Debating Single Versus Multiport Robotic Prostatectomy

At the American Urological Association (AUA) 2022 meeting in New Orleans, one of the highlights of the plenary session was a debate between Jeffrey A. Cadeddu, MD, of UT Southwestern Medical Center, and Jihad Kaouk, MD, of the Cleveland Clinic, on the subject of single versus multiport robotic prostatectomy (RARP) for patients with prostate cancer. The robotic platform referenced in these discussions was the da Vinci surgical system (Intuitive Surgical). The core components of the system include a surgeon’s console, a 3-dimensional vision system, and proprietary EndoWrist technology that allows for flexible articulation and precision during surgery.

A commonly used version of the platform is the da Vinci Xi, which uses up to 4 robotic trocar ports to perform minimally invasive surgery. The most recent iteration of the platform is the single port (SP) robot, which was approved by the US Food and Drug Administration (FDA) in May 2018 for use in urologic surgery. Similar to the da Vinci Xi, the SP platform provides the surgeon with a 3-dimensional high-definition camera and highly articulate instruments through a single incision.

Achieving a Pentafecta

Dr Cadeddu began by defending the view that multiport RARP is superior. The multiport robot is supported by more than 2 decades of literature comparing it to open radical prostatectomy and demonstrating equivalent oncologic outcomes and equivalent, or possibly improved, functional outcomes including reduced blood loss, less pain, and shorter durations of hospital stay. He explained that introduction of the SP platform should begin by demonstrating at least equivalent metrics to justify the higher expense and learning curve associated with switching to SP.

Equivalency can be measured through a concept referred to as “pentafecta,” coined originally by Patel et al,1 to describe 5 key metrics for RARP. These include complication rates, positive surgical margins, potency, urinary continence, and biochemical recurrence-free rate. Dr Cadeddu asserted that any utility for the SP platform should originate from the ability to demonstrate overall complication rates of <7%, positive surgical margin rates <10%, potency >90%, and urinary continence and biochemical-free rates >96%, all based on the large series presented by Dr Patel. These results are achievable in the hands of an expert robotic surgeon, explained Dr Cadeddu. Furthermore, citing data from Patel et al, he explained that at least 83% percent of patients should achieve trifecta (or 3 of 5 metrics) and at least 71% percent should achieve pentafecta (5 of 5 metrics). If these are not achievable in the hands of an expert surgeon, then the SP platform should not be considered for RARP.

Dr Cadeddu remarked that since the inception of the RARP and its gradual transition to mainstream adoption (90% of radical prostatectomy by 20142), surgeons have been learning and evolving to achieve pentafecta for their patients. The introduction of a new technology, totally distinct from the multiport robotic approach, risks setting functional outcome progress backward, he explained. Citing an article by Thompson et al3 examining the learning curve for RARP, he explained that surgeons would need to perform at least 100 to 200 prostatectomies to achieve equivalency to open radical prostatectomy outcomes.

Benefits of RARP

Although another selling point for SP RARP is less perceived patient pain, it is well-documented that multiport RARP can be conducted without the use of any opioid analgesics according to Dr Cadeddu. He explained that these clinical pathways often utilize ketorolac, IV acetaminophen and ibuprofen and that up to 95% of patients can be managed without opioids. He noted that the ability to perform outpatient surgery, allowing patients to return home in the same day, is another marketing point for SP RARP but rebutted the point by citing data from Trabulsi et al4 and Khalil  et al5 showing that even with multiport RARP, patients are able to go home the same day. In expert hands, he remarked, patients can be discharged after multiport RARP and have a <3% rate of readmission.6

Questioning the intent of the SP robot, Dr Cadeddu asked whether surgeons need a new robot or just better surgical techniques to improve outcomes. He cited prior documented improvements, including Rocco stitches, anterior suspensions, posterior urethral suspensions, bladder neck sparing and membranous urethral sparing approaches. He also highlighted the latest Retzius-sparing approach which, by Rosenberg et al7, demonstrated to have a distinct advantage for urinary continence recovery compared to standard RARP.

At this point, Dr Kaouk took the stage to make the case for SP RARP. He began by rebuking the debate topic, explaining that the goal should not be to assert the superiority of a multiple versus single incision, but rather to utilize instruments that allow regionalizing surgical dissection for a procedure and further minimizing the impact of minimally invasive surgery on the patient. As a critical example, he displayed several images showing examples of patients who are ideal candidates for a SP RARP, primarily due to significant prior abdominal surgical history. He explained that the low profile and single port would allow surgeons to perform this lifesaving procedure through an extraperitoneal, transvesical, or even perineal approach, none of which are possible with the multiport robot.

