INTRODUCTION
In recent years, the treatment of prostate cancer has predominantly involved surgical intervention, with robotic surgery becoming the standard approach because of its superior outcomes compared to traditional open or laparoscopic approaches [1,2]. These outcomes encompass not only the treatment success rate of prostate cancer but also the functional recovery rates, including urinary incontinence and erectile dysfunction [3]. In particular, urinary incontinence poses a substantial issue that affects patients’ quality of life by necessitating the use of adult diapers or causing an inability to control urination [4]. Although robotic surgery significantly reduces these complications and enhances recovery prospects compared with other surgical methods, it cannot guarantee full continence recovery. Moreover, patients cannot avoid the severe urinary incontinence in the early postoperative period.
To address these challenges, ongoing advancements and innovations in robotic surgical techniques have been developed. Techniques such as bladder neck preservation, neurovascular bundle sparing (NVBS), maximal urethral length preservation, and anterior and posterior reconstruction of the prostate have been introduced and are currently being implemented [5,6]. Despite these techniques, the recovery of continence and reduction of urinary incontinence remain areas that require improvement. Approximately 15% of patients continue to require the use of adult diapers 1-year postsurgery or undergo artificial urinary sphincter implantation [7]. To achieve better functional outcomes, the Retzius-sparing technique, which approaches the prostate posteriorly without detaching the bladder from the abdominal wall, has gained increasing attention. This method reportedly improves the early postoperative continence outcomes [8,9]. However, a notable drawback is the increased rate of positive surgical margins, which can reach up to 40% compared to the traditional 15% [10]. This is primarily due to the limited visibility of the prostate contour during the procedure and the constrained movement of surgical instruments.
To overcome these limitations, transvesical single-port robotic prostatectomy has been introduced [11]. This surgical approach allows for surgery without detaching the bladder from the abdominal wall and provides a traditional operative view. This method demonstrated excellent early continence, rapid recovery, and reduced hospital stay. Moreover, a reasonable positive surgical margin rate of 15% was maintained [12].
Currently, there are no reported cases of this surgery performed in Korea. Therefore, this study aimed to evaluate the feasibility and safety of this procedure. Moreover, oncological and functional outcomes were assessed.
MATERIALS AND METHODS
1. Patients
Four patients underwent transvesical robotic radical prostatectomy using the single-port robotic system between May 2024 and July 2024 by a single surgeon at a single institution. All patients had clinically localized prostate cancer. The inclusion criteria were as follows: (1) prostate cancer patients aged ≥40 years; (2) patients with localized or locally advanced prostate cancer who were candidates for radical prostatectomy (cT2-T3a); and (3) patients eligible for general anesthesia. The exclusion criteria were as follows: (1) patients with severe benign prostatic hyperplasia (BPH) with a prostate volume of ≥80 mL; (2) patients with a history of previous surgery or procedure for BPH; (3) patients unable to void normally due to neurological issues; (4) patients with lymph node metastasis; (5) patients with urethral stricture; and (6) patients who had been treated with neoadjuvant androgen deprivation therapy.
During the same period, 11 patients underwent robotic radical prostatectomy for prostate cancer. Among them, 7 patients underwent the transperitoneal multiport approach. Two patients had severe BPH with a prostate volume >80 mL, 3 patients were needed maximal NVBS due to good preoperative erectile function, and 2 patients underwent the transperitoneal multiport approach due to the institution’s operation schedule.
2. Operation Technique
The procedure involved a 2.5-cm suprapubic skin incision to access the anterior bladder wall. The anterior wall of the bladder was incised to approximately 2 cm. The patients were placed in the Trendelenburg position and robot docking was performed using the floating-docking technique (Fig. 1). The cart approach was performed at a slight diagonal angle from the patient’s leg direction, and docking was accomplished by manually adjusting boom rotation. For the instrument setup, the camera was positioned at the top; Maryland bipolar forceps were used in arm 1, Cadiere forceps in arm 2, and monopolar curved scissors in arm 3 (Fig. 2). Continuous suction was achieved using a homemade device constructed from an endotracheal tube, and the AirSeal system (Conmed, FL, USA) was used to maintain a constant pneumovesicum. The pneumovesicum pressure was maintained at 10 mmHg and reduced to 4-6 mmHg during anastomosis (Fig. 2).
