Intriguing future: single-site robotic-assisted radical prostatectomy

Introduction

Prostate cancer (PCa) remains a significant public health challenge, presenting substantial difficulties for both patients and surgeons. Robot-assisted radical prostatectomy (RARP) has become the gold standard for treating localized PCa (1). In 1995, Intuitive Surgical was founded and subsequently developed the Da Vinci surgical system, following several prototype iterations. On May 23, 2000, Binder and Kramer performed the first robot-assisted laparoscopic radical prostatectomy (RALP) (2). In 2004, Intuitive Surgical acquired Computer Motion, solidifying its monopoly on robotic surgery. Since then, the Food and Drugs Administration (FDA) has approved five generations of Da Vinci systems for urological applications (3). The desire for minimally invasive approaches has spurred the development of single-site robotic-assisted radical prostatectomy (ssRARP). This innovative technique gained traction within the urological community in 2008 with the arrival of novel robotic instruments and single-port access technologies (4). Kaouk et al. pioneered laparoendoscopic single-site surgery (LESS) in urology by performing a radical prostatectomy, a pyeloplasty, and a radical nephrectomy on three patients using the Da Vinci S robotic system through a single-port multi-channel platform (4). Kaouk et al. performed the clinical application of a dedicated single-port robotic platform following FDA approval in 2018, underscoring the technology’s potential for minimally invasive surgery (MIS) (5).

Building upon the established benefits of MIS, ssRARP offers additional benefits like improved cosmesis, reduced pain, and potentially faster recovery (6). Furthermore, it leverages the strengths of robotic surgery, including magnified three-dimensional visualization and tremor filtration, to potentially minimize surgical trauma, enhance postoperative quality of life (7,8). However, technical challenges, a steep learning curve, limited instrument accessibility, and a paucity of long-term oncological data hinder its widespread adoption (9,10). This review aims to comprehensively address the evolution, technical aspects, oncological and functional outcomes, and considerations for special situations during ssRARP.

The standardized term of ssRARP or single-port RARP: expert consensus statement from China

Terminology for ssRARP has been inconsistent, with terms such as “single-port”, “single-incision”, and “single-site” (7,9). To establish standardization, the International Multidisciplinary Laparoendoscopic Single-Site Surgery Consortium for Assessment and Research (LESSCAR) introduced “LESS” for single-port laparoscopic procedures in 2008 (11).

In 2023, Chinese urological experts issued a consensus statement advocating for “ss-RARP” as the standardized term (12). This definition precisely characterizes the procedure as a robotically performed radical prostatectomy through a single, small abdominal incision, typically located around the umbilicus. Surgeons now have the flexibility to employ various techniques, facilitated by platforms like da Vinci Si/Xi and SP, which offer options such as single-port multi-channel, single-channel, and modified portless approaches (13). The term “single-site” comprehensively encompasses this diversity of surgical approaches.

The consensus underscores the importance of tailoring the surgical approach to individual patient factors, surgeon expertise, and available technology. By optimizing surgical techniques and effectively managing specific complications, individualized ssRARP strategies can potentially enhance patient outcomes (Figure 1).

Figure 1 Expert consensus statement of ssRARP, initiated by Robotics Group of CUA, after effective questionnaire survey by 89 experts. ssRARP, single-site robot-assisted radical prostatectomy; CUA, Chinese Urological Association; MP-RARP, multi-port robot-assisted radical prostatectomy; LRP, laparoscopic radical prostatectomy; BPH, benign prostatic hyperplasia; SP, single-port.

Approach and technique

Preoperative decision-making for ssRARP is contingent upon on a patient’s clinical stage, risk stratification, and tumor location as determined by imaging. This comprehensive assessment ensures optimal patient selection and aims to preserve critical structures, potentially leading to “Perfecta” outcomes—urinary continence, oncological control, sexual function, negative surgical margins, and minimal complications. Common ssRARP approaches include transperitoneal, extraperitoneal, transvesical, and transperineal. The transperitoneal approach further subdivides into posterior, anterior, and lateral variations (Figure 2).

Figure 2 Common approaches of ssRARP. SETv, single-port extraperitoneal transvesical robotic-assisted radical prostatectomy; Tv, transvesical robot-assisted radical prostatectomy; ssRARP, single-site robotic-assisted radical prostatectomy.

