Single-port robotic-assisted simple prostatectomy is associated with decreased post-operative narcotic use in a propensity score matched analysis

Single port robot-assisted radical and simple prostatectomy: a systematic review and meta-analysis

BACKGROUND

Aim of our study was to review the current evidence on single port robot-assisted radical prostatectomy (SP-RARP) and SP robot-assisted simple prostatectomy (SP-RASP) procedures.

METHODS

A comprehensive bibliographic search on multiple databases was conducted in July 2023. Studies were included if they assessed patients with non-metastatic prostate cancer or candidate for benign prostatic hyperplasia surgery (P) who underwent SP-RARP or SP-RASP, respectively, (I), compared or not with other surgical techniques (C), evaluating perioperative, oncological, or functional outcomes (O). Prospective and retrospective original articles were included (S). A meta-analysis of comparative studies between SP-RARP and MP-RARP was performed.

RESULTS

A total of 21 studies investigating 1400 patients were included in our systematic review, 18 were related to SP-RARP while 3 to SP-RASP. Only 8 comparative studies were eligible for meta-analysis. Mean follow-up was 8.1 (±5.8) months. Similar outcomes were observed for SP-RARP and MP-RARP in terms of operative time, catheterization time, pain score, complications rate, continence and potency rates, positive surgical margin, and biochemical recurrence. Length of hospital stay was shorter in the SP group after sensitivity analysis (WMD -0.58, 95% IC -1.17 to -0.9, p < 0.05). Subgroup analysis by extraperitoneal approach did not show any statistical difference, except for a lower positive margins rate in the SP extraperitoneal technique compared to MP-RARP. Overall, SP-RASP exhibited shorter hospital stay and lower rate of de novo urinary incontinence when compared to other techniques, while no differences were reported in terms of postoperative International Prostate Symptom Score, post void residual and maximum flow.

CONCLUSIONS

Overall comparable oncological, functional, and perioperative outcomes can be achieved with SP platform. Subgroup analysis by different approaches did not reveal significant variations in outcomes. However, the retrospective nature of the studies, the limited follow-up, and the relatively small sample size of selected Centers may impact these results.

Single-port transvesical simple prostatectomy for the surgical treatment of benign prostatic hyperplasia: functional and continence outcomes

BACKGROUND

Robot-Assisted Simple Prostatectomy (RASP) is recommended for the treatment of large prostate glands. The introduction of the Single-Port (SP) platform in 2018 has enabled transvesical approach to SP-RASP with promising outcomes. Our aim was to describe the functional and urinary continence outcomes of SP-RASP.

METHODS

Clinical and surgical data from all consecutive patients who underwent transvesical SP-RASP between February 2020 and March 2024 were collected in a prospectively maintained institutional dataset and retrospectively analyzed. All procedures were performed using the da Vinci SP platform without any conversions to open surgery. Postoperative outcomes were gathered and analyzed, with a particular focus on the incidence of urinary incontinence (UI) and the time to continence recovery.

RESULTS

Overall, 89 patients underwent SP-RASP, with a median prostate size of 110 grams (90-171.5) and a median PSA level of 5.5 mg/dl (2.77-10.93). All patients were on at least one prostate medication prior to surgery. Preoperative evaluations showed a median International Prostate Symptoms Score (IPSS) of 23 (20-27), Quality of Life (QoL) of 4 (3-5), and Post-voiding Residual (PVR) of 153 ml (60-400). The median operative time was 180 min (164-200), with a median estimated blood loss of 100 ml (30-180). Postoperatively, no patients required continuous bladder irrigation. The median postoperative opioid intake was 6.5 morphine equivalents (0-10), with over 78% not requiring narcotics after discharge. Overall, 77.5% were same day discharged. No Clavien-Dindo > 2 complications were recorded. The median follow-up time was 18 (7-35) months. At the last postoperative urological evaluation, the median IPSS was 5 (3-7), QoL was 1 (0-2), and PVR was 10 ml (0-25). Only 4 patients (4.5%) experienced UI postoperatively, and all were continent within 3 months.

CONCLUSIONS

The UI incidence rate and functional outcomes of SP-RASP are very encouraging, likely due to precise adenoma and urethra dissection and bladder neck reconstruction. This approach also allows for same-day discharge.

Predictors of Same-day Discharge After Single-port Transvesical Enucleation of the Prostate

OBJECTIVE

To determine the rate of outpatient cases and identify predictors for same-day discharge (SDD) after single-port transvesical enucleation of the prostate (STEP).

