We live in an era, thanks to evolving technology, where surgical options for benign prostatic hyperplasia (BPH) treatment continue to expand, intending to minimize patient morbidity and obtain the best outcomes. According to the current guidelines, a robotic simple prostatectomy is a treatment modality for BPH with glands larger than 80 cc.^1,2

In 2018, a new surgical platform was introduced in the field of Urology, the Da Vinci Single-Port (SP)^® robot (Intuitive Surgical, Sunnyvale, California). This robot originated unique features as opposed to the standard multiport Da Vinci Xi^® robot (Intuitive Surgical): single entry point, distal endoscope and instruments triangulation, multi-joint endowrist instruments, and 360° anatomical rotation capability. These characteristics permitted access to ­narrow spaces, avoiding the peritoneal cavity, and limiting the surgical space to the area of the disease, with an aim to further minimize minimally invasive surgery. Using this rationale, and through direct percutaneous bladder access (Fig. 1), the single-port robot-assisted simple prostatectomy (SP RASP) technique was first developed in 2020 and resulted in a low complication rate, same-day discharge, minimal opioid use, short catheter duration, quick recovery, and reproducibility among urologists.^3–6

Figure 1. Illustration of the SP RASP approach. The SP robot is percutaneously docked into the bladder.

Most importantly, the question remains, why adopt a new platform and technique if similar results were achieved with the conventional multiport approach? For this reason, we investigated, in the largest multi-institutional setting, the outcomes between the SP RASP and the standard multiport robotic simple prostatectomy (MP RASP). Data of 91 consecutive patients who underwent SP RASP prostatectomy were compared to 91 MP RASP patients. Both groups were matched for preoperative prostate size. Only patients with a prostate volume larger than 80 cc were ­included in this study.

Figure 2. SP robot and instruments docked directly into the bladder via a 3 cm cystotomy using the SP Da Vinci access port.

While both groups had comparable baseline characteristics with a median preoperative prostate size of 161 cc, the SP RASP group had a shorter operative time (median 162 vs 177 minutes, p=0.005), less pelvic drainage, and continuous bladder irrigation postoperatively p <0.001). Both groups had no to minimal intraoperative or high-grade postoperative complication rates, however MP RASP had a higher readmission rate (0% vs 8.8%, p=0.016). Moreover, patients in the SP RASP used less opioid medication postoperatively (morphine milligram equivalents score 7.5 vs 10, p=0.006) and were more likely to be discharged the same day of the surgery (43.1% vs 0%, p <0.001). Decreasing Foley catheter duration to 3 days was another major achievement with the SP RASP technique (p <0.001).

With the standard MP RASP approach, the bladder is accessed transperitoneally and bivalved to reach the prostatic adenoma. On the other hand, The SP robot, due to its narrow profile, is directly docked into the bladder via a small cystotomy incision (Fig. 2), thus avoiding the peritoneal cavity and limiting the disturbance of the Retzius space. These small technical variations have translated into major outcomes favoring the SP over MP RASP in terms of less drain and continuous bladder irrigation placement, less pain and opioid intake, same-day discharge, and shorter Foley catheter duration while maintaining the low complication rate.

We acknowledge that this current study is limited by its retrospective study, small sample size, and inherent selection bias; however, to our knowledge, this is the first and largest multi-institutional cohort to date. Future randomized control studies comparing the SP RASP technique to other surgical approaches such as MP RASP and laser enucleation are needed to set its rank within the armamentarium of BPH management.

Finally, going back to answering our question, why adopt a new platform? It is because of the added values that the SP RASP provides to patients in terms of decreased morbidity, faster recovery, and outpatient setting.