Patient selection

The consensus among Chinese experts provides a valuable framework for patient selection for single-port robotic-assisted radical prostatectomy (SP-RARP) or ssRARP (12). Ideal candidates typically present with localized PCa (T1–2c stage) and are categorized as low- to intermediate-risk. A life expectancy of at least a decade is generally recommended, along with good overall health and the absence of severe cardiopulmonary conditions. Patients with higher-risk disease, such as those with a prostate-specific antigen (PSA) level exceeding 20 ng/mL or a Gleason score of 8 or more, may be considered for ssRARP if they meet the aforementioned criteria, although adjuvant therapy might be necessary postoperatively. For patients with locally advanced disease, extended lymph node dissection may be considered, but this decision should be made on an individual basis after careful discussion.

In principle, contraindications include non-localized PCa (≥ cT3a), previous abdominal surgeries or radiotherapy that could hinder port placement, and recent pelvic surgeries. Special considerations include patients with a history of pelvic surgery or those who may face difficulties with standard surgical approaches. Additionally, ssRARP is generally not recommended for patients with a history of benign prostatic hyperplasia (BPH) surgery or those with a significantly enlarged prostate. However, it’s crucial to obtain informed consent from all patients, ensuring they understand the potential benefits, risks, and alternative treatment options.

Transperitoneal approach

The transperitoneal approach remains the predominant technique for ssRARP, typically involving a 4–5 cm midline umbilical incision to access the abdominal cavity. The transperitoneal approach, with the bladder as anatomical landmarks, can be categorized as anterior, posterior, and lateral approach.

The transperitoneal anterior approach is a common technique for ssRARP. It begins with a 4–5 cm midline incision near the umbilicus, followed by entry into the abdominal cavity through the dissected parietal peritoneum. This approach shares similarities with the extraperitoneal approach prostatectomy after accessing the surgical field (14). While oncological outcomes remain acceptable, it presents challenges such as instrument clashing within the confined space, both inside and outside the peritoneal cavity (9). This drawback has spurred ongoing innovation among surgeons worldwide to refine the transperitoneal anterior approach for ssRARP.

The posterior approach, pioneered by Bocciardi’s retzius-sparing technique, prioritizes urinary continence by preserving the retropubic space (15). This approach prioritizes urinary continence by meticulously preserving structures within the retropubic space, which are crucial for bladder control. It avoids opening the pelvic peritoneum, thereby maintaining the natural position and angulation between the bladder and urethra. Nevertheless, the superiority of Retzius-sparing technique in preserving urinary continence is still a subject of debate (16-19).

The transperitoneal lateral approach creates a “cave-like” space between the bladder neck and prostate base, facilitating dissection within a blood vessel-sparse plane (20). This approach prioritizes the preservation of surrounding anatomical structures critical for urinary continence and sexual function. Consequently, it demonstrates favorable clinical outcomes in these areas, making it a suitable option for patients with low-risk PCa (21). However, investigations into the application of single-port lateral approach for RARP are currently limited.

The transperitoneal approach, while versatile, presents inherent challenges. The distance between the umbilicus and the surgical field can lead to frequent instrument collisions, hindering maneuverability and requiring a steeper learning curve for surgeons. Additionally, studies have shown a potential increased risk of positive surgical margins, particularly for tumors located in the transition zone and the prostate apex (17,22,23). This necessitates careful patient selection and potentially additional surgical steps to ensure complete tumor removal. Furthermore, disruption of the gastrointestinal tract during transperitoneal surgery can delay function recovery and increase the risk of postoperative complications like bowel obstruction and adhesions (14). Consequently, the transperitoneal approach may not be the preferred choice for patients with a history of abdominal surgery.

Transvescical approach

The transvesical approach provides a unique route to the prostate gland by utilizing the bladder itself as the entry point. This approach encompasses two main techniques: single-port extraperitoneal transvesical RARP (SETvRARP) and transvesical robot-assisted radical prostatectomy (TvRARP). SETvRARP is a minimally invasive technique involving a single trocar inserted directly into the bladder (24). Surgery then proceeds beneath an inflated bladder, remaining outside the abdominal cavity (extraperitoneal) for enhanced safety. Conversely, TvRARP involves a bladder incision to facilitate an entirely intravesical surgical approach (25).

Desai et al. pioneered the use of robotic surgery for TvRARP on cadavers (25). This approach aims to preserve structures crucial for urinary continence and erectile function recovery, such as the puboprostatic ligaments, endopelvic fascia, and neurovascular bundles. Wang’s team subsequently reported the first clinical experience using the Da Vinci system for TvRARP (24). Their findings suggest its feasibility for treating low-risk PCa with favorable initial urinary continence rates. However, long-term functional recovery and oncological control require further investigation.

Compared to the transperitoneal anterior approach, TvRARP eliminates the need for separate dissection of the deep venous complex and neurovascular bundles. However, strict patient selection is essential for achieving optimal outcomes (26). This approach is contraindicated in patients with larger prostates, and pelvic lymph node dissection can be challenging due to limited visibility. Additionally, the risk of acute urinary retention from bladder injury is increased with TvRARP (26).