Port placement was performed and the posterior bladder neck was dissected after identification of the bilateral ureteral orifices. Following identification of the vas deferens and seminal vesicles, the vas deferens were transected and the seminal vesicles were dissected. The posterior plane was accessed by incising the Denonvilliers fascia, continuing towards the prostatic apex. At this stage, the degree of NVBS was determined by choosing either the interfascial or the extrafascial plane. An anterior bladder mucosal incision was then made. The endopelvic fascia and puboprostatic ligaments were then identified and excised. Pedicle dissection was performed using the Hem-o-lok robotic clips with bipolar energy. The urethra was identified and transected to ensure maximum preservation of length. Vesicourethral anastomosis was initiated at the 6 o’clock position and continued in the laterosuperior direction by using a double-arm barbed suture. The sutures were tied together at the top position. A Foley catheter was inserted into the bladder and ballooning was performed with distilled water. Finally, the specimen was extracted from a single-port site by using a lap bag (Fig. 3).
3. Feasibility, Safety, and Efficacy
All patients underwent preoperative diagnostic evaluations, including prostate magnetic resonance imaging, abdominal and chest computed tomography, and whole body bone scans for the clinical staging of prostate cancer. We assessed baseline characteristics, such as age, prostate specific antigen (PSA) level, clinical stage, Gleason score, and the presence of neoadjuvant therapy before surgery. To evaluate the feasibility of the surgery, we analyzed the total operation time, console time, and performance of NVBS. Pathological reports, including pathological stage, Gleason score, and margin status, were analyzed. PSA levels 1 month after surgery were also assessed. To assess safety, we assessed the pre- and postoperative levels of hemoglobin, hematocrit, blood urea nitrogen (BUN), and creatinine and evaluated intraoperative and perioperative complications. The efficacy of surgery was assessed by evaluating the duration until fluid and food intake, Foley catheterization duration, and length of hospital stay. Pad usage, including the quantity used, was evaluated 1-month postsurgery.
RESULTS
1. Feasibility of the Surgical Approach
All surgeries were completed successfully without the need for additional ports or conversion to open surgery, demonstrating the technical feasibility of the approach. The median operative time was 188.5 minutes, with console times ranging from 96 to 198 minutes (median, 159 minutes), and NVBS was achieved bilaterally in all cases.
Two patients had positive surgical margins, both with locally advanced pathological stages (pT3a and pT3b) and high Gleason scores (4+3 and 4+4). Lymphovascular invasion was observed in 1 patient, correlating with a higher pT3b stage.
PSA levels were measured 1-month postsurgery to assess biochemical recurrence risk. Three patients achieved PSA levels <0.01 ng/mL. However, 1 patient with a positive margin and pT3b stage presented a persistent PSA level of 0.48 ng/mL, necessitating further monitoring and potential adjuvant therapy.
2. Safety Outcomes
The estimated blood loss was minimal, with a median of 300 mL, and no patient required perioperative transfusion. The median hemoglobin decrease was 1.2 g/dL, and the median hematocrit reduction was 3.5%. BUN and creatinine levels remained stable preoperatively and on the day after the surgery.
Intraoperative complications were not observed. Postoperative complications included 2 cases of gross hematuria, which occurred within 2-week postdischarge. Both patients were managed conservatively without the need for further intervention.
3. Efficacy
All patients had fluid intake a day after surgery, and 2 patients advanced a full diet on the same day. The other 2 patients had a full diet 2 days after surgery as their own want. The median Foley catheter indwelling time was 7.5 days and the day when the Foley catheter was removed, the patients were discharged.
None of the patients experienced total incontinence after removal of the Foley catheter. One patient showed immediate continence, whereas the others showed continence during straining. One month after surgery, all the patients required only a safety pad. Mild stress urinary incontinence was noted when standing or coughing in 2 patients (Table 1).
DISCUSSION
This study investigated the feasibility, safety, and potential efficacy of transvesical single-port robotic prostatectomy in the treatment of clinically localized prostate cancer. As the first report of this surgical technique in Korea, our findings provide evidence supporting innovative approaches for prostate cancer surgery.
