGICAL PROCEDURE: In the mod-RALP technique, significant dissection of the apical complex was avoided with maximized preservation of periurethral tissue around the urethral stump. Nerve sparing was also modified with intrafascial dissection inside of the lateral fascia, leaving the lateral tissue including the neurovascular bundle (NVB) untouched and covered. MEASUREMENTS: The mod-RALP and conventional RALP groups were compared for continence and potency recovery at 1 and 6 wk postoperatively, as well as at 3, 6, and 12 mo. Kaplan-Meier curves and multivariate Cox regression models were used to identify survival estimations and their predictors. RESULTS AND LIMITATIONS: The mod-RALP technique resulted in faster continence (mean 46 vs 70 d) and potency (mean 74 vs 118 d, p < 0.05 for both) recovery. Functional recovery rates at postoperative follow-up were significantly higher in the mod-RALP group at all time points within the first 6 mo following surgery. Multivariate analyses revealed age, baseline functional status, surgical technique, and lymph node dissection as independent predictors of early functional recovery. This study is limited by its retrospective design and small size of the study groups. CONCLUSIONS: Our results with a modified technique intended to better preserve the apical complex and NVBs suggest earlier recovery of urinary continence and sexual function. These results should be tested with future randomized studies. PATIENT SUMMARY: We report a modified approach to apical dissection and lateral prostatic fascia preservation in robotic-assisted laparoscopic prostatectomy that resulted in earlier continence and potency recovery as compared with our conventional technique.

Technical Modifications Necessary to Implement the da Vinci Single-port Robotic System.

BACKGROUND: Since the implementation of robotic surgery, the platforms have been updating constantly in terms of arm configuration, tool design, scope settings, and the number of trocars placed. The introduction of new robotic technology is challenging and requires studies followed by technique adaptions. OBJECTIVE: This study aims to report a logical and technologically safe approach to the learning curve using the da Vinci single-port (SP) console and describes our robotic-assisted radical prostatectomy (RARP) technique step by step. DESIGN, SETTING, AND PARTICIPANTS: A prospective study from 26 consecutive patients who underwent RARP with the da Vinci SP console from June to August 2019. SURGICAL PROCEDURE: All surgeries were performed with a transperitoneal technique; one robotic trocar was placed above the umbilicus and one additional 12 mm trocar was placed in the right lower quadrant. MEASUREMENTS: We described the step-by-step technique and reported the perioperative and pathological data. In addition, we considered the hospital length of stay and pain scale following surgery. Continuous variables were reported as median and interquartile ranges. Categorical variables were reported as frequencies and proportions. RESULT AND LIMITATIONS: The total median operative time was 121 min, console time was 85 min, and blood loss was 50 ml. No complications were reported. In the final pathology, four patients had Gleason 6, 20 had Gleason 7, one had Gleason 8, and one had Gleason 9.Of the patients, 70% were ≤pT2 and 30% were ≥pT3a. Only 11% had positive surgical margins. This study is limited by the small number of patients and a short period of follow-up to evaluate functional and oncological outcomes of this new technology. CONCLUSIONS: RARP with the da Vinci SP is feasible and safe. Therefore, the step-by-step technique described in this study could be considered an option to perform radical prostatectomies. However, we still need better-designed studies to compare the outcomes with those of the multiport platform. PATIENT SUMMARY: We reported our step-by-step technique describing a safe approach to robotic-assisted radical prostatectomy during the transition from the Xi to the da Vinci single-port robot.