Transperineal approach

The perineal approach, utilizing perineal radical prostatectomy (PRP), boasts a long history dating back over 150 years. This approach involves a 4–5 cm inverted U-shaped incision between the ischial tuberosities, followed by meticulous dissection of tissues to access the prostate. Historically, PRP was the primary surgical modality for PCa. In 1905, Hugh Hampton Young refined the procedure, rendering it suitable for patients ineligible for abdominal surgery or radiotherapy (27).

A recent Cleveland Clinic study explored single-port robot-assisted perineal radical prostatectomy (SP-RPP), comparing its initial outcomes to the more prevalent multi-port transperitoneal RARP. While the study showed comparable functional and oncological results within a year for both groups, SP-RPP had a higher complication rate and a significantly higher rate of positive surgical margins (38.5% vs. 7.7%). Additionally, performing bilateral pelvic lymph node dissection in the confined perineal space proved challenging (28). The complex anatomy, narrow surgical field, and bulky robotic arms can lead to instrument clashes and difficulty maneuvering (29). The proximity to the rectum also raises the risk of injury during surgery. These factors, coupled with the steeper learning curve, have contributed to the decline of the perineal approach in the era of MIS (30).

Extraperitoneal approach

The extraperitoneal approach for ssRARP, previously limited by multiport systems, has gained renewed interest due to its potential benefits. Studies by Kaouk et al. demonstrated promising results, including shorter hospital stays, reduced pain medication needs, and faster surgery times in the extraperitoneal group compared to the traditional transperitoneal approach (14,31). However, Zeinab et al. also reported longer surgery times in their extraperitoneal group, attributing this to factors like surgeon experience, creating the extraperitoneal space, and more frequent lymph node dissection (32).

While offering potential benefits, the extraperitoneal approach presents surgical challenges. The limited operating space can lead to instrument clashes, requiring a steeper learning curve and hindering maneuverability (10). Accidental peritoneal tears can compromise surgical visibility and stability, necessitating immediate repair and increasing the risk of lymphatic complications. Moreover, adequate postoperative drainage is crucial to prevent fluid collections (14). Patients with prior abdominal surgeries like laparoscopic extraperitoneal mesh herniorrhaphy or kidney transplantation may not be suitable candidates due to scar tissue and adhesions restricting access to the surgical area (33).

Our center prioritizes the extraperitoneal approach for ssRARP to maximize workspace. We achieve this by placing a 20F Foley catheter to empty the bladder and create a 4–5 cm incision above the pubic symphysis. A four-channel port is then inserted, and the space is inflated to 12 mmHg. Our center has tackled the challenge of instrument interference inherent in the extraperitoneal approach for ssRARP through a combination of innovative solutions. This includes strategically positioning the laparoscopic camera downwards and angling it 30 degrees upwards throughout surgery. This placement allows for continuous focus adjustments, maintaining a clear view of the surgical field and minimizing visual obstructions for precise execution. Additionally, we’ve optimized robotic arm functionality by shortening the working arms while preserving triangulation. This modification grants the arms more wrist-like flexibility, improving the surgeon’s field of view, minimizing instrument clashes, and facilitating more delicate manipulation of surgical instruments. Finally, effective tissue management is achieved by the surgical assistant utilizing an aspirator to retract the peritoneum and manage tissue tension during surgery. This technique effectively creates additional working space, optimizes surgical exposure, and facilitates a more efficient and controlled procedure. These technical refinements effectively address the limitations associated with the extraperitoneal approach, allowing our center to perform ssRARP with enhanced precision and potentially improved patient outcomes. However, further research is warranted to validate the long-term benefits of these refinements and their impact on patient results. Our center has also implemented a novel peritoneal fenestration technique within the single-site extraperitoneal approach (34). This innovation creates a small opening in the peritoneum, allowing transperitoneal reabsorption of lymphatic fluid, potentially reducing the risk of lymphoceles and subsequent infections. While none of our patients developed symptomatic lymphoceles in the short term, further high-quality studies are necessary to confirm the long-term benefits of this approach.

Our center has exclusively utilized the da Vinci Xi system for single-site procedures, providing valuable experience for transitioning to single-port platforms. Consistent with Bertolo et al.’s perspective, the limitations of current single-port instrumentation are anticipated to be mitigated by emerging robotic technologies (35). A comprehensive assessment of the learning curve for transitioning from conventional robotic surgery is essential.

