Single-port robot-assisted radical prostatectomy: transperitoneal versus extraperitoneal approach

3.1 Introduction

Since the advent of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, California, United States) in 2000, the robotic-assisted radical prostatectomy (RARP) has quickly risen to become the gold standard for the minimally invasive surgical treatment of prostate cancer. The introduction of the da Vinci single-port (SP) system, which was approved by the FDA in 2018, increases the variety of approaches to the SP RARP described in the literature, with two of the most common approaches being transperitoneal and extraperitoneal. In this chapter, we will describe the major similarities and differences between the transperitoneal and extraperitoneal approaches with the SP, patient selection considerations and contraindications, potential complications, and preliminary outcomes data for each approach.

3.2 Basic technique of the transperitoneal SP RARP

The transperitoneal approach is currently the most popular approach for the multiarm RARP and was therefore the first to be performed with the novel SP platform. The first report of the transperitoneal SP RARP being performed on a patient was published by Kaouk et al. in 2019, with a case report describing their surgical experience with two patients. This was closely followed by case series published by other academic centers, including Dobbs et al. in 2019.

The technique of the transperitoneal RARP can be summarized as follows. The patient is first placed in supine position with the arms tucked. Once the patient is prepped and draped in the usual sterile fashion and placed in steep Trendelenburg, a 3 cm vertical incision is made 3 cm superior to the umbilicus and the peritoneum is entered under direct vision via a Hasson technique. Once the peritoneal cavity is entered, the Alexis retractor (Applied Medical, Rancho Santa Margarita, California, United States) is introduced through the incision and secured under the peritoneum to provide 360 degree retraction of the incision. The GelPOINT Mini Advanced Access Platform (Applied Medical, Rancho Santa Margarita, California, United States) is then attached to the retractor. A 5 mm AirSeal (ConMed Corp., Utica, New York, United States) “side car” port is then placed through the same skin incision, through a different fascial incision and eventually through the Alexis retractor under direct digital control (see Fig. 3.1 ).

The robot is then docked to the SP access port with the camera at the 12 o’clock position, a monopolar scissor at 3 o’clock, a Cadiere forceps at 6 o’clock, and a fenestrated bipolar forceps at 9 o’clock.

The dissection is then undertaken with similar technique to a multiport transperitoneal RARP, with either a posterior or anterior approach to the dissection of the seminal vesicles depending on needs of the case.

Of note, our institution utilizes the remotely operated suction irrigation system (ROSI) (Vascular Technology, Nashua, New Hampshire, United States) for suction, which allows the surgeon at the console control of the suction throughout the procedure. This is placed through the “side car” port and switched out for instruments depending on operative need. Given the use of the Airseal system, the suction is able to be kept on for most of the procedure, thanks to the possibility of locking the suction through the ROSI pedal. This will allow instantaneous evacuation of smoke during the procedure, removing the need for the operator to hit the pedal for suction.

3.3 Basic technique of the extraperitoneal SP RARP

The first described extraperitoneal SP RARP was published by Kaouk et al. in 2019, with a handful of studies published since detailing single-institutional experiences with this approach. The extraperitoneal technique for the multiport system is well described, and lends itself particularly well to the SP platform due to the small amount of working space required by the SP to be effective in the space of Retzius. The small working distance between the instruments and the camera and the overall smaller field of view makes the SP platform ideal for this approach. In addition, due to the single entry site needed for the SP approach, there is a reduced risk of accidental peritoneal puncture from lateral port placement, which is necessary for the multiport.

Key differences to note with the SP extraperitoneal approach is that the patient can be positioned in the supine position without need for the steep Trendelenburg traditionally used for the transperitoneal approach. A single, horizontal 3 cm infraumbilical incision is made below the umbilicus, and electrocautery is used to divide the anterior rectus sheath in the midline. We then use blunt finger dissection to develop the space of Retzius to the pubic bone. Once the space of Retzius is developed just underneath the rectus fascia, we insert the Balloon Dissector Spacemaker (Covidien, Dublin, Ireland), which is inflated with 800 cc air to further expand the working space. A novel SP Access Port (Intuitive Surgical, Sunnyvale, California, United States) is used for the extraperitoneal approach. This access port consists of a combination of a wound retractor, an inflatable plastic globe that serves as a floating platform to provide extra space for the robotic arms, and an SP robotic trocar. The SP access port retractor is then introduced through the incision and secured under the posterior rectus fascia to provide 360 degree retraction of the incision. The SP access port itself is then attached to the retractor. A 5 mm “side car” port is then placed through the same skin incision, through a different fascial incision and eventually through the SP Access Port retractor under direct digital control. A 5 mm AirSeal (ConMed Corp., Utica, New York, United States) trocar is inserted for insufflation through the lateral blue entry point on the SP access port (see Fig. 3.2 ).