WCET 2024: Extraperitoneal and Transvesical Approaches to SP RALP

(UroToday.com) This was a special plenary held by two esteemed urologists, Dr. Jihad Kaouk and Dr. Ryan Nelson, who gave a talk on extraperitoneal and transvesical approaches to single-port robotic radical prostatectomy.


Part One- Single Port Robotic Radical Prostatectomy: Extraperitoneal and Transvesical Approaches

Up first, Dr. Kaouk, delivered a presentation on the advancements and benefits of Single Port (SP) Robotic Radical Prostatectomy, specifically focusing on extraperitoneal and transvesical approaches.

His talk emphasized the importance of regionalizing surgery using a low-profile robotic system that offers excellent access to challenging anatomical areas, contrasting it with the more invasive multiport systems that traverse the entire abdominal cavity.
Reflecting on his journey, Dr. Kaouk shared how he transitioned from a multiport surgeon with over 20 years of experience to primarily utilizing the single-port transvesical approach.

He underscored the importance of replicability and teachability in surgical innovations, emphasizing that “surgery done by the few does not have much value.” Dr. Kaouk strongly advocated for single-port surgery, highlighting its versatility as a customizable surgical approach. He recommended the transvesical approach as the default choice, particularly for patients with a hostile abdomen or those requiring concurrent management of bladder stones and diverticula, as well as for prostate volumes under 80-100 grams. The extraperitoneal approach, he suggested, is best suited for obese patients or when extended lymph node dissections are necessary. For patients with a history of bladder trauma or previous bladder surgery, Dr. Kaouk advised using the transperineal approach.

Through a video demonstration, Dr. Kaouk highlighted the benefits of the single-port approach in both extraperitoneal and transvesical techniques, such as improved vision, less invasiveness, and the ability to target specific areas with ease. The transvesical single-port technique also allowed for precise nerve sparing, resulting in an 80% rate of post-surgical erectile function recovery, though he noted that further data is needed to substantiate this; more surgical data regarding the transvesical approach’s post-operative outcomes are in the image below.further data is needed to substantiate this; more surgical data regarding the transvesical approach’s post-operative outcomes are in the image below.
In comparing multiport and single-port outcomes, Dr. Kaouk found no significant differences in biochemical recurrence (BCR)-free survival in respect to oncological outcome, but single-port approaches consistently outperformed multiport surgeries in terms of patient comfort.Dr. Kaouk found no significant differences in biochemical recurrence (BCR)-free survival in respect to oncological outcome, but single port approaches consistently outperformed multiport surgeries in terms of patient comfort.
Single port surgery resulted in shorter hospital stays, reduced opioid use, quicker removal of Foley catheters, and a remarkable 40% of patients experiencing immediate urinary continence post-surgery.
Single port surgery resulted in shorter hospital stays, reduced opioid use, quicker removal of Foley catheters, and a remarkable 40% of patients experiencing immediate urinary continence post-surgery.earlier return urinary continence
Additionally, single-port patients showed a lower incidence of post-operative hernias due to the minimally invasive nature of the procedure.single-port patients showed a lower incidence of post-operative hernias due to the minimally invasive nature of the procedure.
The transvesical single-port approach, with its direct percutaneous access into the bladder, proved especially valuable for patients with intra-abdominal adhesions or those who have a hostile abdomen or had previously undergone aborted radical prostatectomies. The approach was so minimally invasive that some patients could even remain awake during surgery.direct percutaneous access into the bladder
Dr. Kaouk concluded by emphasizing the multidimensional value of single-port robotic surgery. For patients, it allows for customizable surgeries, quicker recovery at home, minimal narcotic use, favorable cosmetic outcomes, and excellent long-term results. For surgeons, it offers better ergonomics, opportunities to master various approaches, and the use of state-of-the-art technology. For healthcare systems, single-port robotic surgery improves outpatient care, increases patient flow, and represents cutting-edge innovation.

Part Two- Single Port Extravesical vs. Transvesical prostatectomy

The subsequent talk was presented Dr. Nelson, who provided deeper insights into the ongoing discussion of single port extravesical versus transvesical prostatectomy. Building on Dr. Kaouk’s earlier presentation, Dr. Nelson reviewed the advantages and disadvantages of each approach.

Single Port Extravesical vs. Transvesical prostatectomy
To illustrate his points, he presented a side-by-side video comparison of the two methods. The transvesical approach, he noted, offers easier access and greater preservation of local anatomy for subjects under 80 grams but is constrained by limited space within the bladder. This restricted workspace also makes suturing more challenging. In contrast, the extravesical approach allows for easier instrument rotation, which can simplify certain aspects of the procedure.

However, Dr. Nelson highlighted a significant drawback of the transvesical approach: a higher incidence of erectile dysfunction compared to the extravesical method. This key distinction emphasizes the need for careful consideration of each patient’s circumstances when choosing the surgical approach.
Single Port Extravesical vs. Transvesical prostatectomy 2
The talks by Drs. Kaouk and Nelson exemplified how single-port robotic surgery is advancing patient care and transforming surgical practice. Dr. Kaouk demonstrated that single-port robotic surgery is not only advancing patient care but also transforming surgical practice and healthcare delivery while Dr. Nelson illustrating how choosing the appropriate technique can significantly impact patient outcomes and surgical efficacy.

Presented by:
  • Jihad Kaouk, MD, FACS, FRCS, Cleveland Clinic, Cleveland, OH @drjkaouk on Twitter
  • Ryan Nelson, DO, Michigan Institute of Urology, Utica, MI @NelsonNelsonr2 

Moderated by: Jean V. Joseph, MD, MBA

Panelists: Michael S. Cookson, MD, S. Duke Herrell, III, MD, FACS, Ill Young Seo, M.D.

Written by: Seyed Amiryaghoub M. Lavasani, B.A., University of California, Irvine, @amirlavasani_ on Twitter during the 2024 World Congress of Endourology and Uro-Technology (WCET) Annual Meeting, August 12 -16, 2024, Seoul, South Korea