Perioperative outcomes and complications

Recent systematic reviews have compared ssRARP with multi-port robotic-assisted radical prostatectomy (MP-RARP). In a study by Bertolo et al. involving 610 patients, SP-RARP was demonstrated non-inferiority to MP-RARP in terms of operative time, blood loss, complication rate, and positive surgical margins. The study also revealed a shorter length of stay for patients undergoing SP-RARP, although this finding should be interpreted with caution due to potential biases related to the US healthcare system (36). Hinojosa-Gonzalez et al. (37) analyzed data from over 1,000 patients, while Li et al. (38) included nearly 1,240 patients, further differentiating by surgical approach (transperitoneal, extraperitoneal, and perineal). Both studies observed similar perioperative outcomes between ssRARP and MP-RARP. However, ssRARP patients consistently benefited from shorter hospital stays and reduced need for pain medication.

Positive surgical margin

Bertolo et al. included four studies comparing perioperative outcomes between SP-RARP and MP-RARP (36). The results showed that of the 268 patients in the SP-RARP group, 66 had positive surgical margins, while 102 of the 342 patients in the MP-RARP group had positive surgical margins. There was no significant difference in the incidence of positive surgical margins between the SP-RARP and MP-RARP groups [95% confidence interval (CI): 0.53–1.37, P=0.51]. Multiple meta-analyses comparing single-port and multi-port platforms have consistently shown the same results (7,37,38). Agarwal et al. (6) found positive margin rate of 19% in patients with International Society for Urological Pathology (ISUP) grade groups of 1–2 and 55% in those with ISUP grade groups of 3–5. Factors contributing to higher rates in transperitoneal approach include the learning curve associated with new techniques, a higher proportion of high-risk pathology, and nerve-sparing procedures (22,23,39,40). The positive surgical margin rate was significantly higher in the single-port transperineal approach group compared to the multi-port platform group (38.5% vs. 7.7%, P=0.006) (28). The bladder neck and apex are commonly reported sites of positive margins in perineal procedures (41). A plausible explanation is that using surgical instruments to remove the prostate through the levator ani muscle may result in accidental capsular incisions during specimen extraction, potentially leading to false-positive margins. Benidir et al. found no significant difference in positive surgical margins between single-port and MP-RARP by the transvesical approach (P≥0.05) (42). Yoon et al. confirmed that the extraperitoneal approach using single-port platform did not show a statistically significant difference in positive surgical margins compared to the multi-port platform (P=0.049) (43). Similarly, Jiang et al. demonstrated that there was no statistically significant difference in positive surgical margins between single-port extraperitoneal and transperitoneal approaches (P>0.05) (44). These studies suggest that single-site or single-port platforms may be non-inferior to multi-port platform in terms of positive surgical margins. However, it is recommended that surgeons initially use the single-port or single-site system for low-risk diseases and progress to high-risk patients once a sufficient level of skill and proficiency has been achieved.

Continence and erectile function

Similar to traditional robotic approaches, ssRARP retains the ability to perform nerve-sparing procedures, bladder neck reconstruction, and preserve urethral length, all crucial for maintaining erectile function and urinary continence. Schwen et al. compared ssRARP and MP-RARP regarding these functional outcomes, finding no significant differences in continence rates at 3, 6, and 12 months, with ssRARP achieving rates of 69%, 80%, and 85%, respectively (45). It’s important to acknowledge that longer follow-up is necessary to comprehensively assess continence outcomes, including post-prostatectomy incontinence rates and the need for interventions. Comparable to MP-RARP, ssRARP demonstrates promise in preserving erectile function, as evidenced by high nerve-sparing rates. Studies suggest comparable recovery rates between the two approaches at 12 months, with ssRARP achieving a 70% erectile function recovery rate and MP-RARP at 63%. However, ssRARP patients reported a higher rate of mild to moderate erectile dysfunction (50% vs. 38% for MP-RARP) (7,14).

Complication

Studies comparing complication rates in ssRARP found no significant difference between the extraperitoneal and transperitoneal approaches (7,14,37,46). Extraperitoneal approach significantly reduces the risk of ileus (post-surgical bowel obstruction) by 80% and inguinal hernia formation by 80% (14). A potential drawback of the extraperitoneal approach is an increased incidence of symptomatic lymphoceles, fluid collections that may require drainage (47). This is likely because the extraperitoneal space doesn’t reabsorb lymphatic fluid as effectively as the peritoneal cavity. Our experience with ssRARP aligns with this, as we observed a higher rate of symptomatic lymphoceles requiring drainage, consistent with other studies (14).

