“Show Me How” VideoSingle-Port Robot-Assisted Radical Prostatectomy: First Clinical Experience Using The SP Surgical System
Abstract
Objectives
To describe the first clinical experience with the novel purpose-built single-port robotic platform after Food Drug Administration approval.
Methods
Two male patients diagnosed with prostate cancer amenable of radical prostatectomy underwent single-port robot-assisted radical prostatectomy with bilateral pelvic lymph-nodes dissection performed by using the da Vinci SP Surgical System (Intuitive Surgical, Sunnyvale, CA). The surgeries were completed through a 2.5-cm periumbilical incision through which a GelPOINT Mini advanced access platform (Applied Medical, Rancho Santa Margarita, CA) and the dedicated 25-mm multichannel port accommodating a 12 × 10 mm oval articulating robotic camera, three 6-mm double-jointed articulating robotic instruments and a 6-mm accessory laparoscopic instrument were placed. One port for the assistant was placed at the level of the para-rectal line, at the planned final site for the drainage. The primary aim was to report, for the first time in the United States after Food Drug Administration approval of the system, the technical feasibility in the living human. The secondary aim was to report the perioperative outcomes.
Results
The surgeries were successfully completed without conversion. In both cases, the total operative time was 140 minutes. Blood loss was negligible. No complications were recorded. Patients were discharged within 24 hours postoperation.
Conclusions
Herein, we documented the first clinical application of the SP surgical platform for single-port transumbilical robot-assisted radical prostatectomy in the United States. This approach will be further investigated regarding the surgical morbidity and the outcomes.
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Cited by (70)
Predictors of Early Continence After Single-port Transvesical Robot-assisted Radical Prostatectomy
2024, UrologyTo identify the factors associated with a short time of return to continence.
We analyzed the first 110 SP TV RARP consecutive cases performed by one surgeon from 2020 to 2022. Continence was defined as zero to one safety pad. Two statistical analyses were done. First, patients were divided: group A (n = 62) included individuals who achieved continence within the initial week postcatheter removal; group B (n = 48) rest of the patients. Descriptive statistics were compared, followed by logistic regression for independent variables. Second, time to continence was analyzed as a continuous variable employing linear regression. The primary outcomes were the independent variables significantly associated with a short time to continence.
All cases were completed successfully, without additional ports or conversions. Median urinary catheter duration and time to continence were 3 and 3.5 days, respectively. Patients achieving continence within 1 week significantly presented with fewer preoperative urinary tract symptoms, lower prostate-specific antigen levels, and had smaller specimen weights postoperatively. Multivariable logistic regression established low specimen weight as the sole significant factor (P = .04). Furthermore, linear regression demonstrated that alterations in independent variables accounted for 12.7% of the variance in time to continence (P = .62).
The regionalization of surgery to the bladder employing a retropubic space-sparing extraperitoneal approach during SP TV RARP contributes to a fast return to continence. According to our model, the factors that significantly predict a shorter time to continence include lower preoperative International Prostate Symptom Score, prostate-specific antigen, and postoperative specimen weight.
Single-port Transvesical Robot-assisted Radical Prostatectomy: The Surgical Learning Curve of the First 100 Cases
2023, UrologyTo determine the number of cases required to reach plateau performance.
We performed a single-surgeon review of the first 100 consecutive procedures. All procedures were performed using the da Vinci single-port robotic system between November 2020 and March 2022. Time was used as the measure of the learning curve (LC). Relevant surgical steps were considered separately for detailed analysis. Data were collected retrospectively and analyzed through the cumulative sum method and moving average graphing. A comparative analysis was done between subgroups of 20 consecutive cases for perioperative outcomes.
All cases were completed successfully, without extra ports or conversion. The LC for prostate excision showed initial exponential improvement and reached plateau at case 28. Vesicourethral anastomosis time gradually shortened over time, with a clear inflection point at case 10. Total operative time rapidly improved and plateaued early to 213.0 minutes. Robot-docking and undocking, achieving hemostasis, wound closure, and intraoperative idle times were consistent throughout the series. Estimated blood loss decreased significantly after the first 20 cases (from median of 135.0-88.0 mL, P = .03).
In our early experience, the LC for single-port transvesical robot-assisted radical prostatectomy suggests that performance improved after 10-30 cases in the hands of an experienced robotic surgeon.
Recent advances in single-site/incision robotic-assisted radical prostatectomy
2023, European Journal of Surgical OncologySingle-site robotic-assisted radical prostatectomy (ssRARP) has been successfully applied to treat prostate cancer. This review aims to describe the recent advances of surgical approaches, working accesses and novel robotic platforms in ssRARP.
A systematic literature search was performed by searching the PubMed, EMBASE, Web of Science and Scopus databases in December 2022 to identify all literature related to ssRARP.
A total of 48 relevant studies were found worldwide from 2008 to 2023. Since the introduction of ssRARP, various modifications of this technique in surgical approaches, working accesses and novel robotic platforms have been developed. The application of ssRARP using the da Vinci SP platform has shown great superiority with encouraging clinical outcomes.
There has been a potential shift toward ssRARP using the da Vinci SP platform due to its potential advantages in terms of lower blood loss, minimal postoperative pain, better cosmetic outcome and rapid recovery. More convincing evidence, further technical improvement and higher cost-effectiveness are needed for its widespread acceptance.
To compare the perioperative and early postoperative outcomes between single-port (SP) extraperitoneal radical prostatectomy (EPRP) and SP transperitoneal radical prostatectomy (TPRP), in a multi-institutional setting.