The completion of all surgeries without the need for any additional ports or conversion to open surgery demonstrates the technical feasibility of the transvesical single-port approach. The median console time of 159 minutes (96-198 minutes) was longer than that reported for established robotic techniques [13]. However, these cases were the initial experiences of single-port robotic surgery. The median resection time was 106 minutes (72-127 minutes), and the anastomosis time was 33.5 minutes (14-53 minutes). The most time-consuming procedures was anterior resection and anastomosis. In anterior resection, there was an event which was dissection between the transition zone and the peripheral zone. However, after lateral dissection, an optimal surgical plane was obtained. The surgical planes become obvious once the learning curve is overcome. When anastomosis was performed, the bladder mucosa was not considered intact in 2 cases. The Foley catheter period was extended in these patients. Cystography was performed 2 days after the resolution of gross hematuria, and the Foley catheter was removed. In anastomosis, optimal anastomosis can be expected by reducing the pneumovesicum pressure. However, there were difficulties in the early stage of pressure setting, and there were no problems when the pressure was lowered to 4-6 mmHg [14]. The single-port approach can be integrated into surgical practice without significant increases in operative time. However, the success of this technique may depend on the surgeon’s experience with robotic systems [15].
Conventional robot-assisted laparoscopic prostatectomy has a surgical margin positivity rate of approximately 15%-20% [16]. In our study, the positive margin rate was 50%; however, cases of margin involvement were diagnosed as locally advanced prostate cancer (pT3a and pT3b). Two patients with localized prostate cancer had a PSA level <0.01 ng/mL at 1 month after surgery. However, in this study, oncological outcomes, such as margin status or PSA persistence, could not be assessed in very small cases. Retzius-sparing robotic prostatectomy is associated with a higher positive surgical margin rate in anterior tumors [17]. However, transvesical single-port robotic prostatectomy allows for the preservation of anterior structures to the greatest extent possible while providing flexibility in choosing dissection above or below the dorsal venous complex. Additionally, maximal urethral length sparing can be performed selectively. Consequently, contraindications for anterior tumors may not be necessary in this approach.
Transvesical single-port robotic prostatectomy demonstrated a favorable safety profile, with blood loss and no intraoperative complications. Two cases of gross hematuria occurred postoperatively, both of which were resolved with conservative management. The single-port technique does not introduce additional risks compared to traditional multiport robotic prostatectomy [18].
A notable feature of the transvesical singleport approach is the preservation of the anatomical structures that are critical for urinary continence. By avoiding dissection of the Retzius space, this technique minimizes trauma to the surrounding tissues, potentially facilitating the early recovery of urinary function [19,20]. In this study, none of the patients experienced immediate total incontinence after catheter removal. All patients showed stress-induced urinary incontinence after Foley removal. Moreover, the requirement for only a safety dry pad 1-month postsurgery suggests that the single-port technique may facilitate early recovery of urinary function, potentially improving patients’ quality of life in the immediate postoperative period.
Currently, no long-term follow-up data are available on continence rates for single-port transvesical radical prostatectomy. For conventional robotic prostatectomy, a urinary continence rate of approximately 90% has been reported [21]. Thus, in the case of long-term follow-up, it is likely that there will be no significant difference in continence rates when compared with the conventional approach. However, continence may decline over time postrecovery, especially in elderly patients who are likely to experience poorer outcomes [22]. Therefore, a high rate of early recovery is expected to benefit overall continence and improve quality of life; however, it is crucial to confirm these findings through long term follow-up in future studies.
The small sample size and short follow-up period limited the generalizability of our results. Further research involving larger multicenter trials with extended follow-up periods is essential to validate the feasibility and safety of the transvesical single-port approach and to explore its long-term oncological and functional outcomes. Since this was my initial attempt, patients with good preoperative sexual function who could undergo interfacial NVBS were treated using a conventional approach during the study period.
Moreover, the learning curve associated with this novel technique warrants further consideration. Successful implementation of the single-port approach in clinical practice requires surgeons to acquire specific skills and experience, which may initially limit its widespread adoption. Future studies should focus on defining the learning curve and identifying strategies to facilitate the transition to single-port robotic prostatectomy in surgeons accustomed to conventional techniques.
CONCLUSIONS
In conclusion, transvesical single-port robotic prostatectomy is a feasible and potentially promising surgical option for the management of clinically localized prostate cancer. This technique offers the potential for improved early functional outcomes, particularly urinary continence, without compromising oncological integrity. However, further research is needed to establish its role within the broader context of prostate cancer surgery, and to ensure that it can be safely and effectively implemented in diverse clinical settings. Continuing to explore and refine innovative surgical approaches can enhance the quality of care for patients with prostate cancer and improve their postoperative quality of life.
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