Biochemical recurrence (BCR) rates

BCR is a critical oncological outcome for PCa treatment. A meta-analysis by Bertolo et al., including 6 studies and 1,068 patients, found no significant difference in BCR rates between patients who underwent SP-RARP and those who underwent MP-RARP (36). Another meta-analysis by Li et al., encompassing 7 studies and 1,239 patients, yielded similar results (38). Moschovas et al. compared the postoperative BCR rates of single-port and MP-RARP by the transperitoneal approach, with median follow-up times of 4.4 and 3.2 months, respectively. No BCR was observed in either group (48). Kim et al. reported the perioperative outcomes of 157 patients who underwent SP-RARP via a transperitoneal approach, with a BCR rate of 8.2% at a median follow-up of 9 months (49). For the extraperitoneal approach, Lenfant et al. demonstrated no statistically significant difference in PSA progression-free survival at 12 months between single-port and multi-port platforms (P=0.09) (7). Similar results were observed for transperineal (28) and transvesical (42) SP-RARP, with no significant differences in BCR rates compared to multi-port platform at 12 months (P=0.32, P=0.09). Pettenuzzo compared the perioperative outcomes of single-port extraperitoneal RARP with MP-RARP combined with extended lymph node dissection via a transperitoneal approach, and found no significant difference in BCR rates (6% vs. 5%, P=0.9) (50). These studies suggest the potential non-inferiority of single-site or single-port platforms in terms of BCR rates within shorter follow-up periods. However, definitive conclusions regarding oncological outcomes can only be drawn with longer-term follow-up.

Special situations

Excellent outcomes have been reported in large ssRARP cohort. However, challenges arises when special situations happen such as previous BPH surgery, large median lobe (ML) and RARP after focal therapy (FT) for prostate.

Previous BPH surgery

Patients with a history of BPH surgery present unique challenges for ssRARP (51). This scenario frequently arises in two ways: incidental PCa discovered unexpectedly during routine pathology examination after transurethral resection of the prostate (TURP) or elevated PSA levels prompting a PCa diagnosis following BPH surgery. The altered anatomy caused by prior BPH surgery can make ssRARP more technically demanding for surgeons. The altered anatomy resulting from prior BPH surgery can increase the technical complexity of ssRARP.

Prior BPH surgery, particularly TURP, can impact the entire lower urinary tract, complicating ssRARP due to hypertrophic scar tissue formation around the prostate. This can compromise surgical precision, nerve function, and increase the risk of blood loss, postoperative erectile dysfunction, urinary incontinence, and positive surgical margins (52). Studies have shown that patients with a history of TURP experience increased blood loss, higher need for bladder neck reconstruction, longer surgery duration, and inferior patient outcomes, including higher positive surgical margin rates, increased risk of BCR, and more urinary incontinence (53).

While ssRARP offers a minimally invasive approach for PCa, patients with a history of BPH surgery require careful consideration due to anatomical changes. Meticulous dissection of the bladder neck becomes crucial to avoid damaging the ureters and bladder opening. Additionally, various techniques exist for bladder neck reconstruction, with the posterior tennis-racket method offering protection for the ureters. However, reconstructed bladder necks may require careful testing for leaks and potential postoperative drainage. To optimize surgical planning and clinical outcomes for these patients, thorough preoperative evaluation is essential (51).

Large ML

An enlarged ML is a relatively common occurrence, affecting approximately 8–18% of patients undergoing RARP (54). The ML’s prominence obstructs visualization between the prostate and bladder neck, potentially leading to technical challenges during dissection, increased risk of positive surgical margins, compromised perioperative outcomes, including blood loss and operative time, and even ureteric orifice injury (55,56). Additionally, a larger bladder neck defect caused by the ML may hinder the recovery of urinary continence following surgery (57). These factors emphasize the need for highly experienced surgeons when managing patients with large MLs during RARP.

While research specifically addressing techniques for managing ML during ssRARP remains scarce, a promising approach was introduced (58-60). Utilizing a four-arm multi-port robotic system, this technique prioritizes preoperative imaging for precise posterior bladder neck identification. Intraoperatively, a traction-type Foley catheter facilitates ML extraction. The ML is then maneuvered and anchored superiorly to optimize posterior bladder neck exposure. Ureteric orifice identification is crucial, and nerve preservation requires skilled assistance. Bladder neck reconstruction emphasizes maintaining a safe distance from the ureteric orifices, with stent placement considered if necessary. Robust research in this area is still needed, our surgical team has successfully implemented these techniques for managing ML during ssRARP, achieving positive postoperative functional recovery outcomes for our patients.

