Single Port for Prostate Surgery

René J. Sotelo,¹ Oscar D. Martín Garzón,² Camilo Giedelman,³ Fatima Z. Husain,¹ & Mihir Desai¹

¹ USC Institute of Urology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA

² Clínica Cooperativa de Colombia, Universidad Cooperativa de Colombia – Facultad de Medicina, Villavicencio, Colombia

³ Clínica Marly and Fundación Universitaria Ciencia de la Salud, Hospital de San Jose, Bogotá, Colombia

Introduction

The prostate is a pelvic organ with two main pathologies: benign hyperplasia and cancer. These conditions have been more frequently diagnosed in the past 50 years, and there have been significant advances in the surgical management of prostate pathology.

With the introduction of minimally invasive surgery and the development of modern and novel techniques, there has been continued progress over time from the standard use of trocars, through mini‐laparoscopy, to single‐port robotic surgery. The search for perfect results, not only cosmetically, but also in terms of reducing the morbidity of the procedures, has manifested itself in the reduction in the number and size of trocars.

Single‐port surgery globally has continued to evolve and progress with effective and safe results. These advances by surgeons experienced in laparoscopy and robotics have kept the risk of complications low and helped to set strict criteria for the selection of patients appropriate for this surgical approach, while demonstrating, according to some experts, better postoperative pain control, earlier recovery of intestinal function, and smaller scar length than is achieved with standard techniques [1, 2].

Access, instruments, and viewing

Technical difficulties that may be identified during single‐port minimally invasive surgery include: reduced working space, collision of instruments, restricted movements, and difficulty in the display. However, there have been significant improvements and evolution in four important aspects of this surgical approach: trocars, instruments, optical, and mechanism of retraction [3].

Simple prostatectomy by single port

Currently, despite advances in endoscopic techniques with the application of new technologies (e.g. bipolar transurethral resection, holmium laser resection, and potassium titanyl phosphate (KTP) laser vaporization) and the emergence of new access devices, open surgery is considered the standard management for prostates of large size in terms of cost‐effectiveness for benign hyperplasia.

Over the last decade, with the advent of laparoscopic and robotic surgery, new treatment alternatives have been developed and implemented. In 2002, Mariano et al. described a technique for simple laparoscopic prostatectomy [4], which was reproduced with some modifications and then performed with robotic assistance. The described surgery essentially duplicated the techniques of open surgery, while maintaining a comparable proportion of prostatic tissue extracted as in open surgery, but with the benefits associated with minimally invasive surgery [5, 6].

With the aim of improving cosmetic results and maintaining the good surgical outcomes of laparoscopy, the use of a single point of access into the abdominal cavity through the umbilicus was implemented. This approach was named laparoendoscopic single‐site (LESS) surgery, which is the use of endoscopic and laparoscopic techniques through a single hole, using a unique device that enables the introduction of several instruments [7]. We began to explore the possibilities of applying this new access method to our technique of laparoscopic simple prostatectomy, initially through the umbilicus and later through a small suprapubic incision to place the port directly into the bladder.

Single‐port transvesical enucleation of the prostate

LESS adenomectomy can be performed by placing a single‐port device through the umbilicus using a transperitoneal approach. This is challenging, because the bladder must be dropped and the finger cannot be used to assist with enucleation of the prostate adenoma. In addition, at the end of surgery, the bladder incision must be closed laparoscopically in a watertight manner. With the introduction of the new double‐bend instruments, this step has become easier, but can still be technically difficult to complete.

Another option is to place the port directly through the bladder (Figure 153.1). With this approach, the bladder does not need to be dropped, and the finger can be used to assist with the enucleation. At the end of surgery, the bladder closure can be done in a standard open fashion.

Photo (left) and illustration (right) displaying hands demonstrating insertion of TriPort under cytoscopic guidance, depicting port placement directly through the bladder. — **Figure 153.1** (a, b). Port placement directly through the bladder. Insertion and deployment of the TriPort under cystoscopic guidance.

Laparoendoscopic transvesical simple prostatectomy is performed through a small incision approximately 2.5–3 cm long, located 3 cm above the pubic symphysis, through which a specialized access device is directly inserted. Through this single access point, multiple instruments can be inserted to complete the operation. The R‐port® (Advanced Surgical Concepts, Wicklow, Ireland) was the initial design of this access device, and modifications have led to the development of the TriPort® and QuadPort® (Advanced Surgical Concepts), which each have three and four channels, respectively. This device has two important features: first, it has multiple flexible valves that do not protrude into the cavity and enable the introduction of curved instruments; and second, it has a valve component that is easy to open and does not need to be taken out to be changed – a crucial aspect in intraluminal surgery. Increasing interest in LESS surgery has led to the introduction of new instruments, such as the 5 mm flexible EndoEye videoscope (Olympus, Tokyo, Japan), which provides excellent optics and images, and flexible, curved instruments that permit dissection and laparoscopic intracorporeal suturing [8].

The approach to the surgical management of urinary tract obstructive symptoms secondary to benign growth of the prostate is selected according to the technique used, size of the prostate, and the ability of the surgeon.

Technique

Current surgical approaches used include endoscopic techniques, such as transurethral resection of the prostate (TURP) (main standard), new trends with laser technology (enucleation with a holmium laser (HoLEP), laser green, among others), open surgery, and laparoscopic and robotic surgery [9].

Size

Surgery on prostates of less than 80 g should be performed using endoscopic techniques, although there are reports of prostates of larger size (≥120 g) being managed this way. For prostates ≥80 g, open, laparoscopic, and robotic surgery have traditionally been the recommended approaches.

