Performing RARC in patients with a history of pelvic surgery or radiotherapy for prostate cancer remains challenging due to dense fibrosis and adhesions, which increase the risk of bowel and rectal injuries during bladder resection 1, 2. Although previous studies have described the use of the da Vinci system in Japanese patients who have undergone previous prostate cancer treatment, to the best of our knowledge, none of them involved novel surgical platforms 3, 4. Therefore, we describe our initial experience using the hinotori Surgical Robot System in RARC for patients with a history of RP or radiotherapy for prostate cancer and highlight technical points for safely managing these complex cases 5. Five consecutive patients with MIBC or high-risk NMIBC previously treated with RP or IMRT underwent RARC using the hinotori platform at a single institution. All procedures were performed by a single surgeon. The baseline characteristics of patients are shown in Figure 1A. All five procedures were completed robotically without conversion to open surgery. No perioperative or postoperative complications or readmissions occurred within 30 days. The median total operative time, time using the robotic system, and estimated blood loss were 445 min, 300 min, and 55 mL, respectively. LND was performed in all cases, with a range of 5–39 nodes removed (median 24). No patient required an intraoperative blood transfusion. Per the ERAS protocol, all patients resumed oral solid intake within five days, and the median length of stay was 9 days. Surgical margins were negative in all cases. RC and pelvic LND were initially performed, and urethrectomy was not performed. ICIC was performed using the Wallace technique in four cases. At our institute, ICIC involves using NBI and IR observation systems with ICG fluorescence to visualize the mesenteric artery during ileal division and reconstruction (Figure 1B). The LigaSure sealing system and Signia stapling system (Medtronic, Minneapolis, MN, USA) were used to seal the bladder pedicle and for bowel reconstruction. Figure 1C,D show fibrosis and adhesions on Denonvilliers' fascia and the DVC (case 1). These were carefully separated and cut. Figure 1E shows adhesions on the levator ani muscle and lateral pedicle after RARP (case 2). These were partly cut from the muscles, then separated. Figure 1F shows fibrosis and adhesions on the endopelvic fascia (case 3). This part was gently peeled off. As shown in Figure 1G,H, adhesions on the NVB with the pelvic wall were observed in cases 4 and 5. The urethral mucosa was exposed in Figure 1G, which posed a risk of urine leakage containing cancer cells. Since anatomical landmarks differ from normal after prostatectomy, these cases require the utmost care. Dense adhesions were encountered around Denonvilliers' fascia and the vesicourethral anastomosis in RARP and RRP cases, while moderate fibrosis of the Retzius, lateral vesical, and rectovesical spaces was present in IMRT cases. Three key factors in these cases are as follows: complicated areas are left for later processing, and the surrounding normal tissues are addressed; dissection is performed as broadly as possible in areas of adhesion and fibrosis (cancer invasion was also considered); if broad dissection is impossible (e.g., adhesion with the rectum), the surface of the normal organ is checked and cut gently. The use of scissors-cutting techniques is also important, as follows: selecting cold-cut and dry-cut for sharp dissection; selecting the single- or double-edged technique; and selecting optimal traction for organs. The hinotori system allowed stable dissection in fibrotic pelvic fields, thanks to iconic eight-axis compact arms and relaxed eye point settings 5, 6. While da Vinci is sharper, hinotori may feel more direct and human-like, helping with delicate operations 7. In these cases, including RARC with a previous history of pelvic organ treatment, an expert should perform the procedure for the following reasons: anomalies in anatomical landmarks can cause injury to adjacent organs; rupture of the bladder may expose the cancer; and there may be a prolongation of the operative time. In our experience, RARC using hinotori with complicated cases was completed without conversion or unexpected perioperative adverse events. This report is limited by the small sample size, the single experienced surgeon, and the lack of a comparator platform. Larger studies are necessary to confirm safety and generalizability in broader settings. Kosuke Uchida: writing – original draft. Hiromitsu Watanabe: writing – review and editing. Yuto Matsushita: investigation. Keita Tamura: investigation. Daisuke Motoyama: validation. Teruo Inamoto: supervision. We thank the Department of Urology, HUSM, for supporting these research efforts. This research did not receive specific funding from any public, commercial, or not-for-profit sectors. This article was not funded by any grants. Written informed consent for releasing this case series and accompanying images was obtained from the patients. The authors declare no conflicts of interest. This study was approved by the Institutional Review Board of Hamamatsu University School of Medicine (approval No. 21–090). Not applicable. Not applicable.
Uchida et al. (Sun,) studied this question.