Managing prostate cancer after proctocolectomy and ileal pouch-anal anastomosis: feasibility and outcomes of single-port transvesical robot-assisted radical prostatectomy.

INTRODUCTION: Patients with proctocolectomy and ileal pouch-anal anastomosis (PC-IPAA) face unique challenges in managing prostate cancer due to their hostile abdomens and heightened small bowel mucosa radiosensitivity. In such cases, external beam radiation therapy (EBRT) is contraindicated, and while brachytherapy provides a safer option, its oncologic effectiveness is limited. The Single-Port Transvesical Robot-Assisted Radical Prostatectomy (SP TV-RARP) offers promise by avoiding the peritoneal cavity. Our study aims to evaluate its feasibility and outcomes in patients with PC-IPAA. METHODS: A retrospective evaluation was done on patients with PC-IPAA who had undergone SP TV-RARP from June 2020 to June 2023 at a high-volume center. Outcomes and clinicopathologic variables were analyzed. RESULTS: Eighteen patients underwent SP TV-RARP without experiencing any complications. The median hospital stay was 5.7 h, with 89% of cases discharged without opioids. Foley catheters were removed in an average of 5.5 days. Immediate urinary continence was seen in 39% of the patients, rising to 76 and 86% at 6- and 12-month follow-ups. Half of the cohort had non-organ confined disease on final pathology. Two patients with ISUP GG3 and GG4 exhibited detectable PSA post-surgery and required systemic therapy; both had SVI, multifocal ECE, and large cribriform pattern. Positive surgical margins were found in 44% of cases, mostly Gleason pattern 3, unifocal, and limited. After 11.1 months of follow-up, no pouch failure or additional BCR cases were found. CONCLUSION: Patients with PC-IPAA often exhibit aggressive prostate cancer features and may derive the greatest benefit from surgical interventions, particularly given that radiation therapy is contraindicated. SP TV-RARP is a safe option for this group, reducing the risk of bowel complications and promoting faster recovery.

Complications of single-port robot-assisted radical prostatectomy: multi-institutional analysis from the Single-Port Advanced Research Consortium (SPARC).

OBJECTIVE: To evaluate the perioperative complications of single-port robot-assisted radical prostatectomy (SP-RARP). PATIENTS AND METHODS: A retrospective review was performed on the prospectively maintained, Institutional Review Board-approved, multi-institutional Single-Port Advanced Research Consortium (SPARC) database. A total of 1103 patients were identified who underwent three different approaches of SP-RARP between 2019 and 2022 using the purpose-built SP robotic platform. In addition to baseline clinical, perioperative outcomes, this study comprehensively analysed for any evidence of intraoperative complication, as well as postoperative complication and readmission within 90 days of the respective surgery. RESULTS: Of the 244, 712, and 147 patients who underwent transperitoneal, extraperitoneal, and transvesical SP-RARP, respectively, intraoperative complications were noted in five patients (0.4%), all of which occurred during the transperitoneal approach. Two patients had bowel serosal tears, two had posterior button-holing of the bladder necessitating repair, and one patient had an obturator nerve injury. Postoperative complications were noted in 143 patients (13%) with major complications (Clavien-Dindo Grade ≥III) only identified in 3.7% of the total cohort. The most common complications were lymphocele (3.9%), acute urinary retention (2%), and urinary tract infection (1.9%). The 90-day re-admission rate was 3.9%. CONCLUSION: The SP-RARP is a safe and effective procedure with low complication and readmission rates regardless of the approach. These results are comparable to current multi-port RARP literature.

Single-Port Robotic Radical Prostatectomy Using Transvesical and Transperineal Access in Patients with a Hostile Abdomen.