Ability of the surgeon

The surgeon must resect the greatest amount of tissue in the shortest time possible to avoid complications such as bleeding, irritative symptoms, and postresection syndrome. It is reported that expert hands can achieve a resection rate of 1–1.5 g/min.

Laparoscopic robotic surgery can duplicate the open surgery technique, and demonstrates the same surgical outcomes. It is safe and effective, with less blood loss and a shorter length of hospitalization. It may, however, have a longer operative time. Comparisons of laparoscopic and endoscopic surgery show that the former has the highest percentage of tissue resection and shorter use of a bladder catheter, at the expense of greater bleeding [10, 11].

Simple prostatectomy by single port was initially described in 2008 by Desai et al. [8]. An early experience in three patients with large prostates involved use of the R‐port device, which was introduced percutaneously into the bladder through a 2.5 cm infra‐umbilical incision under the guidance of cystoscopy (with prior introduction of a hypodermic needle), followed by a U‐shaped incision into the bladder neck and adenoma dissection. This direct bladder approach allowed the dissection of the adenoma to be made with assistance of the surgeon’s finger, in addition to the apparent advantage of not needing to close the bladder [8]. Sotelo and his group also detailed their technique of simple prostatectomy in 2009 using a multilumen single port through an umbilical incision of 2.5 cm. They described difficulty in developing the prevesical space and subsequent bladder dissection, and after making the cystotomy, had to complete the dissection of the adenoma without the use of additional trocars or percutaneous traction maneuvers [12]. These two groups of researchers have together presented a multi‐institutional series of large‐scale single‐port simple prostatectomies.

Surgical technique

The equipment and instruments required for single‐port transvesical enucleation are listed in Box 153.1. The TriPort is a multiport access device that allows several instruments to pass through simultaneously. It consists of a retractor and a valve. The Choker has an inner ring, two outer rings, and a retractable plastic sleeve. The valve has three openings (two of 5 mm and one of 12 mm) for laparoscopic instruments and a port for inflation. The valve contains a thermoplastic elastomer that enables the proper introduction of the instruments, including needles, with insignificant air loss.

Box 153.1 Equipment and instruments required for single‐port transvesical simple prostatectomy.

Equipment

Laparoscopic video tower (21‐inch monitor, EXERA II image processor with light source)
Video laparoscope: EndoEye (Olympus, Tokyo, Japan), 5 mm, 30° lens
UHI‐3 high‐flow CO₂ inflator (up to 35 l/min)
Ultrasonic generator
Electrosurgical unit (monopolar/bipolar)
Aspiration–irrigation pump
Flexible cystoscope

Instruments to develop the procedure

TriPort (Advanced Surgical Concepts, Wicklow, Ireland/Olympus)
5 mm flexible articulating instruments: scissors (Cambridge Endo, Framingham, MA, USA)
5 mm J hook electrocautery instrument
Ultrasonic 5 mm shears
5 mm suction–irrigation cannula, prebent
Carter–Thomason device
Two laparoscopic needle holders
Silicone three‐way 22 Fr and two‐way 24 Fr Foley catheters, in case a suprapubic tube is needed
Sutures: Monocryl 0 with CT‐1 needle for adenoma traction, and 2/0 with CT‐1 needle for ligature of lateral pedicles and trigonization (the monofilament facilitates the extracorporeal knotting)
Sotelo prostatotomy device
Knot pushers

Surgical steps

The advantages and disadvantages of this procedure are summarized in Box 153.2 and the key points in Box 153.3.

Box 153.2 Advantages and disadvantages of single‐port transvesical simple prostatectomy.

Advantages

Pneumovesicum maintains a broad field of work
Allows the observation of all anatomic details of the bladder, prostate and urethra during each step of the surgery
Lower risk of intestinal injury and lower likelihood of development of postoperative ileus
Easy opening of the device enables the extraction of fragments during surgery. Furthermore, it allows the introduction of a finger if necessary to remove the adenoma
Due to the fact that the adenoma fragments are confined in the bladder and are not released in the abdominal cavity, extraction pouches are not necessary

Disadvantages

Steep learning curve. At first, enucleation is difficult, but the location of the suprapubic incision allows bimanual dissection if necessary. The index finger of the left hand in the rectum elevates the prostatic fossa and the index finger of the right hand through the ring of the TriPort helps the mobilization of the adenoma

Box 153.3 Key points during the procedure.

Placement of a traction suture through the full thickness of the bladder using absorbable material. The same stitch will enable placement of subsequent stitches, which will facilitate introduction of the trocar and the closure of the defect at the end of the case.
It is important to lubricate the entrance of the TriPort in order to facilitate entry of instruments through the membranes, as well as facilitating the introduction of the videoscope and its rotational movement.
The incision should be made between the adenoma and the mucosa of the bladder. The surgeon can observe a faint change in color. This serves as a reassuring reference point.
If problems arise in the traction of the adenoma, the suture can be exteriorized through the abdominal wall with the assistance of a Carter–Thomason device.
A useful tool designed specifically for prostatic adenomectomy is the Sotelo prostatotomy device. This consists of three parts: a Teflon sleeve, a stainless‐steel cylinder body, and a curved shape with sharp edges at the distal end.
It is important to note that, if necessary, the surgeon can convert the procedure to a standard laparoscopic surgery with the addition of more trocars as necessary.

Patient position and endoscopic evaluation

All procedures are performed under general anesthesia with the patient in a modified low lithotomy position. Initially, cystoscopy is performed and the prostate evaluated endoscopically. The bladder is filled with normal saline solution.

Insertion and deployment of the TriPort

An approximately 2.5 cm skin incision is carried down to the rectus fascia. The incision is located just above the pubis. The bladder wall is identified and cleared of any prevesical fat. Two stay sutures of 2‐0 Vicryl are placed.

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