METHODS

Retrospective analysis of all consecutive STEP cases performed at a single center by 3 surgeons from February 2019 to October 2023. The cohort was categorized into SDD cases (<8 hours until discharge) and inpatient cases. Group comparisons were made and logistic regression was used to identify predictors of SDD.

RESULTS

A total of 152 STEP cases were performed successfully without additional ports or conversions. Fifty-two patients were pre-planned admissions, leaving 100 planned outpatient cases, of which 86% were discharged on the same day (median length of stay of 4.7 hours). Comparing the groups, inpatient cases were older, had higher Charlson Comorbidity Index (CCI) scores, higher estimated blood loss (EBL) during surgery, and more intraoperative complications than SDD patients. Univariate logistic regression identified age and CCI as the predictors associated with SDD after STEP. Notably, there were no major postoperative complications or readmissions in either group.

CONCLUSION

In our 4-year experience with STEP, lower age and CCI score were significant predictors of SDD. The comprehensive evaluation criteria for discharge foster a safe recovery at home, coupled with a 0% rate of major postoperative complications and readmissions. These findings underscore the safety and efficacy of STEP, guiding patient counseling and surgeon expectations.

Incidental prostate carcinoma after single-port robot-assisted simple prostatectomy: a multi-institutional report (SPARC)

BACKGROUND

Single-port robot-assisted simple prostatectomy is a minimally invasive alternative for patients with large benign prostatic hyperplasia with severe symptoms and/or failure of medical treatment. In recent literature, the rate of incidental prostate cancer after simple prostatectomy ranges from 1.8% to 13.0%. Our objective is to report the rate of incidental prostate cancer after single-port robot-assisted simple prostatectomy and to compare our findings to other approaches.

METHODS

A Single-Port Advanced Research Consortium [SPARC] multi-institutional retrospective analysis of all initial consecutive single-port robot-assisted simple prostatectomy cases performed from 2019 to 2023 by eleven surgeons from six centers. Our primary outcome was the rate of incidental prostate cancer in adenoma specimens. We used descriptive statistics to analyze the data.

RESULTS

A total of 235 cases were performed successfully without conversions or additional ports. Eleven patients (4.6%) were found to have incidental prostate cancer on pathological analysis. The median percentage of tissue involved by the tumor was 5%. The overall rate of clinically significant prostate cancer was 2.1%. Most cases were Gleason Grade Group 1 (55%). Those with Grade Group ≤3 were subsequently managed with active surveillance with a median follow-up of 17 months. A patient with Gleason Grade Group 4 underwent an uncomplicated multi-port robot-assisted radical prostatectomy with satisfactory functional and oncological outcomes.

CONCLUSIONS

Initial multi-institutional experience with single-port robot-assisted simple prostatectomy showed an incidental prostate cancer rate of 4.6%, comparable to MP, laparoscopic, and open techniques.

Single-port Transvesical Robot-Assisted Simple Prostatectomy: Surgical Technique and Clinical Outcomes

BACKGROUND

Surgical management of large prostatic adenomas can be performed via open, endoscopic, or robotic approaches. A low-profile single-port (SP) robot was built to work in confined areas (ie, the bladder) and regionalize surgery.

OBJECTIVE

To describe the novel SP transvesical (TV) robot-assisted simple prostatectomy (RASP) and report clinical outcomes.

DESIGN, SETTING, AND PARTICIPANTS

SP TV RASP cases were performed in an academic hospital by two surgeons from 2019 to 2023. A total of 117 cases were performed, and data from patients with at least 12 mo of follow-up were analyzed. The inclusion criterion was severe obstructive urinary symptoms or catheter-dependent urinary retention due to large prostates with volume >80 ml.

SURGICAL PROCEDURE

The procedure consisted of two main steps through a single 3-cm suprapubic incision: first, enucleation of the adenoma, and second, a 360° bladder mucosal flap reconstruction. No drains or continuous bladder irrigation was used routinely.

MEASUREMENTS

Intraoperative parameters, pre- and postoperative uroflowmetry, and 1-yr clinical outcomes were assessed. We used descriptive statistics to analyze the data.

RESULTS AND LIMITATIONS

All procedures were completed successfully without additional ports or conversions. The median console time and estimated blood loss were 107 min and 100 ml, respectively. Transfusion rate was 0%. Intraoperative complications included two suspected air emboli attributed to high insufflation pressures. There were no major postoperative complications. In total, 95.8% were discharged within the first 24 h, with a median length of stay and pain score of 5 h and 3/10, respectively. There was persistent improvement in the median International Prostate Symptom Score and flow rate after 1 yr. The median Sexual Score Inventory for Men score was 20 at 12 mo. Our study is limited by its retrospective nature and cohort size.

