In 2024, the novel Da Vinci® Single Port system (Intuitive Surgical, Sunnyvale, CA, USA), made its debut in Europe, inspiring the ideation of a new approach for the Retzius-sparing robot-assisted radical prostatectomy (RS-RARP): The extraperitoneal Single Port RS-RARP. The current video aims to provide a step-by-step description of this novel approach, and to report the perioperative data of the first ten prostate cancer (PCa) patients submitted to the extraperitoneal RS-RARP.
The video describes the case of a 73-year-old gentleman diagnosed with a Gleason grade group (GGG) 2 PCa and submitted to extraperitoneal Single Port RS-RARP at the ASST Grande Ospedale Metropolitano Niguarda, Milan (Italy). The MRI showed a 20 mm Pi-RADS 5 lesion in the left lobe, with capsular bulging. The patient was placed in a 5 degrees Trendelemburg position, and a four cm incision below the umbilicus allowed the access to the extraperitoneal space. An intra-fascial nerve-sparing was performed on the right lobe, whereas an extra-fascial nerve-sparing on the left lobe, due to the non-negligible likelihood of extracapsular extension. A standard van Velthoven modified anastomosis, starting from 12 o’clock, was performed. Total operative time was 170 minutes, and the two days post-operative course was uneventful. The bladder catheter was removed on the seventh post-operative day. The final pathology revealed a pT2c-pNx-R0 GGG 2 PCa.
To date, ten patients have been submitted to extraperitoneal Single Port RS-RARP for localized PCa. Median age at surgery was 65 years (interquartile range [IQR] 62, 72) and median body mass index was 26.0 kg/mq (IQR 23.7, 27.7). Median operative time was 195 minutes and one intra-operative complication (namely, massive subcutaneous emphysema requiring 24-hours intensive care monitoring, EAUiaiC grade 2) was recorded. Median length of stay was 2 days (IQR 2, 4) and two (20%) post-operative complications occurred (namely, one extended subcutaneous emphysema, Clavien Dindo 1; one venous bleeding requiring two blood transfusions, Clavien Dindo 2). Of the seven patients with available final pathology, two (28%) harbored seminal vesicles’ invasion (pathologic T3b stage) and two (28%) harbored positive surgical margins.
The extraperitoneal Single Port RS-RARP is a novel approach for the surgical management of localized PCa. Its feasibility is under evaluation, but the preliminary results are promising. Keeping the patient in an almost supine decubitus might reduce the pulmonary disfunction often related to the steep Trendelemburg position. The extraperitoneal approach might also minimize the post-operative pain. These advantages need proper testing in the context of robust comparisons between the extraperitoneal and the transperitoneal Single Port RS-RARP, which are currently ongoing at our Institution.