Robot‐assisted single‐port transvesical enucleation of the prostate: step‐by‐step technique and early single‐centre experience

Abstract

In recent years, robot-assisted simple prostatectomy (RASP) has become one of the various minimally invasive techniques for the surgical treatment of severe LUTS due to benign prostatic enlargement [1]. It is primarily recommended for patients with large prostate glands (>80–100 mL) as an alternative to currently available and rapidly evolving transurethral enucleation [2, 3]. The concept of performing RASP via a single skin incision was initially explored by Fareed et al. [4] in 2012 using a transvesical approach and a multi-port system. While the procedure was found to be feasible and effective, the authors recorded a high risk of complications, which was primarily due to inadequate instrumentation. Thus, interest in this technique declined until recently. In 2018, the Da Vinci Single Port (SP) system (Intuitive Surgical, Sunnyvale, CA, USA) was introduced in the US market. The SP platform is designed to minimise skin incisions and operate effectively in limited spaces, maintaining the benefits of robotic instruments. Hence, the concept of a SP transvesical enucleation of the prostate (STEP) has regained interest, leading to increasing evidence on the topic. The Cleveland Clinic group was the pioneer of this approach, showing its feasibility and safety [5]. Additional single-centre and multicentre studies have been reported over the past 3 years [6, 7]. Recently, the Single-Port Advanced Research Consortium (SPARC) published the largest STEP series with 110 procedures compared to the standard multiport (MP) approach. Perioperative outcomes showed significantly lower estimated blood loss (100 vs 150 mL, P < 0.001), shorter hospital stay (17 vs 33 h, P < 0.001), less use of opioids (0 vs 8.4 morphine milligram equivalents) and a shorter duration of Foley catheter (6 vs 9 days, P < 0.001) with the SP robot. The median operating times were 160 and 175 min in SP and MP, respectively [8]. In the present study, we illustrate and guide readers on a step-by-step STEP approach, along with preliminary data of our single-centre experience. We describe the case of a 77-year-old patient with Charlson Comorbidity Index of 4 and past medical history significant for hypertension, hyperlipidaemia, BPH with moderate-to-severe LUTS poorly responding to medical therapy (IPSS: 20), and a prostate volume (PV) of 110 mL with prominent median lobe. He ultimately experienced an episode of urinary retention, which was managed with an indwelling catheter. After careful counselling of the patient, it was decided to perform a STEP procedure using the DaVinci SP platform. With the patient in supine position, a 3 cm midline suprapubic skin incision was performed at 6–8 cm (3–4 fingerbreadths) above the pubic symphysis, to gain access to the bladder (Fig. 1A). Incision of the rectus fascia (Fig. 1B) and identification of the bladder dome was performed under cystoscopic guidance with use of CO2 insufflation to allow bladder filling at 8 mmHg. Two Polysorb™ (Medtronic, Minneapolis, MN, USA) 2–0 stay sutures were placed, and the bladder dome opened vertically for 2.5 cm (Fig. 1C). When performing this step, the flexible cystoscope ensures the correct placement of stay sutures. Then the Access port with the Alexis internal ring into the bladder was placed (Fig. 1D). This port consists in the Access port, an Alexis wound retractor, an ‘entry guide’, a 25-mm multichannel trocar that houses one entry channel for an 8-mm flexible scope, and three entry channels for robotic instruments, and an inflatable plastic globe, which allows for ‘floating docking’ (Fig. 1E). Optional insertion of an additional transvesical 5-mm port under digital guidance is feasible, to ensure rigid suction and more traction during adenoma enucleation. Dynamic insufflation was maintained throughout the procedure using an 8 mm AirSeal (Conmed Linvatec, Largo, FL, USA). The SP robot was docked (Fig. 2A) and pneumovesicum was induced keeping the pressure below 10 mmHg, in order to prevent air e