Introduction: Prostate cancer diagnosis and treatment is challenging in surgically complex patients. Radical prostatectomy can be performed without peritoneal entry using novel single-port (SP) transperineal (TP) and transvesical (TV) approaches. We sought to examine the outcomes of radical prostatectomy using novel TP and TV approaches in patients with extensive prior abdominal surgeries. Materials and Methods: From 2019 to 2023, 51 patients with extensive prior abdominal surgeries were identified who underwent TP (18) and SP TV (33) robotic radical prostatectomy. Indications included history of various surgeries with open laparotomy, including J-pouch reconstruction (22, 43%), active stoma (14, 27%), and open bowel resection (9, 18%). In all patients, 12/51 (24%) had a history of incisional hernia repair with mesh. A retrospective analysis was performed. Results: All cases were completed without open conversion, bowel injuries, or blood transfusions. Length of stay was 5.6 hours for TV and 22 hours for TP. No opioids were prescribed in 91% of TV vs 56% of TP. One intraoperative complication (ureteral injury) occurred in a patient undergoing the TP approach. Postoperative complications were noted in 14/51 (27%), including 10/18 (56%) TP vs 4/33 (12%) TV. High-grade complications (Clavien 3) occurred in three patients (6%, all TP). Pathologic staging showed pT3 in 26/51 (17 TV vs 9 TP), while the remainder were pT2. Biochemical recurrences were noted in four patients (8%, three TV and one TP). Immediate continence was noted in 30% of TV patients. Long-term continence after 12 months was 92% in TV and 67% in TP. Conclusions: In patients with extensive prior abdominal surgeries, radical prostatectomy is feasible using a TP or TV approach. No bowel injuries or open conversion were observed. The SP TV approach offers advantages of shorter hospital stay, shorter catheter duration, less opioid use, fewer complications, and improved continence recovery.

Perioperative Complications of Single-Port and Multiport Robotic Radical Prostatectomy: A Single Institutional Comparison Analysis.

Background: Following its introduction in 2018, the Single-Port (SP) robotic platform has been increasingly utilized for various approaches of robotic radical prostatectomy (RARP). Despite the demonstrable benefits in enhancing postoperative outcomes, there has been limited evidence on its perioperative morbidity, especially when compared to the gold-standard multiport (MP). This study sought to compare the perioperative morbidity between SP and MP-RARP. Methods: A retrospective review was performed on 911 patients who underwent RARP between January 2015 and May 2023. At our institution, SP-RARP has been performed since October 2018 with Extraperitoneal and Transvesical (TV) techniques. To reduce the risk of selection bias, only MP-RARP cases performed before October 2018 were included. Baseline clinicodemographic and perioperative parameters were collected. Perioperative complications were classified in accordance to the Clavien-Dindo system with postoperative complications and readmission reported within 90 days of surgery. Statistical analysis was performed with R Packages for Statistical Computing with descriptive statistics as presented. Results: Of the 484 SP and 322 MP-RARP cases included in our analysis, one intraoperative complication was reported, which pertained to a small enterotomy during TV SP-RARP. Postoperative complications were identified in 14.5% and 14.6% of SP and MP-RARP cases (p = 0.989), respectively. Major complication represents 4.1% of the SP and 3.4% of MP cohorts. The 90-day rates of hospital readmission following SP and MP-RARP were 5.6% and 4.9%, respectively (p = 0.717). Limitations of this study included the retrospective single surgeon, single institution nature of our series that also included the early learning curve experience associated with the novel SP platform. Conclusion: This comparative study provided evidence highlighting the low rates of perioperative complication and readmission following SP-RARP that were comparable to the Transperitoneal MP approach. The low morbidity associated with SP-RARP supports its wider application as an addition to the contemporary minimally invasive surgical armamentariums for prostate cancer.

Predictors of Early Continence After Single-port Transvesical Robot-assisted Radical Prostatectomy.

