Robot‐assisted single‐port transvesical enucleation of the prostate: step‐by‐step technique and early single‐centre experience

In recent years, robot-assisted simple prostatectomy (RASP) has become one of the various minimally invasive techniques for the surgical treatment of severe LUTS due to benign prostatic enlargement 1. It is primarily recommended for patients with large prostate glands (>80–100 mL) as an alternative to currently available and rapidly evolving transurethral enucleation 2, 3. The concept of performing RASP via a single skin incision was initially explored by Fareed et al. 4 in 2012 using a transvesical approach and a multi-port system. While the procedure was found to be feasible and effective, the authors recorded a high risk of complications, which was primarily due to inadequate instrumentation. Thus, interest in this technique declined until recently. In 2018, the Da Vinci Single Port (SP) system (Intuitive Surgical, Sunnyvale, CA, USA) was introduced in the US market. The SP platform is designed to minimise skin incisions and operate effectively in limited spaces, maintaining the benefits of robotic instruments. Hence, the concept of a SP transvesical enucleation of the prostate (STEP) has regained interest, leading to increasing evidence on the topic. The Cleveland Clinic group was the pioneer of this approach, showing its feasibility and safety 5. Additional single-centre and multicentre studies have been reported over the past 3 years 6, 7. Recently, the Single-Port Advanced Research Consortium (SPARC) published the largest STEP series with 110 procedures compared to the standard multiport (MP) approach. Perioperative outcomes showed significantly lower estimated blood loss (100 vs 150 mL, P < 0.001), shorter hospital stay (17 vs 33 h, P < 0.001), less use of opioids (0 vs 8.4 morphine milligram equivalents) and a shorter duration of Foley catheter (6 vs 9 days, P < 0.001) with the SP robot. The median operating times were 160 and 175 min in SP and MP, respectively 8. In the present study, we illustrate and guide readers on a step-by-step STEP approach, along with preliminary data of our single-centre experience. We describe the case of a 77-year-old patient with Charlson Comorbidity Index of 4 and past medical history significant for hypertension, hyperlipidaemia, BPH with moderate-to-severe LUTS poorly responding to medical therapy (IPSS: 20), and a prostate volume (PV) of 110 mL with prominent median lobe. He ultimately experienced an episode of urinary retention, which was managed with an indwelling catheter. After careful counselling of the patient, it was decided to perform a STEP procedure using the DaVinci SP platform. With the patient in supine position, a 3 cm midline suprapubic skin incision was performed at 6–8 cm (3–4 fingerbreadths) above the pubic symphysis, to gain access to the bladder (Fig. 1A). Incision of the rectus fascia (Fig. 1B) and identification of the bladder dome was performed under cystoscopic guidance with use of CO2 insufflation to allow bladder filling at 8 mmHg. Two Polysorb™ (Medtronic, Minneapolis, MN, USA) 2–0 stay sutures were placed, and the bladder dome opened vertically for 2.5 cm (Fig. 1C). When performing this step, the flexible cystoscope ensures the correct placement of stay sutures. Then the Access port with the Alexis internal ring into the bladder was placed (Fig. 1D). This port consists in the Access port, an Alexis wound retractor, an 'entry guide', a 25-mm multichannel trocar that houses one entry channel for an 8-mm flexible scope, and three entry channels for robotic instruments, and an inflatable plastic globe, which allows for 'floating docking' (Fig. 1E). Optional insertion of an additional transvesical 5-mm port under digital guidance is feasible, to ensure rigid suction and more traction during adenoma enucleation. Dynamic insufflation was maintained throughout the procedure using an 8 mm AirSeal (Conmed Linvatec, Largo, FL, USA). The SP robot was docked (Fig. 2A) and pneumovesicum was induced keeping the pressure below 10 mmHg, in order to prevent air embolism. Robotic instruments were deployed with camera at the 12 o'clock position, monopolar scissors at 3 o'clock, a Cadiere forceps at 6 o'clock, and a fenestrated bipolar forceps at 9 o'clock. Alternatively, a monopolar spatula can be used instead of the monopolar scissors. Suction was performed with the remotely operated suction