Dr Kaouk emphasized this point by playing a video demonstrating a transvesical RARP where, instead of insufflating the abdomen, the bladder is inflated, allowing surgeons to avoid issues from prior abdominal surgery such as adhesions or frozen pelvises. One limitation of this approach, however, is the limited ability to perform a lymph node dissection. This further supports the idea that it should be considered one among other tools, to be used in selected cases.

Single RARP Benefits

Dr Kaouk also spoke about the functional outcomes of this approach. He cited data from his institution where among 106 patients undergoing transvesical SP RARP, there was a median catheter time duration of just 3 days and 97% achieved full urinary control by 24 weeks after surgery. He also cited data comparing urinary continence with the multiport Retzius-sparing approach versus the SP transvesical approach showing SP RARP yielded equivalent, if not superior, urinary control outcomes at 3 and 6 months postoperatively.8 To further contest Dr Cadeddu’s position, he cited data showing that length of stay for patients receiving SP RARP is also equivalent, if not superior. In his own series of patients, he explained that 87% of those undergoing SP transvesical RARP were discharged home within 4 hours after surgery.

What if surgeons feel uncomfortable or unfamiliar with the transvesical approach to RARP? Dr Kaouk explained that extraperitoneal RARP is also significantly easier with the SP robot because there is only one midline port to place (whereas the multiport extraperitoneal approach requires lateral ports that can be difficult to place). Furthermore, Dr Kaouk explained that while traditional urologic open surgery is primarily extraperitoneal, the majority of multiport approaches to RARP require transperitoneal access. He explained that another benefit of the SP platform is the ability to return to the extraperitoneal space. He noted that despite the increased cost of the SP platform, there has been research demonstrating that the overall cost may be lower due to shorter durations of hospital stay.9

Dr Kaouk concluded by emphasizing the importance of seeking innovations that provide value. For the patient, the SP RARP allows for faster return to continence and less morbidity. For the surgeon, it offers an additional approach to treat patients with hospital intraperitoneal cavities. Finally, for hospital systems, it helps achieve lower costs through outpatient encounters for surgery.

Akhil Abraham Saji, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include urology education and machine learning applications in urologic care. He is a founding and current member of the EMPIRE Urology New York AUA section team.

References

  1. Patel VR, Sivaraman A, Coelho RF, et al. Pentafecta: a new concept for reporting outcomes of robot-assisted laparoscopic radical prostatectomy. Eur Urol. 2011;59(5):702-707. doi: 1016/j.eururo.2011.01.032
  2. Intuitive Surgical. Da Vinci Single-Site Technology product guide; 2016. https://www.intuitive.com/en-us/-/media/ISI/Intuitive/Pdf/1025290ra-isi-brochure-single-site-digital-low-res-394110.pdf. Accessed May 2022.
  3. Thompson JE, Egger S, Böhm M, et al. Superior quality of life and improved surgical margins are achievable with robotic radical prostatectomy after a long learning curve: a prospective single-surgeon study of 1552 consecutive cases. Eur Urol. 2014;65(3):521-531. doi: 1016/j.eururo.2013.10.030
  4. Trabulsi EJ, Patel J, Viscusi ER, Gomella LG, Lallas CD. Preemptive multimodal pain regimen reduces opioid analgesia for patients undergoing robotic-assisted laparoscopic radical prostatectomy. 2010;76(5):1122-1124. doi: 10.1016/j.urology.2010.03.052
  5. Khalil MI, Bhandari NR, Payakachat N, Davis R, Raheem OA, Kamel MH. Perioperative mortality and morbidity of outpatient versus inpatient robot-assisted radical prostatectomy: a propensity matched analysis. Urol Oncol. 2020 Jan;38(1):3.e1-3.e6. doi: 1016/j.urolonc.2019.07.008
  6. Ploussard G, Dumonceau O, Thomas L, et al. Multi-institutional assessment of routine same day discharge surgery for robot-assisted radical prostatectomy. J Urol. 2020;204(5):956-961. doi: 1097/JU.0000000000001129
  7. Rosenberg JE, Jung JH, Edgerton Z, et al. Retzius-sparing versus standard robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer. Cochrane Database Syst Rev. 2020;8(8):CD013641. doi: 1002/14651858.CD013641.pub2
  8. Xu JN, Xu ZY, Yin HM. Comparison of Retzius-sparing robot-assisted radical prostatectomy vs. conventional robot-assisted radical prostatectomy: an up-to-date meta-analysis. Front Surg. 2021;8:738421. doi: 3389/fsurg.2021.738421
  9. Lenfant L, Sawczyn G, Kim S, Aminsharifi A, Kaouk J. Single-institution cost comparison: single-port versus multiport robotic prostatectomy. Eur Urol Focus. 2021;7(3):532-536. doi: 1016/j.euf.2020.06.010