CONCLUSIONS

SP TV RASP is a feasible alternative for the management of severe benign prostatic hyperplasia that promotes fast recovery and demonstrates 1-yr improvement in urinary function.

PATIENT SUMMARY

Single-port transvesical robot-assisted simple prostatectomy is a minimally invasive alternative for the treatment of large benign prostatic growth. A single robotic arm goes through a small incision in the skin and bladder to extract the obstructive prostatic tissue. Afterward, reconstruction of the area is done to decrease bleeding and improve postoperative symptoms. We found that patients recover quickly and have excellent clinical results with a low risk of complications.

Single-port robot-assisted simple prostatectomy: techniques and outcomes

PURPOSE

To describe the surgical techniques and to analyse the outcomes of single-port robot-assisted simple prostatectomy (SP RASP) procedure for the surgical treatment of benign prostatic hyperplasia (BPH).

METHODS

Three databases (PubMed®, Web of Science™, and Scopus®) were queried to identify studies reporting on the technical aspects and outcomes of SP RASP. Different combinations of keywords were used, according to a free-text protocol, to identify retrospective and prospective studies, both comparative and non-comparative, systematic reviews (SR) and meta-analysis (MA) describing surgical techniques for SP RASP and the associated surgical and functional outcomes.

RESULTS

The transvesical approach represents the most common approach for SP RASP. A decrease in terms of estimated blood loss was observed when SP RASP was compared to open simple prostatectomy (OSP) and multi-port (MP) RASP. Furthermore, this technique allowed for a shorter length of hospital stay (LoS) and a lower post-operative complication rate, compared to OSP. Post-operative subjective and objective functional outcomes are satisfying and comparable to OSP and MP RASP.

CONCLUSION

SP RASP represents a safe and feasible approach for the surgical management of BPH. It provides comparable surgical and functional outcomes to MP RASP, enabling for minimal invasiveness, enhanced recovery, and potential for improving patient care.

Comparing the safety and efficacy of single-port versus multi-port robotic-assisted techniques in urological surgeries: a systematic review and meta-analysis

OBJECTIVE

Comparing the safety and efficacy of single-port (SP) versus multi-port (MP) robotic-assisted techniques in urological surgeries.

METHODS

A systematic review and cumulative meta-analysis was performed using PRISMA criteria for primary outcomes of interest, and quality assessment followed AMSTAR. Four databases were systematically searched: Embase, PubMed, The Cochrane Library, and Web of Science. The search time range is from database creation to December 2022. Stata16 was used for statistical analysis.

RESULTS

There were 17 studies involving 5015 patients. In urological surgeries, single-port robotics had shorter length of stay (WMD = - 0.63, 95% Cl [- 1.06, - 0.21], P < 0.05), less estimated blood loss (WMD = - 19.56, 95% Cl [- 32.21, - 6.91], P < 0.05), less lymph node yields (WMD = - 3.35, 95% Cl [- 5.16, - 1.55], P < 0.05), less postoperative opioid use (WMD = - 5.86, 95% Cl [- 8.83, - 2.88], P < 0.05). There were no statistically significant differences in operative time, positive margins rate, overall complications rate, and major complications rate.

CONCLUSION

Single-port robotics appears to have similar perioperative outcomes to multi-port robotics in urological surgery. In radical prostatectomy, single-port robotics has shown some advantages, but the specific suitability of single-port robots for urological surgical types needs to be further explored.

Single-port and multiport robot-assisted radical prostatectomy: A meta-analysis

Objective

To compare the perioperative, oncological, and functional outcomes between single-port robot-assisted radical prostatectomy (SP-RARP) and multiport robot-assisted radical prostatectomy (MP-RARP) via a meta-analysis.

Methods

For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until January 15, 2022. A meta-analysis has been reported in line with PRISMA 2020 and AMSTAR Guidelines. The risk ratio and weighted mean difference (MD) were applied for the comparison of dichotomous and continuous variables with 95% confidence intervals (CI).