RARP after FT for prostate

It is worth noting that focal therapies for the prostate, such as photoselective vaporization, cryotherapy, high-intensity focused ultrasound (HIFU), and focal laser ablation (FLA), have become increasingly popular (61). While FT is less invasive than radical therapy, it carries the risk of recurrence. Salvage RARP is a potential option following FT failure (62,63). However, the actual impact of focal ablation on local anatomy remains poorly understood and unpredictable, which may affect surgical outcomes. Salvage RARP after any form of prior FT is technically challenging due to collateral damage and fibrosis. Given that salvage RARP is considered complex and unsafe (64), poorer functional outcomes are attributed to lower levels and quality of nerve preservation and loss of anatomical planes due to fibrosis of surrounding structures (65). In particular, fibrosis of the lateral pelvic fascia and nerve damage lead to a loss of structural support, impacting urinary continence (63). Currently, there are no definitive studies on the feasibility of single-site or single-port platform for salvage RARP after FT, but it remains technically challenging.

Limitations

While this review offers a valuable overview of ssRARP, it likely has some limitations due to its focus and the nature of a review. The review primarily concentrates on the current state of ssRARP research, lacking explicit inclusion and exclusion criteria. Consequently, it may have a bias towards studies with positive outcomes for ssRARP, potentially neglecting a comprehensive discussion of potential drawbacks or complications. Additionally, the review does not delve into the specific surgical details of ssRARP, nor does it discuss alternative treatment options for PCa to facilitate appropriate comparisons. Finally, the review does not provide a detailed analysis of the cost-effectiveness of ssRARP.

Conclusions

ssRARP has emerged as a promising technique. However, MP-RARP remains the current gold standard. As technology advances, personalized surgical options will become increasingly essential. While ssRARP offers potential benefits, widespread adoption necessitates a broader surgeon experience base. Rigorous prospective studies are required to definitively establish its superiority.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Davide Campobasso, Stefano Puliatti and Stefania Ferretti) for the series “New Evidence and Advances in Surgical Treatment of Prostate Cancer” published in Chinese Clinical Oncology. The article has undergone external peer review.

