The advent of minimally invasive surgery introduced the laparoscopic and robotic approaches to performing radical prostatectomy with advantages such as less blood loss and shorter length of stay compared to the open version of this procedure. The evolution of robotic platforms and the introduction of the da Vinci SP® Surgical System (Intuitive Surgical, Sunnyvale, CA) offers the option to re-evaluate different approaches to treat prostate cancer and propose the single port as a safe, feasible and reproducible option to perform radical prostatectomy.
To describe our technique of Extra-peritoneal single port robotic radical prostatectomy and present the clinical experience with the first 10 cases.
Ten consecutive patients diagnosed with localized prostate cancer underwent extra-peritoneal single port radical prostatectomy. Exclusion criteria include previous surgery through an infra-umbilical midline incision, prostate over 100 grams or preoperative evidence of extraprostatic disease. All surgeries were performed by a single surgeon with a previous experience of over 3000 cases in robotic surgery. Demographics, and perioperative information were collected including operative time, estimated blood loss, complications, length of stay and days with Foley catheter. The extra-peritoneal single port radical prostatectomy is performed by doing: a 3 cm incision one finger breadth below the umbilicus. Dissection of the extra-peritoneal space is achieved using a kidney shape space-maker 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) 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 SP® surgical platform (Intuitive Surgical, Sunnyvale, CA) robot is docked with the patient in a supine position. Robotic-assisted radical prostatectomy is performed replicating the technique previously described for multi-arms platforms or trans-peritoneal single port prostatectomy. No drain and no additional assistant ports were utilized.
Patient's ages ranged between 48 and 70 years and mean preoperative PSA was 9 ng/ml. No conversions or intraoperative complications were recorded. Median operative time was 197.5 minutes (IQR 185.5-229.7). Estimated blood loss ranged between 50 and 400 cc, 6 patients were discharged the same day of surgery and the median of days with Foley catheter after surgery was 8 days.
Extra-peritoneal Single Port Robotic Radical Prostatectomy is a feasible and safe surgical option to treat localized prostate cancer. In our early experience, promising results and possible advantages were observed 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. This article is protected by copyright. All rights reserved.
BJU international. 2019 Aug 06 [Epub ahead of print]
Jihad Kaouk, Rair Valero, Guilherme Sawczyn, Juan Garisto
Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.