157 patients underwent SP RARP by two surgeons who have collectively completed over 3000 multiport robotic surgeries. We collected and analyzed basic demographic pre-operative variables and peri-operative outcomes.
Our patient population’s median age was 63 years and their PSA levels were 6.3 ng/mL before treatment (IQR 4.7 - 8.2 ng/mL). The median operating time was 195 min (IQR 165 - 221.25 min) with a median estimated blood loss of 100 mL (IQR 100 - 200 mL). There were no intraoperative complications. There were six total post-operative complications (3.8%). Four (2.5%) were major complications as classified by the Clavien-Dindo scale (IIIa or higher), which included two patients with bladder neck contracture, small anterior urine leak, and urinary retention after foley removal. 70% of patients went home the same day, 29% stayed one night at the hospital, and only 1% stayed longer. With the median follow-up period of nine months, rates of biochemical recurrence, pad-free, and potency preservation were 8.3%, 82.5%, and 64.4%, respectively. Surgeon 1's operating time stabilized around case #56, and Surgeon 2 steadied around case #26. Surgeon 2 used the transperitoneal approach for the first seven cases.
Robot-assisted radical prostatectomy (RARP) has been a standard of care in the management of prostate cancer since the approval of the da Vinci surgical robotic platform by the Food & Drug Administration (FDA) in 2001.2,3 With four articulating instruments, RARP reduced the technical difficulties associated with laparoscopy, and patients were attracted to the procedure due to the prospect of minimizing postoperative surgery-related complications and surgical scars. In 2018, the USFDA approved the da Vinci single-port (SP) system, in which the four instruments enter via a single-site access trocar, allowing for one surgical scar. This new platform boasted a camera now including two points of articulation, but the instruments’ fixed positions reduce the dimensions of the surgical field and limited their movement.
Despite these potential benefits, the SP platform is associated with a significant learning curve and is due to few specific differences between the SP and multi-port platform. First, SP instruments do not have an endowrist and articulate instead at the elbow. Second, they are not as rigid as the multi-port instruments and cannot perform efficient blunt dissection. Third, true SP-RARP does not have an assistant port and thus some steps of the procedure facilitated by an assistant are significantly longer.
In conclusion, this case series analysis confirms that SP RARP is safe and feasible with acceptable short-term outcomes. However, there is a significant learning curve for this new modality due to reduced flexibility of the instruments and diminishment of the surgical field.
Written by: Juliana Kim, Alain Kaldany, Benjamin Lichtbroun, Eric Singer, Thomas L Jang, Saum Ghodoussipour, Moses Kim, Isaac Yi Kim
Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, United States; New Brunswick, United States; New Brunswick, United States; Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, United States; New Brunswick, United States; Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey, United States; Orange County Urology Associates, Irvine, United States; The Cancer Institute of New Jersey, Surgery/Urologic Oncology, New Brunswick, New Jersey, United States.
References:
- Lai, A., et al., Single port robotic radical prostatectomy: a systematic review. Translational andrology and urology, 2020. 9(2): p. 898-905.
- Dobbs, R.W., et al., Cost effectiveness and robot-assisted urologic surgery: does it make dollars and sense? Minerva Urol Nefrol, 2017. 69(4): p. 313-323.
- Checcucci, E., et al., Single-port robot-assisted radical prostatectomy: a systematic review and pooled analysis of the preliminary experiences. BJU Int, 2020. 126(1): p. 55-64.
- Arenas-Gallo, C., J.E. Shoag, and J.C. Hu, Optimizing Surgical Techniques in Robot-Assisted Radical Prostatectomy. Urol Clin North Am, 2021. 48(1): p. 1-9.
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