Peer Review File: Available at https://cco.amegroups.com/article/view/10.21037/cco-24-96/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://cco.amegroups.com/article/view/10.21037/cco-24-96/coif). The series “New Evidence and Advances in Surgical Treatment of Prostate Cancer” was commissioned by the editorial office without any funding or sponsorship. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Cornford P, van den Bergh RCN, Briers E, et al. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer-2024 Update. Part I: Screening, Diagnosis, and Local Treatment with Curative Intent. Eur Urol 2024;86:148-63. [Crossref] [PubMed]
2. Binder J, Kramer W. Robotically-assisted laparoscopic radical prostatectomy. BJU Int 2001;87:408-10. [Crossref] [PubMed]
3. De Marchi D, Mantica G, Tafuri A, et al. Robotic surgery in urology: a review from the beginning to the single-site. AME Med J 2022;7:16. [Crossref]
4. Kaouk JH, Goel RK, Haber GP, et al. Robotic single-port transumbilical surgery in humans: initial report. BJU Int 2009;103:366-9. [Crossref] [PubMed]
5. Kaouk J, Bertolo R, Eltemamy M, et al. Single-Port Robot-Assisted Radical Prostatectomy: First Clinical Experience Using The SP Surgical System. Urology 2019;124:309. [Crossref] [PubMed]
6. Agarwal DK, Sharma V, Toussi A, et al. Initial Experience with da Vinci Single-port Robot-assisted Radical Prostatectomies. Eur Urol 2020;77:373-9. [Crossref] [PubMed]
7. Lenfant L, Sawczyn G, Aminsharifi A, et al. Pure Single-site Robot-assisted Radical Prostatectomy Using Single-port Versus Multiport Robotic Radical Prostatectomy: A Single-institution Comparative Study. Eur Urol Focus 2021;7:964-72. [Crossref] [PubMed]
8. Huang MM, Patel HD, Wainger JJ, et al. Comparison of Perioperative and Pathologic Outcomes Between Single-port and Standard Robot-assisted Radical Prostatectomy: An Analysis of a High-volume Center and the Pooled World Experience. Urology 2021;147:223-9. [Crossref] [PubMed]
9. Chang Y, Lu X, Zhu Q, et al. Single-port transperitoneal robotic-assisted laparoscopic radical prostatectomy (spRALP): Initial experience. Asian J Urol 2019;6:294-7. [Crossref] [PubMed]
10. Chang YF, Gu D, Mei N, et al. Initial experience on extraperitoneal single-port robotic-assisted radical prostatectomy. Chin Med J (Engl) 2020;134:231-3. [Crossref] [PubMed]
11. Gill IS, Advincula AP, Aron M, et al. Consensus statement of the consortium for laparoendoscopic single-site surgery. Surg Endosc 2010;24:762-8. [Crossref] [PubMed]
12. Wang D, Guo J, Gu D, et al. Expert consensus statement of single-site robot-assisted radical prostatectomy from the Robotics Group of Urology branch of Chinese Medical Association. Journal of Minimally Invasive Urology 2023;12:18-24.
13. Shangqing R, Yong O, Yaoqian W, et al. Establishment of the operative pathway in single incisional robot-assisted radical prostatectomy without dedicated extraperitoneal access devices. Asian J Surg 2022;45:1584-6. [Crossref] [PubMed]
14. Kaouk J, Aminsharifi A, Wilson CA, et al. Extraperitoneal versus Transperitoneal Single Port Robotic Radical Prostatectomy: A Comparative Analysis of Perioperative Outcomes. J Urol 2020;203:1135-40. [Crossref] [PubMed]
15. Galfano A, Ascione A, Grimaldi S, et al. A new anatomic approach for robot-assisted laparoscopic prostatectomy: a feasibility study for completely intrafascial surgery. Eur Urol 2010;58:457-61. [Crossref] [PubMed]
16. Rosenberg JE, Jung JH, Edgerton Z, et al. Retzius-sparing versus standard robot-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer. BJU Int 2021;128:12-20. [Crossref] [PubMed]
17. Dalela D, Jeong W, Prasad MA, et al. A Pragmatic Randomized Controlled Trial Examining the Impact of the Retzius-sparing Approach on Early Urinary Continence Recovery After Robot-assisted Radical Prostatectomy. Eur Urol 2017;72:677-85. [Crossref] [PubMed]
18. Menon M, Dalela D, Jamil M, et al. Functional Recovery, Oncologic Outcomes and Postoperative Complications after Robot-Assisted Radical Prostatectomy: An Evidence-Based Analysis Comparing the Retzius Sparing and Standard Approaches. J Urol 2018;199:1210-7. [Crossref] [PubMed]
19. Umari P, Eden C, Cahill D, et al. Retzius-Sparing versus Standard Robot-Assisted Radical Prostatectomy: A Comparative Prospective Study of Nearly 500 Patients. J Urol 2021;205:780-90. [Crossref] [PubMed]
20. Menon M, Shrivastava A, Kaul S, et al. Vattikuti Institute prostatectomy: contemporary technique and analysis of results. Eur Urol 2007;51:648-57; discussion 657-8. [Crossref] [PubMed]
21. Mattei A, Naspro R, Annino F, et al. Tension and energy-free robotic-assisted laparoscopic radical prostatectomy with interfascial dissection of the neurovascular bundles. Eur Urol 2007;52:687-94. [Crossref] [PubMed]
22. Ng CF, Teoh JY, Chiu PK, et al. Robot-assisted single-port radical prostatectomy: A phase 1 clinical study. Int J Urol 2019;26:878-83. [Crossref] [PubMed]
23. Jones R, Dobbs RW, Halgrimson WR, et al. Single port robotic radical prostatectomy with the da Vinci SP platform: a step by step approach. Can J Urol 2020;27:10263-9. [PubMed]
