Robot-assisted Radical Prostatectomy Using Single-port Perineal Approach: Technique and Single-surgeon Matched-paired Comparative Outcomes

Background: Radical perineal prostatectomy (RPP) has been revived with the advent of single-port (SP) robotic surgery. However, its interest and precise role need to be evaluated and better defined. Objective: To describe in detail the technique of SP-RPP and compare initial perioperative outcomes with those of multiport robot-assisted transperitoneal radical prostatectomy (MP-RARP). Design, setting, and participants: From October 2018 to June 2020, perioperative data of 26 consecutive patients who underwent SP-RPP for localized prostate cancer (PCa) in a single institution were prospectively entered into an institutional review board–approved database. Data of 86 consecutive patients treated from September 2017 to September 2018 with MP-RARP by the same surgeon, before the beginning of the SP experience, were used as comparators. Surgical procedure: SP-RPP was performed using the SP robotic platform (Intuitive Surgical, Sunnyvale, CA, USA) according to the technique described in the supplementary video. Measurements: Demographics, and intra- and postoperative data were analyzed in a matched-paired design with a 1:1 ratio on the following factors: age at surgery, prostate-specific antigen level, preoperative Gleason score, and history of abdominal surgery. Results and limitations: After matching, baseline characteristics were comparable except for the rate of prior laparotomy, which was higher in the SP-RPP group (52% vs 8%, p < 0.001). In the SP-RPP group, 84% of the patients had a high risk and an unfavorable intermediate risk of positive surgical margins (PSMs) versus 57% in the MP-RARP group (p = 0.03). While the rate of nonlimited PSMs (ie, >3 mm) was higher in the SP-RPP group (38.5% vs 7.7%, p < 0.01), the number of patients with biochemical recurrence at 1 yr was comparable between SP-RPP and MP-RARP (1 vs 3, p = 0.3). Conclusions: SP-RPP is a complex procedure for patients with a complex surgical history and high-risk localized PCa with limited alternative therapeutic options. Patient summary: Our study suggests that patients with high-risk localized prostate cancer and limited treatment options due to a complex abdominal surgical history (ie, frozen pelvis) may be suitable candidates for single-port radical perineal prostatectomy. Single-port radical perineal prostatectomy is a feasible but challenging procedure for patients with complex surgical history (ie, frozen pelvis) and high-risk localized prostate cancer who have limited alternative therapeutic options.