OBJECTIVE: To identify the factors associated with a short time of return to continence. METHODS: We analyzed the first 110 SP TV RARP consecutive cases performed by one surgeon from 2020 to 2022. Continence was defined as zero to one safety pad. Two statistical analyses were done. First, patients were divided: group A (n = 62) included individuals who achieved continence within the initial week postcatheter removal; group B (n = 48) rest of the patients. Descriptive statistics were compared, followed by logistic regression for independent variables. Second, time to continence was analyzed as a continuous variable employing linear regression. The primary outcomes were the independent variables significantly associated with a short time to continence. RESULTS: All cases were completed successfully, without additional ports or conversions. Median urinary catheter duration and time to continence were 3 and 3.5days, respectively. Patients achieving continence within 1week significantly presented with fewer preoperative urinary tract symptoms, lower prostate-specific antigen levels, and had smaller specimen weights postoperatively. Multivariable logistic regression established low specimen weight as the sole significant factor (P = .04). Furthermore, linear regression demonstrated that alterations in independent variables accounted for 12.7% of the variance in time to continence (P = .62). CONCLUSION: The regionalization of surgery to the bladder employing a retropubic space-sparing extraperitoneal approach during SP TV RARP contributes to a fast return to continence. According to our model, the factors that significantly predict a shorter time to continence include lower preoperative International Prostate Symptom Score, prostate-specific antigen, and postoperative specimen weight.

Predictors of Same-day Discharge After Single-Port Transvesical Enucleation of the Prostate.

OBJECTIVE: To determine the rate of outpatient cases and identify predictors for same-day discharge (SDD) after single-port transvesical enucleation of the prostate (STEP). METHODS: Retrospective analysis of all consecutive STEP cases performed at a single center by 3 surgeons from February 2019 to October 2023. The cohort was categorized into SDD cases (<8 hours until discharge) and inpatient cases. Group comparisons were made and logistic regression was used to identify predictors of SDD. RESULTS: A total of 152 STEP cases were performed successfully without additional ports or conversions. Fifty-two patients were pre-planned admissions, leaving 100 planned outpatient cases, of which 86% were discharged on the same day (median length of stay of 4.7 hours). Comparing the groups, inpatient cases were older, had higher Charlson Comorbidity Index (CCI) scores, higher estimated blood loss (EBL) during surgery, and more intraoperative complications than SDD patients. Univariate logistic regression identified age and CCI as the predictors associated with SDD after STEP. Notably, there were no major postoperative complications or readmissions in either group. CONCLUSION: In our 4-year experience with STEP, lower age and CCI score were significant predictors of SDD. The comprehensive evaluation criteria for discharge foster a safe recovery at home, coupled with a 0% rate of major postoperative complications and readmissions. These findings underscore the safety and efficacy of STEP, guiding patient counseling and surgeon expectations.

Long-Term Functional and Oncologic Outcomes Following Robotic Partial and Radical Nephrectomy: A Report from a Single Institution with up to 15 Years of Follow-Up.

Objective: To evaluate the long-term functional and oncologic outcomes after robotic partial nephrectomy (RAPN) and radical nephrectomy (RARN). Materials and Methods: A retrospective review was performed on 1816 patients who underwent RAPN and RARN at our institution between January 2006 and January 2018. Patients with long-term follow-ups of at least 5 years were selected. Exclusion criteria included patients with a previous history of partial or radical nephrectomy, known genetic mutations, and whose procedures were performed for benign indications. Statistical analysis was performed with results as presented. Results: A total of 769 and 142 patients who underwent RAPN and RARN, respectively, met our inclusion criteria. The duration of follow-up was similar after the two procedures with a median of ∼100 months. The 5- and 10-year chronic kidney disease (CKD) upstaging-free survivals were 74.5% and 65.9% after RAPN and 53% and 46.4% after RARN, respectively. Older age was identified as a potential predictor for CKD progression after RARN, whereas older age, higher body mass index, baseline renal function, and ischemia time were shown to predict CKD progression after RAPN. Renal cell carcinoma-related mortality rates for RAPN and RARN were equally 1.1%. No statistically significant differences were identified in the local recurrence, metastatic, and disease-specific survival between the two procedures. Conclusion: Compared with RARN, RAPN conferred a better CKD progression-free survival. Several factors were identified as potential predictors for clinically significant CKD progression both in the early and late postoperative phase. Long-term oncologic outcomes between the two procedures remained similarly favorable.