Results

Of the 368 retrieved abstracts, 41 underwent full-text review, and seven studies were included in the final analysis, comprising a total cohort of 1,934 cases of RARP (355 SP-RARP cases and 1,579 MP-RARP cases). Compared to MP-RARP, the SP-RARP group had less postoperative pain score (MD = -0.7, 95% CI -1 to -0.4, P<0.001), morphine milligram equivalents usage (MD = -3.8, 95% CI -7.5 to -0.1, P=0.04), hospital stay (MD = -1, 95% CI -1.8 to -0.1, P=0.019), and urinary catheterization time (MD = -1.1, 95% CI -1.9 to -0.3, P=0.008). However, the SP-RARP group had a longer console time than the MP-RARP group (MD = 5.3, 95% CI 2.6 to 7.9, P<0.001).

Conclusions

Our study demonstrated that early results were mostly equivalent with the single-port approach. This technology may help to reduce the hospital stay and postoperative pain for patients undergoing radical prostatectomy compared to MP-RARP, without compromising the functional and early oncological outcomes.

Holmium Laser Enucleation of the Prostate vs Transvesical Single-port Robotic Simple Prostatectomy for Large Prostatic Glands

OBJECTIVE

To compare the perioperative outcomes of transvesical single-port robotic simple prostatectomy (SP-RASP) and holmium laser enucleation of the prostate (HoLEP).

MATERIALS AND METHODS

A retrospective review was performed of patients undergoing SP-RASP and HoLEP from 2019 to 2022 with preoperative prostatic volume (PPV) >80 cm3. Percent of prostate adenoma removed (%PAR) was estimated by specimen weight normalized by PPV. Univariate analysis was performed using chi-square, Fisher exact, and Wilcoxon rank-sum tests. A subgroup analysis with 1:1 matching for PPV was also performed.

RESULTS

A total of 50 SP-RASP and 90 HoLEP cases were analyzed. The median (interquartile range) PPV was 169 (128-244)cm3 for SP-RASP and 129 (100-150)cm3 for HoLEP, (P < .01). The median (interquartile range) %PAR was 57(44-68) for SP-RASP vs 51(42-62) for HoLEP (P = .10). Overall, 11(12%) HoLEP and 5(10%) SP-RASP patients experienced complications (P = .51). Same-day discharge occurred in 24(48%) SP-RASP vs 7(8%) HoLEP patients (P < .01). Median foley catheter duration was longer in SP-RASP (6 vs 1 day, P < .01) and trial of void was successful at first attempt in >94% (P = .68). Transient de novo incontinence was reported in 24(28%) HoLEP vs 2(5%) SP-RASP (P < .01). No differences in voiding parameters were observed at latest follow up. Subgroup postmatched analysis revealed analogous findings.

CONCLUSION

SP-RASP and HoLEP have similar favorable perioperative outcomes for management of large prostatic adenomas. SP-RASP may be considered in patients unwilling to accept the risk of transient incontinence and in those with unfavorable urethral access, large bladder stone burden, or diverticula.

Single-Port Robotic Applications in Urology

Objective: The da Vinci single-port (SP) platform represents the latest innovation in minimally invasive urologic surgery, and the adoption of this technology by urologists is increasing. In this article, we briefly describe the evolution of minimally invasive and single-site surgery, and offer a comprehensive review of the current literature on the SP platform. Materials and Methods: For relevant articles, three electronic databases, including PubMed, Scopus, and Web of Science, were searched from their inception until August 15, 2022. The published literature to date within SP robotic surgery in urology will be discussed. Evidence Synthesis: There are relatively few high-quality studies on the SP system, but there are multiple case series describing unique indications and surgical approaches with the SP robot, demonstrating safety and feasibility in the hands of experienced robotic surgeons. There also are an increasing number of prospective, larger cohort studies comparing outcomes between SP and multiport (MP) approaches that show benefits of the SP system regarding improved cosmesis, postoperative pain control, and decreased length of stay. Conclusions: Multiple prospective studies have shown benefits regarding cost and pain control for SP platform procedures compared to the traditional MP robotic approach. While its high cost and learning curve represent barriers to adoption, the SP platform represents a critical development in minimally invasive surgery. As this technology is further implemented at more institutions, long-term, high-quality data should accrue that will demonstrate its true value.

Single Port Versus Multiport Robot-assisted Simple Prostatectomy: A Multi-institutional Study From the Single-port Advanced Research Consortium (SPARC)

OBJECTIVE

To compare robot-assisted simple prostatectomy intraoperative and postoperative.ßoutcomes between single-port (SP) and multiport (MP) robotic systems in a multi-institutional setting.

METHODS

We analyzed all-consecutive robot-assisted simple prostatectomy cases done in 5 centers from January 2017 to October 2022. Data were analyzed with descriptive statistics and compared with appropriate tests depending on the type of variable and distribution. Statistical significance was considered when P.ß<.05.