irrigation (ROSI) system, a flexible tube with a short rigid tip directly handled by the surgeon (Fig. 2B). Occasionally, the Foley catheter can be connected to a suction device to help maintain a bloodless surgical field (Fig. 3A). The procedure started with the incision of the posterior aspect of bladder mucosa overlying the middle lobe (Fig. 2B); enucleation of prostate adenoma was performed from the base towards the apex, developing posterior and lateral planes between prostate adenoma and surgical capsule with sharp and blunt dissection (Fig. 2C,D). The specimen was divided into smaller nodules, which were removed by the assistant and placed into the access port (Fig. 2E). However, extraction can either be performed en bloc, especially for PVs below 110–120 mL (Fig. 3C). Last steps of the procedure included a 360° bladder neck to urethra anastomosis (circumferential re-trigonisation): a 3–0 barbed suture (V-Lock™, Medtronic) was used to achieve capsular haemostasis, and to recreate bladder trigone after the enucleation (Fig. 3B). In doing so, the vesicourethral flap tension is decreased. Finally, final catheter was inserted, and bladder wall closed in two layers. No continuous bladder irrigation was used for this case. The patient was discharged the next day without any opioid prescription, symptoms free, and with a small single surgical incision (Fig. 3D). The catheter was removed on postoperative Day 6. At our institution, we performed 10 STEP procedures between 2022 and 2023. The median (IQR) PV was 96 (60–152) mL, operating time 322.5 (186–444) min, estimated blood loss 300 (80–700) mL, length of hospital stay 33 (26–79) h, and pain score at discharge 3 (1–7). No perioperative complications were recorded. The median (IQR) catheterisation time was 6 (5–9) days. At 3 months all patients were symptoms free, with a median (IQR) IPSS of 5 (2–8), median (IQR) post-void residual urine volume of 12 (0–46) mL and median (IQR) maximum urinary flow rate of 21.4 (16.3–27.6) mL/s. Our study is not devoid of limitations. First, the sample size is limited as this represents the first 10 cases performed at our Centre. Second, there is no control group. While we recognise that comparative studies are fundamental to determine pros and cons of a new technique, a comparison involving a limited number of cases would not provide sufficient statistical significance. Moreover, the aim of the manuscript is to illustrate the technical steps of the procedure. Furthermore, the operating time was quite long compared to other series. However, it is important to note that here we report our initial experience including our initial learning curve. As a matter of fact, a positive trend towards shorter operating times was observed when comparing the latest procedures with the earlier ones. In addition, different surgeons', including trainees, were involved in the procedures. Follow-up is too short to extensively evaluate long-term postoperative and functional outcomes. Last, the STEP procedure requires specific robotic equipment and skilled surgeons trained in robotic surgery, which may limit its accessibility and applicability in various healthcare settings. The accessibility to the SP platform is still limited worldwide, and the implementation of the technique is largely dependent on having an available platform and a solid robotic surgical programme in place. On the other hand, we believe that the procedure can be quickly adopted with a relatively short learning period. Notwithstanding these limitations, we sought to describe in a practical video-based fashion the key steps of the STEP procedure, focusing on the technical aspects of this approach. A STEP may represent a safe, feasible and reproducible alternative for the management of BPH due to large glands. Besides avoiding the peritoneal cavity, advantages of this approach include minimal dissection of the bladder, excellent visualisation of the prostatic fossa, minimal postoperative pain, and quick recovery. The procedure holds promise to become a competitive player in the crowded landscape of BPH surgery. None. There are no relationships that may pose a conflict of interest, nor any financial incentives or supports that have been received by any author as a result of this manuscript. Video S1 Robotic single-port transvesical enucleation of the prostate (STEP): step-by-step technique. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.