Transvesical Percutaneous Access Allows for Epidural Anesthesia Without Mechanical Ventilation in Single-Port Robotic Radical and Simple Prostatectomy.

OBJECTIVES: To determine the feasibility of epidural anesthesia in patients undergoing transvesical single-port (SP) robotic simple and radical prostatectomy. METHODS: Patients undergoing transvesical SP robotic radical or simple prostatectomy were selected. Exclusions were underlying obstructive sleep apnea, pulmonary disease, prior lumbar spinal surgery, or BMI >35. Low thoracic or high lumbar epidural catheters were placed in the preoperative unit prior to operating room transport. Demographic information, intraoperative variables, and perioperative outcomes were collected in an IRB-approved database. A descriptive statistical analysis was performed. RESULTS: A total of 12 patients underwent epidural placement prior to transvesical SP radical (N = 7) and simple (N = 5) prostatectomy. All cases were completed without extra ports, open conversion, or conversion to general anesthesia. No surgical interruptions were noted in 9 of 12 cases and all movement-related interruptions were brief and transient. No anesthetic complications were noted. The one postoperative complication noted was unrelated to anesthesia. Intraoperative opioids were avoided in 5 patients. No patients required opioid medications after discharge and all patients with outpatient encounters were same-day discharges. One patient was a pre-planned admission. Limitations include small number of patients and a single surgeon experience. CONCLUSION: Epidural anesthesia without mechanical ventilation is a safe and feasible technique in selected patients undergoing transvesical SP robotic radical and simple prostatectomy. This approach was not associated with any anesthesia-related complications or compromise in perioperative outcomes.

The Transition Toward Opioid-sparing Outpatient Radical Prostatectomy: A Single Institution Experience With Three Contemporary Robotic Approaches.

OBJECTIVE: To evaluate for differences in the perioperative and early postoperative outcomes between three different contemporary approaches of robotic radical prostatectomy (RARP), namely Single-Port (SP) Transvesical (TV), SP Extraperitoneal (EP), and Multi-Port (MP) Transperitoneal (TP). METHODS: Retrospective review was performed on 865 consecutive patients with localized prostate cancer who underwent SP-TV, SP-EP, and MP-TP RARP. SP-TV and SP-EP RARP were performed using the purpose-built SP robotic platform. All procedures were performed by a single, experienced robotic surgeon. Demographics, perioperative, and early postoperative data were collected from the prospectively-maintained database. Statistical analysis was performed with descriptive statistics as presented. RESULTS: All SP cases were completed without any need for conversion or additional ports. When compared with MP-TP RARP, both SP-EP and SP-TV RARP were associated with significantly reduced length of stay (median, SP-TV 5.07 vs SP-EP 5.1 vs MP-TP 26.6 hours, P = <.05) and with most patients being discharged within 24 hours (SP-TV 92.3% vs SP-EP 84.6% vs MP-TP 30.4%, P = <.05). Postoperative analgesia requirements were significantly reduced following SP-TV RARP with 95% did not require opioid analgesia after discharge, as opposed to 77.6% and 12.1% of patients in the SP-EP and MP-TP RARP cohorts, respectively (P = <.05). Additionally, SP-TV RARP demonstrated the added benefit of a shorter Foley catheter duration of 4 days with an earlier return of urinary continence. CONCLUSION: The localization of RARP, as facilitated by the SP robotic platform, provided the opportunity for enhanced postoperative recovery resulting in decreased length of admission and postoperative pain, which allowed for increasing adoption of opioid-sparing outpatient prostatectomy.

