Single‐port versus multiport robotic‐assisted radical prostatectomy: A systematic review and meta‐analysis on the da Vinci SP platform

Abstract

Context Prostate cancer is the most common cancer in men; robotic prostatectomy has cemented itself as part of the standard of care. Since its approval by the Food and Drug Administration in 2018, the SP console's application has been increasingly studied and compared with the multiport (MP) robotic approach. Methods Following PRISMA guidelines and PROSPERO registration CRD42021228744, a systematic review was performed in April 2021 on single‐port robotic‐assisted radical prostatectomies (SP‐RARPs) compared to MP. Outcomes of interest were operative time, bleeding, complications, analgesic use, and postoperative continence, and erectile function. Data were analyzed with Review Manager 5.3. Results Seven studies were included, of which six studies met the inclusion criteria for quantitative synthesis, totalling 1068 patients, out of which 324 underwent SP‐RARP and 744 underwent MP‐RARP. No differences were found in baseline characteristics such as age, body mass index, prostatic‐specific antigen, or stage. No differences in blood loss—15.77 mL [−42.44, 10.89], p = 0.25, operative time 3.93 min [−4.12, 11.98], p = 0.34, or positive surgical margins, with an odds ratio (OR) of 0.78 [0.55, 1.10], p = 0.15—were found. Length of stay was significantly shorter in SP −0.94 days [−1.56, −0.33], p = 0.003, with no differences in complication rates, with an OR of 1.29 [0.78, 2.14], p = 0.32, continence rates, with an OR of 1.29 [0.90, 1.83], p = 0.16, erectile function, with an OR of 0.86 [0.52, 1.40], p = 0.54, or biochemical recurrence. Qualitative evidence suggests decreased opioid consumption. Conclusion SP‐RARPs are feasible alternatives to the traditional MP with possible benefits in pain management and length of stay. Future high‐quality studies are needed to confirm these findings.

Robot-assisted radical prostatectomy: Advancements in surgical technique and perioperative care

“…Not surprisingly, various approaches and techniques have emerged. The conventional transperitoneal RARP is the most commonly done approach using the SP platform and it usually involves the use of an additional port incision for bedside assistance ( 67 , 79 , 81 – 83 , 85 – 87 ), albeit the largest series of SP-RARP outcomes was performed using a pure single-port transperitoneal approach ( 63 ). Second most common SP-RARP modality is via an extraperitoneal approach ( 87 ), which was described using pure SP that allows for SDD ( 28 ), SP + 1 with a drain that is removed on POD 1 ( 88 ), and single-site using a MP robotic platform ( 74 , 76 ).…”

“…The conventional transperitoneal RARP is the most commonly done approach using the SP platform and it usually involves the use of an additional port incision for bedside assistance ( 67 , 79 , 81 – 83 , 85 – 87 ), albeit the largest series of SP-RARP outcomes was performed using a pure single-port transperitoneal approach ( 63 ). Second most common SP-RARP modality is via an extraperitoneal approach ( 87 ), which was described using pure SP that allows for SDD ( 28 ), SP + 1 with a drain that is removed on POD 1 ( 88 ), and single-site using a MP robotic platform ( 74 , 76 ). The extraperitoneal approach may be indicated if planning for SDD as it minimizes peritoneal irritation, or for men with hostile abdomen and/or comorbidities at odds with maintaining a prolonged pneumoperitoneum ( 28 , 88 ).…”

“…Advantages include the Retzius-sparing nature of this approach and associated improved urinary control along with avoidance of peritoneal contents and a theoretical lower risk of complications that make this approach and attractive option in all patients regardless of history of prior abdominal surgery ( 29 ). To date, the use of SP-RARP offers similar outcomes compared to MP-RARP in terms of urinary control and erectile function; longer follow-up is needed to determine if they are oncologically equivalent ( 87 ).…”

The Availability, Cost, Limitations, Learning Curve and Future of Robotic Systems in Urology and Prostate Cancer Surgery

“…As with the Xi, a dual surgeon console setup can facilitate training of surgeons [ 29 ]. A recent meta-analysis suggests equivalence of initial outcomes between single-port and multi-port RAS for RARP in terms of blood loss and operative time, with SP systems associated with having a shorter length of stay [ 32 ]. However, the studies included are predominately single-centre case series and due to the nascency of SP RASS, longer term functional and oncological outcomes are not yet known [ 32 ].…”

“…A recent meta-analysis suggests equivalence of initial outcomes between single-port and multi-port RAS for RARP in terms of blood loss and operative time, with SP systems associated with having a shorter length of stay [ 32 ]. However, the studies included are predominately single-centre case series and due to the nascency of SP RASS, longer term functional and oncological outcomes are not yet known [ 32 ]. The technical differences between a SP and multi-port systems inevitably means that there will be a learning curve required to transition to single-port system, even for surgeons with substantial experience at performing RARPs using multi-port systems [ 30 ].…”