Initial experience on extraperitoneal single-port robotic-assisted radical prostatectomy

Abstract

The surgical spectrum for radical prostatectomy (RP) has evolved from open surgery to novel minimally invasive approaches during the past few decades, with robotic-assisted radical prostatectomy (RARP) being collectively reckoned as an increasingly popular option for prostate cancer (PCa). A previous study has demonstrated the safety and effectiveness of radical-assisted Laparoscopic radical Prostatectomy (RALP).[1] While the transperitoneal route is the most popular surgical access option, alternative propositions include extraperitoneal, perineal, or transvesical access. Since the advent of the next-generation da Vinci Xi and single-port (SP) platforms, robotic laparoendoscopic single-site surgery (R-LESS) has emerged as an intriguing concept in various general or gynecological procedures and in partial nephrectomy. The first single-port robotic-assisted radical prostatectomy (spRARP) was reported in 2008,[2] but has not seen much improvement in surgical techniques and popularity thereafter, with less than 60 total cases reported globally.[3] A previous report[4] demonstrated that the adoption of transumbilical incision in spRARP surgery may cause reduced flexibility, limited working space, and frequent instrument clashing, potentially leading to longer surgeries and increased difficulty. Extraperitoneal RARP has been widely reported in the literature with similar trifecta outcomes and shows more rapid recovery and reduced peri-operative complication rates.[5] The current study aims to investigate the feasibility of extraperitoneal single-port RARP (espRARP) with the use of the da Vinci Si HD model. We retrospectively analyzed 19 patients, aged 57 to 78 years with biopsy-confirmed PCa from November 15, 2018, to September 5, 2019, following institutional review board approval and informed consent signed by each individual. Multiparametric magnetic resonance imaging and bone scintigraphy were performed for all patients in the cohort, showing organ-confined disease. After informed consent, the patients had undergone espRARP. After evaluation with Briganti nomogram, all patients ruled out the necessity of performing pelvic lymph node dissection. Nerve-sparing procedures were performed for four pre-operatively potent patients. The surgical operations were performed in a high-volume center by a console surgeon with a RARP caseload over 700. Surgical assistants and scrubbing nurses were a fixed team who have all passed the learning curve. Under general anesthesia, the patient was placed in a 15° to 20° Trendelenburg position. A 5 cm transverse incision was made approximately 5 cm above the pubic symphysis. After incision of the anterior rectus fascia and separation of the rectus abdominis, extraperitoneal working space was created with an inflated surgical glove as a home-made dilator. Then, a commercially available 100-mm multi-channel laparoscopic port (Senscure Biotech Co., Ltd., Ningbo, Zhejiang Province, China) was inserted beneath the rectus muscle [Figure 1A]. Da Vinci Si HD was used (Intuitive Surgical, Sunnyvale, CA, USA), with 8-mm monopolar scissors and Maryland bipolar forceps equipped to perform dissection procedures. As a modification to reduce clashing, a 12-mm 30° high-definition laparoscope was introduced and toggled 30° up throughout the operation [Figure 1B]. The anterior prostatic fat was removed and was followed by an incision of the lateral endopelvic fasciae. Dorsal venous complex was ligated using a 2-0 Monocryl suture. Then, the bladder neck was identified and transected, followed by ligation of the vasa deferentia and dissection of the seminal vesicles. The prostate was then suspended to develop the posterior plane of the prostate to expose posterior fascia. Next, the prostate was dissected extra- or intra-fascially, depending on the patient's eligibility for nerve-sparing procedures. After mobilizing and transecting the distal urethra, the prostate was removed entirely and put in a sample bag, followed by