Single-port Transvesical Robot-assisted Radical Prostatectomy: The Surgical Learning Curve of the First 100 Cases.

OBJECTIVE: To determine the number of cases required to reach plateau performance. METHODS: We performed a single-surgeon review of the first 100 consecutive procedures. All procedures were performed using the da Vinci single-port robotic system between November 2020 and March 2022. Time was used as the measure of the learning curve (LC). Relevant surgical steps were considered separately for detailed analysis. Data were collected retrospectively and analyzed through the cumulative sum method and moving average graphing. A comparative analysis was done between subgroups of 20 consecutive cases for perioperative outcomes. RESULTS: All cases were completed successfully, without extra ports or conversion. The LC for prostate excision showed initial exponential improvement and reached plateau at case 28. Vesicourethral anastomosis time gradually shortened over time, with a clear inflection point at case 10. Total operative time rapidly improved and plateaued early to 213.0 minutes. Robot-docking and undocking, achieving hemostasis, wound closure, and intraoperative idle times were consistent throughout the series. Estimated blood loss decreased significantly after the first 20 cases (from median of 135.0-88.0 mL, P = .03). CONCLUSION: In our early experience, the LC for single-port transvesical robot-assisted radical prostatectomy suggests that performance improved after 10-30 cases in the hands of an experienced robotic surgeon.

Vesicourethral Anastomosis in Transvesical Single-Port Robotic Radical Prostatectomy: A Technical Description and Perioperative Outcomes.

Objective: To describe the technical evolution and perioperative outcomes of vesicourethral anastomosis (VUA) in transvesical (TV) single-port robot-assisted radical prostatectomy (SP-RARP). Materials and Methods: A retrospective review was performed on 189 patients who underwent TV SP-RARP by a single surgeon using the purpose-built SP robotic platform. VUA was completed from within the bladder using two unidirectional V-loc sutures in a continuous, semicircular manner with greater emphasis posteriorly. The most recent 20 cases of TV SP-RARP were selected to evaluate the anastomosis technique and to compare the perioperative outcomes with the first 20 cases of TV SP-RARP performed at our institution. Demographic and clinical data were collected from the prospectively maintained database and statistical analysis was performed. Results: VUA was effectively completed in all cases using the aforementioned technique without any suture breaks, need for conversion, or evidence of intraoperative complication, including urine leak. Marked improvement in the learning curve was observed, which translated to significant reduction in the number of VUA sutures (median: 13 vs 15, p < 0.05) and faster anastomosis time (median: 19.1 vs 33.5 minutes, p < 0.05). The number of anastomotic sutures did not correlate with the prostatectomy specimen weight or volume, especially with both being significantly greater in the latest cases (median weight: 45.1 vs 37.6 g, p < 0.05; median volume: 40.9 vs 36.2 mL, p < 0.05). Postoperative outcomes were favorable with immediate continence achieved in 51.3% of our total cohort and with no patients demonstrating evidence of bladder neck contracture. Conclusion: We provided a detailed technical description of VUA in TV SP-RARP. The improved maneuverability of the SP robotic platform allowed for unique movements to facilitate suture placements from within the confined space of the bladder. The learning curve of a single surgeon was shown in our study, which resulted in notable reduction in the number of sutures, faster anastomosis time, and improved perioperative outcomes.

First 100 cases of transvesical single-port robotic radical prostatectomy.