RESULTS

A total of 405 cases were analyzed:.ß249 and 156 were MP and SP, respectively. Operative times were similar between groups (P.ß=.ß.62). Estimated blood loss during surgery was significantly lower with the SP robot (P.ß<.001). Postoperatively, the SP approach required a significantly shorter hospital stay, less use of opioids, and a shorter duration of Foley catheter (P.ß<.001). There was no significant difference between the post-operative Clavien-Dindo ...3 complication rate (P.ß=.ß.30). The 30-day readmission rate of MP (10.8%) was significantly higher than for SP (0%) (P.ß<.001). De novo urge incontinence was more common in the MP group (P.ß=.ß.02).

CONCLUSION

The SP robotic approach to simple prostatectomy is advantageous when it comes to postoperative comfort for patients. Specifically, it requires a shorter hospital stay, less use of opioids, and a shorter Foley catheter duration.

Mid-term functional outcomes of extraperitoneal robot-assisted simple prostatectomy: a single centre experience

For large prostate volume, open simple prostatectomy (OSP) or holmium laser enucleation are the gold standard surgical treatment medical therapy failure. Robot-assisted simple prostatectomy (RASP) has recently been proposed as an alternative to OSP and endoscopic techniques. Our objective was to describe our extraperitoneal RASP technique for patients with benign prostate obstruction (BPO), and to report on perioperative and mid-term functional outcomes. Data were collected prospectively for all consecutive patients who underwent RASP in our high-volume tertiary hospital over a 6-year period. International Prostate Symptom Score (IPSS), International Index of Erectile Function-5 (IIEF-5) and uroflow findings were compared before and after surgery. Intraoperative and postoperative outcomes were also assessed. Forty-seven patients were included in the study. There was no intraoperative incident and no blood transfusion was needed after surgery. Median time to bladder catheter removal was 4 days and patients were discharged the day after. Within 90 postoperative days, 6 patients (12%) experienced at least one complication, all low-grade except one (2.1%) which was Clavien IIIa grade. By univariate analysis, the only risk factor for postoperative complications was the Charlson comorbidity index (OR = 2.1, 95% CI = [1.1-4.7], p = 0.04). At 12 months, a significant improvement IPSS and uroflow rate was observed. No patient reported stress urinary incontinence. Extraperitoneal RASP appears to be a safe and effective technique for men with LUTS related to large BPO. RASP is less invasive than OSP and wide diffusion of the robot-system could lead to the rapid implementation of RASP as a treatment for large prostate.

Robotic-assisted versus open simple prostatectomy: Results from a systematic review and meta-analysis of comparative studies

PURPOSE

To review safety and efficacy of robotic-assisted simple prostatectomy (RASP) compared to open simple prostatectomy (OP).

MATERIALS AND METHODS

A comprehensive literature search was performed to assess the differences in perioperative course and functional outcomes in patients with benign prostatic hyperplasia and surgical indication. The incidences of complications were pooled using the Cochran-Mantel-Haenszel Method and expressed as odds ratio (OR), 95% confidence interval (CI), and p-values. Perioperative course and functional outcomes were pooled using the inverse variance of the mean difference (MD), 95% CI, and p-values. Analyses were two-tailed and the significance was set at p<0.05.

RESULTS

Eight studies were accepted. Meta-analysis showed significantly longer surgical time (MD, 43.72; 95% CI, 30.57-56.88; p<0.00001) with a significantly lower estimated blood loss (MD, -563.20; 95% CI, -739.95 to -386.46; p<0.00001) and shorter postoperative stay (MD, -2.85; 95% CI, -3.72 to -1.99; p<0.00001) in RASP. Catheterization time did not differ (MD, 0.65; 95% CI, -2.17 to 3.48; p=0.65). The risk of blood transfusion was significantly higher in OP (OR, 0.23; 95% CI, 0.17-0.33; p<0.00001). The risk of recatheterization (OR, 1.96; 95% CI, 0.32-11.93; p=0.47), postoperative urinary infections (OR, 0.89; 95% CI, 0.23-3.51; p=0.87) and 30-day readmission rate (OR, 0.96; 95% CI, 0.61-1.51; p=0.86) did not differ. At 3-month follow-up, functional outcomes were similar.

CONCLUSIONS

RASP demonstrated a better perioperative outcome and equal early functional outcomes as compared to OP. These findings should be balanced against the longer operative time and higher cost of robotic surgery.