We identified all patients who underwent SP robot-assisted radical prostatectomy at 6 different institutes. Data of 650 patients were collected and divided into 2 groups based on the surgical approach: SP EPRP or SP TPRP. A Propensity-score matched-pair analysis for body mass index (BMI), prostate size, and National Comprehensive Cancer Network risk was performed with a 1:1 ratio. Analysis of perioperative and postoperative outcomes was performed using Wilcoxon signed-rank test and chi-square and Fisher's exact tests.
After matching, 238 patients were included in each arm. The median follow-up period was 7 and 6 months for EPRP and TPRP groups, respectively. The total operative time was longer in the EPRP group (206 vs 155 minutes, P < .001). The EPRP group had a shorter length of hospitalization and same-day discharge rate compared to the TPRP approach (P < .001). There was no difference in the overall intraoperative or postoperative complications rate between the 2 groups, nor positive surgical margin rates.
The SP extraperitoneal approach is associated with a shorter hospital stay and higher rate of same-day discharge, with no difference in the surgical margin, or complication rates.
Technique and perioperative outcomes of single-port robotic surgery using the da Vinci SP platform in urology
2023, Asian Journal of SurgeryTo describe surgical technique for single port robotic surgery using the da Vinci SP system and report the perioperative outcomes.
Between Jan 2019 and Jan 2021, single-port robotic urologic surgeries were performed in 120 patients by a single surgeon. Clinicopathologic data and perioperative outcomes were collected. All surgical procedures were performed with a transperitoneal approach through an umbilical single port. Additional assistant port was used in complex procedures for malignant disease. Surgeries were carried out using both above and below camera position for effective retraction. For reconstructive surgery using intestine, an extra-intracorporeal hybrid method was used. Surgical procedures involving both kidney and pelvis were performed without change of patient position or trocar placement.
Mean age was 62.7 years and 102 patients were male. For oncologic indication, 105 patients underwent surgeries including 66 radical prostatectomy, 25 partial nephrectomy, six radical nephrectomies, five nephroureterectomy and three radical cystectomy with urinary diversion. Fifteen cases with benign indication included four ureterolithotomy, seven uretero/pyeloplasty, three ureteroneocystostomy, and one ileal ureter reconstruction. All surgeries were performed successfully without conversion to other surgical approach. Clavien-Dindo grade III complication occurred in two patients.
The da Vinci SP system provides a new robotic surgical platform for single port surgery while maintaining the major features of robotic surgery similar to multi-port surgery. Various single port urologic surgeries can be safely performed with this platform.
Clinical observation of modified single incision robot-assisted laparoscopic radical prostatectomy
2022, Intelligent SurgeryTo retrospectively analyze the feasibility and clinical efficacy of modified single incision robot-assisted laparoscopic radical prostatectomy.
From November 2020 to August 2021, 203 cases of modified single incision (without special channel devices) robot-assisted laparoscopic radical prostatectomy through extraperitoneal approach were reviewed. The average age of the patients was 69 (53–89) years, and the median prostate-specific antigen (PSA) level was 10.89 (2.89, 56.44) ng/ml; Gleason score was 7.0 (6.0–9.0), including 30 cases (14.8%), 108 cases (53.2%) and 65 cases (32.0%) with scores ≤ 6, 7 and ≥ 8 respectively; prostate volume was 59.0 (24.0–200.0) ml. Body mass index (BMI) ≤ 25 and > 25 kg/m2 were 125 cases (61.6%) and 78 cases (38.4%) respectively. Clinical stage was < cT3a in 191 cases, cT3a in 12 cases; 35 cases had a history of abdominal surgery. All operations were performed by the same surgeon in the center. The operation related indexes, postoperative recovery, pathology and follow-up results were observed.
203 operations were successfully performed as planned. The average operation time was 55.07 (37–129) min; the intraoperative blood loss was 68.3 (40–228) ml; the average time of postoperative exhaust was 1.3 (0.5–3.0) days; the average retention time of urinary catheter was 7.2 (6–14) days; the average hospitalization time was 7.5 (6–15) days. Postoperative sepsis occurred in one case. The postoperative Gleason scores ≤ 6, 7 and ≥ 8 were 42 cases (20.7%), 132 cases (65.0%) and 29 cases (14.3%). The postoperative pathological stage was < pT3a in 172 cases (84.7%) and ≥ pT3a in 31 cases (15.3%); 38 cases (18.7%) had positive margin after operation. 154 patients (75.9%) were satisfied with urinary control immediately after removing the urinary catheter, and 173 patients (85.2%) were satisfied with the recovery of urinary control within one month after operation (defined as the use of urinary pad ≤ 1 piece in 24 h). PSA < 0.2 μg/ml at six weeks after operation was in 170 patients (83.7%). The average incision length was 5.91 (5.0–6.8) cm.
The modified single incision robot-assisted laparoscopic radical prostatectomy through extraperitoneal approach is safe and feasible. The clinical effect is satisfactory, and the modified method is not limited by specific special channel devices, so it is easy to be applied in clinical practice.
Financial Disclosure: Jihad H. Kaouk certifies that all conflicts of interest, including specific financial interests and relationships and affiliations relevant to the subject matter or materials discussed in the manuscript (eg, Employment/affiliation, grants or funding, consultancies, honoraria, stock ownership or options, expert testimony, royalties, or patent filed, received or pending) are the following: Endocare, Inc, Intuitive. The authors have nothing to disclose.