Objective: To describe the surgical technique and report the early outcomes of the transvesical (TV) approach to single-port (SP) robot-assisted radical prostatectomy. Methods: All procedures were performed at a single center by one surgeon. We identified the first 100 consecutive patients with clinically localized prostate cancer that underwent SP TV robot-assisted radical prostatectomy using the da Vinci SP robotic surgical system. Data were collected prospectively and analyzed with descriptive statistics. The primary outcomes assessed were postoperative urinary continence, rate of biochemical recurrence, and sexual function. Results: All procedures were performed without extra ports or conversion. The median age was 62.1 years and 49.0% of the patients had abdominal surgery history. The preoperative median prostate-specific antigen value and prostate volume were 5.0 ng/mL and 33.0 mL, respectively. There were no intraoperative complications. The median operative time and estimated blood loss were 212.5 min and 100.0 mL, respectively. A total of 92.0% of patients were discharged within 24.0 h, with an overall median length of stay of 5.6 h. Only 4.0% of patients required opioid prescriptions at discharge. The median Foley catheter duration was 3 days. Positive margins were present in 15.0% of cases. Median follow-up was 10.4 months. Continence rate was immediate after Foley removal in 49.0% of cases, 65.0% at 2 weeks, 77.4% at 6 weeks, 94.1% at 6 months, and 98.9% at 1 year. One case of biochemical recurrence (1.0%) was noted 3 months after surgery. Conclusion: The SP TV approach for radical prostatectomy cases is a safe and feasible technique for patients with clinically localized prostate cancer. This technique offers advantages of short hospital stay, minimal narcotic use postoperatively, and promising early return of urinary continence, without compromising oncologic outcomes.

Single Port Robotic Kidney Autotransplantation: Initial Case Series and Description of Technique.

PURPOSE: Minimally invasive kidney autotransplantation (KAT) has demonstrated reduced morbidity, however multiport robotic approach required patient repositioning and multiple sets of incisions. We present our initial series of single-port (SP) robotic KAT, ideal for multi-quadrant surgeries, and aim to evaluate feasibility and safety of the novel approach. METHODS: Between 2018 and 2022, 8 consecutive patients underwent SP KAT using the DaVinci SP platform. Patient clinicopathologic variables and perioperative outcomes were recorded. Indications for KAT include complex or recurrent ureteral stricture, ureteral avulsion, and chronic visceral pain due to multiple etiologies. RESULTS: All SP KATs were successfully performed without repositioning or conversion to open. Operative times ranged from 366 to 701 minutes, warm and cold ischemia times between 4 to 10 minutes and 86 to 209 minutes, respectively. Median hospital length of stay was 3 days. At a median of 13 months follow-up, latest postoperative GFRs were stable, ranging from +23% to -10%. There were no complications. CONCLUSION: We demonstrate our single port, multiquadrant robotic kidney auto transplantation technique performed though a single incision further reducing surgical morbidity. All cases were completed successfully without conversion or loss of graft function. All patients reported resolution of flank pain and no radiological evidence of urinary obstruction on follow up.

Low Risk of Postoperative Hernia Following Single-port Robot-assisted Radical Prostatectomy: A Report From the Single-port Advanced Research Consortium (SPARC).

OBJECTIVE: To evaluate the risk of postoperative hernia following different approaches of single-port robot-assisted radical prostatectomy (SP-RARP). METHODS: A retrospective review was performed on patients who underwent SP-RARP between February 2019 and December 2022. Demographic and clinical information was collected from the multi-institutional, prospectively-maintained Single-Port Advanced Research Consortium (SPARC) database. Data were analyzed using IBM Statistical Packaging for Social Sciences (SPSS) version 29.0 with descriptive statistics as presented. RESULTS: A total of 1103 patients were identified, consisting of 244 (22.1%), 712 (64.6%), and 147 (13.3%) cases performed via transperitoneal, extraperitoneal (EP), and transvesical (TV) approaches, respectively. During a median follow-up time of 11 months (interquartile range 5.7-17.1 months), only two cases of incisional hernia were reported. Both cases occurred following transperitoneal SP-RARP with one patient requiring surgical repair. There remains no evidence of postoperative hernia following EP and TV SP-RARP at the completion of our review. CONCLUSION: SP-RARP was associated with low risk for postoperative hernia. The risk was lower following TV and EP SP-RARP where the peritoneum is preserved.