Extraperitoneal Single-Port Robotic-Assisted Radical Prostatectomy: Initial Data on a Promising Less Invasive Option
Prostate cancer is the second most common cancer in men globally, and radical prostatectomy (RP)—surgical removal of the prostate—remains a cornerstone of treatment for localized disease. As robotic and minimally invasive technologies advance, surgeons are exploring ways to make RP even safer, faster, and more comfortable. A 2021 study from Chinese urology teams offers early insights into a technique that could reshape recovery for many patients: extraperitoneal single-port robotic-assisted radical prostatectomy (espRARP).
What Is espRARP?
Traditional robotic-assisted radical prostatectomy (RARP) often uses a transperitoneal route—surgeons access the prostate through the abdominal cavity. EspRARP takes a different path: it uses an extraperitoneal approach, working between the abdominal wall and the peritoneum (the lining of the abdomen) to avoid entering the abdomen entirely. For this study, published in the Chinese Medical Journal, researchers from Shanghai Changhai Hospital (Naval Medical University) and The First Affiliated Hospital of Guangzhou Medical University tested a single-port version of this technique using the da Vinci Si HD robotic system.
How the Surgery Works
The team operated on 19 men (ages 57–78) with biopsy-confirmed prostate cancer (all localized, no spread to lymph nodes or distant sites). Here’s a simplified breakdown of the procedure:
- Positioning & Incision: Patients were placed in a mild head-down (15°–20° Trendelenburg) position. A 5cm transverse incision was made ~5cm above the pubic symphysis (the bone at the front of the pelvis).
- Extraperitoneal Space: Surgeons separated the abdominal muscles and used an inflated surgical glove (a homemade dilator) to create a working space. A 100mm multi-channel port was inserted under the rectus muscle.
- Robotic Setup: The da Vinci Si system—equipped with 8mm monopolar scissors and Maryland bipolar forceps—was used for dissection. A key tweak: a 30° upward-facing camera was placed in the lower port to reduce instrument clashing (a major challenge in earlier single-port surgeries).
- Surgical Steps: The team removed prostatic fat, ligated the dorsal venous complex (a blood vessel bundle), transected the bladder neck, and dissected the seminal vesicles. The prostate was removed intact, and the urethra was reconnected to the bladder with a barbed suture. A drainage tube was placed in the same incision before closure.
All surgeries were performed by a high-volume surgeon (over 700 RARPs) with a fixed team that had completed the learning curve.
Key Results: Safe, Fast, and Effective
The data from 19 patients (median follow-up: 7 months) highlights the technique’s promise:
- Short Surgery Time: Median total surgery time was 95 minutes (console time: 68.5 minutes).
- Minimal Blood Loss: Estimated blood loss was just 50mL (range: 50–100mL).
- Rapid Recovery: Median hospital stay was 3 days (some patients went home the next day). No one needed narcotics after surgery.
- Continence: 26% of patients were continent (no pads or one security pad daily) immediately after catheter removal. By 3 months, 74% were continent, and 100% of those followed for 6 months (15/19) had regained full continence.
- Nerve-Sparing: Four patients had nerve-sparing surgery (to protect erectile function). Two regained spontaneous morning erections within a month without PDE5 inhibitors (e.g., Viagra).
- Low Complications: No conversions to open surgery, no major (Clavien grade III+) complications. One patient had a minor wound dehiscence (split) treated in clinic.
- Oncologic Outcomes: 16% (3/19) had positive surgical margins (cancer at the edge of the removed tissue)—consistent with other robotic RP results. Ten patients (53%) had locally advanced disease (extracapsular invasion or seminal vesicle involvement), and four received adjuvant radiation therapy.
Why This Technique Stands Out
Earlier single-port robotic prostatectomies (e.g., through the umbilicus) struggled with instrument collisions and limited working space. This team solved those issues by:
- Lower Incision: Moving the incision to the pubic symphysis area reduced clashing without software fixes.
- Camera Angle: The 30° upward-facing camera improved triangulation (depth perception) for the surgeon.
- Extraperitoneal Route: Avoiding the abdomen is a game-changer for patients with prior abdominal surgeries or adhesions (scar tissue that complicates transperitoneal surgery). It also reduces the need for an extreme Trendelenburg position—cutting down on facial swelling or airway issues.
Limitations to Consider
Like all early studies, this work has caveats:
- Small Sample: Only 19 patients were included, and 4 didn’t reach 6 months of follow-up.
- Retrospective Design: Data was collected after surgery, not prospectively (planned in advance).
- No Lymph Node Dissection: The Briganti nomogram ruled out the need for lymph node removal in all patients, so the team didn’t test espRARP for this step (a limitation shared by other extraperitoneal or single-port RARPs).
- Short Follow-Up: Long-term oncologic outcomes (e.g., cancer recurrence) aren’t yet available.
Who Could Benefit Most?
The authors note espRARP is particularly promising for:
- Patients with prior abdominal surgeries or intra-abdominal adhesions (the extraperitoneal route avoids scar tissue).
- Patients who want faster recovery (shorter hospital stay, less swelling).
- Patients concerned about incontinence (rapid continence recovery rates are a major plus).
The Bottom Line
This initial study suggests extraperitoneal single-port robotic-assisted radical prostatectomy is safe and feasible for localized prostate cancer. By addressing the technical hurdles of earlier single-port approaches (e.g., clashing, space limitations), the team has created a technique that could become routine with the da Vinci Si system.
Of course, more research is needed—prospective trials comparing espRARP to conventional multi-port RARP will be critical to confirm its benefits. But for patients and doctors alike, this work offers a glimpse of a future where prostate cancer surgery is less invasive and recovery is faster.
The full study, Initial experience on extraperitoneal single-port robotic-assisted radical prostatectomy, was published in the Chinese Medical Journal (2021;134(2):231–233) by Yi-Fan Chang, Di Gu, and colleagues. You can access it via doi.org/10.1097/CM9.0000000000001145
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