Extraperitoneal single-port robot-assisted radical prostatectomy: initial experience and description of technique

Objective To describe our technique of extraperitoneal single-port (SP) robot-assisted radical prostatectomy (RARP) and present our clinical experience with the first 10 cases. Patients and Methods In all, 10 consecutive patients diagnosed with localised prostate cancer underwent extraperitoneal SP-RARP using the da Vinci SP (R) Surgical System (Intuitive Surgical, Sunnyvale, CA, USA). Exclusion criteria included previous surgery through an infra-umbilical midline incision, prostate size >100 g, or preoperative evidence of extraprostatic disease. All surgeries were performed by a single surgeon with previous experience of >3000 cases in robotic surgery. Demographics and perioperative information were collected including: operative time, estimated blood loss (EBL), complications, length of stay, and days with Foley catheter. The extraperitoneal SP-RARP is performed as follows. Firstly, a 3-cm incision similar to 2 cm below the umbilicus is made. Dissection of the extraperitoneal space is achieved using a kidney shaped Spacemaker (TM) 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 (R) mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA, USA) 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 da Vinci SP surgical platform robot is docked with the patient in a supine position. RARP is performed replicating the technique previously described for multi-arm platforms or transperitoneal SP-RARP. No drain and no additional assistant ports were utilised. Results The patient's ages ranged between 48 and 70 years, and the mean preoperative prostate-specific antigen (PSA) level was 9 ng/mL. No conversions or intraoperative complications were recorded. The median (interquartile range) operative time was 197.5 (185.5-229.7) min. EBL ranged between 50 and 400 mL, six patients were discharged on the same day as the surgery and the median time with a Foley catheter after surgery was 8 days. Conclusions Extraperitoneal SP-RARP is a feasible and safe surgical option to treat localised prostate cancer. In our early experience, promising results and possible advantages were found 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.