24. Zhou X, Deng W, Li Z, et al. Initial experience and short-term outcomes of single-port extraperitoneal transvesical robot-assisted radical prostatectomy: a two-center study. Transl Androl Urol 2023;12:989-1001. [Crossref] [PubMed]
25. Desai MM, Aron M, Berger A, et al. Transvesical robotic radical prostatectomy. BJU Int 2008;102:1666-9. [Crossref] [PubMed]
26. Kaouk JH, Ferguson EL, Beksac AT, et al. Single-port Robotic Transvesical Partial Prostatectomy for Localized Prostate Cancer: Initial Series and Description of Technique. Eur Urol 2022;82:551-8. [Crossref] [PubMed]
27. Young HH. VIII. Conservative Perineal Prostatectomy: The Results of Two Years' Experience and Report of Seventy-Five Cases. Ann Surg 1905;41:549-57. [PubMed]
28. Lenfant L, Garisto J, Sawczyn G, et al. Robot-assisted Radical Prostatectomy Using Single-port Perineal Approach: Technique and Single-surgeon Matched-paired Comparative Outcomes. Eur Urol 2021;79:384-92. [Crossref] [PubMed]
29. Kaouk JH, Akca O, Zargar H, et al. Descriptive Technique and Initial Results for Robotic Radical Perineal Prostatectomy. Urology 2016;94:129-38. [Crossref] [PubMed]
30. Kaouk JH, Bertolo R. Single-site robotic platform in clinical practice: first cases in the USA. Minerva Urol Nefrol 2019;71:294-8. [Crossref] [PubMed]
31. Kaouk J, Valero R, Sawczyn G, et al. Extraperitoneal single-port robot-assisted radical prostatectomy: initial experience and description of technique. BJU Int 2020;125:182-9. [Crossref] [PubMed]
32. Abou Zeinab M, Beksac AT, Ferguson E, et al. Single-port Extraperitoneal and Transperitoneal Radical Prostatectomy: A Multi-Institutional Propensity-Score Matched Study. Urology 2023;171:140-5. [Crossref] [PubMed]
33. Di Pierro GB, Grande P, Mordasini L, et al. Robot-assisted radical prostatectomy in the setting of previous abdominal surgery: Perioperative results, oncological and functional outcomes, and complications in a single surgeon's series. Int J Surg 2016;36:170-6. [Crossref] [PubMed]
34. Dal Moro F, Zattoni F. P.L.E.A.T.-Preventing Lymphocele Ensuring Absorption Transperitoneally: A Robotic Technique. Urology 2017;110:244-7. [Crossref] [PubMed]
35. Bertolo R, Garisto J, Gettman M, et al. Novel System for Robotic Single-port Surgery: Feasibility and State of the Art in Urology. Eur Urol Focus 2018;4:669-73. [Crossref] [PubMed]
36. Bertolo R, Garisto J, Bove P, et al. Perioperative Outcomes Between Single-Port and "Multi-Port" Robotic Assisted Radical Prostatectomy: Where do we stand? Urology 2021;155:138-43. [Crossref] [PubMed]
37. Hinojosa-Gonzalez DE, Roblesgil-Medrano A, Torres-Martinez M, et al. Single-port versus multiport robotic-assisted radical prostatectomy: A systematic review and meta-analysis on the da Vinci SP platform. Prostate 2022;82:405-14. [Crossref] [PubMed]
38. Li K, Yu X, Yang X, et al. Perioperative and Oncologic Outcomes of Single-Port vs Multiport Robot-Assisted Radical Prostatectomy: A Meta-Analysis. J Endourol 2022;36:83-98. [Crossref] [PubMed]
39. Kaouk JH, Haber GP, Autorino R, et al. A novel robotic system for single-port urologic surgery: first clinical investigation. Eur Urol 2014;66:1033-43. [Crossref] [PubMed]
40. Vigneswaran HT, Schwarzman LS, Francavilla S, et al. A Comparison of Perioperative Outcomes Between Single-port and Multiport Robot-assisted Laparoscopic Prostatectomy. Eur Urol 2020;77:671-4. [Crossref] [PubMed]
41. Salomon L, Anastasiadis AG, Levrel O, et al. Location of positive surgical margins after retropubic, perineal, and laparoscopic radical prostatectomy for organ-confined prostate cancer. Urology 2003;61:386-90. [Crossref] [PubMed]
42. Benidir T, Ferguson EL, Lone Z, et al. Pathologic and Short-Term Oncologic Outcomes of Prostate Cancer Patients Following Transvesical Robot-Assisted Radical Prostatectomy. Urol Oncol 2024;42:370.e15-21. [Crossref] [PubMed]
43. Yoon JH, Kwon T, Kim SC, et al. Comparative study of extraperitoneal singe-port robot-assisted radical prostatectomy and transperitoneal multiport robot-assisted radical prostatectomy using propensity score matching. Transl Androl Urol 2024;13:1004-13. [Crossref] [PubMed]
44. Jiang Y, Liu Y, Qin S, et al. Perioperative, function, and positive surgical margin in extraperitoneal versus transperitoneal single port robot-assisted radical prostatectomy: a systematic review and meta-analysis. World J Surg Oncol 2023;21:383. [Crossref] [PubMed]
45. Schwen ZR, Kaouk J. Single Port Extraperitoneal Radical Prostatectomy. In: Ren S, Nathan S, Pavan N, et al. editors. Robot-Assisted Radical Prostatectomy: Advanced Surgical Techniques. Cham: Springer; 2022:301-8.
46. Uy M, Cassim R, Kim J, et al. Extraperitoneal versus transperitoneal approach for robot-assisted radical prostatectomy: a contemporary systematic review and meta-analysis. J Robot Surg 2022;16:257-64. [Crossref] [PubMed]
47. Ploussard G, Briganti A, de la Taille A, et al. Pelvic lymph node dissection during robot-assisted radical prostatectomy: efficacy, limitations, and complications-a systematic review of the literature. Eur Urol 2014;65:7-16. [Crossref] [PubMed]
48. Moschovas MC, Bhat S, Sandri M, et al. Comparing the Approach to Radical Prostatectomy Using the Multiport da Vinci Xi and da Vinci SP Robots: A Propensity Score Analysis of Perioperative Outcomes. Eur Urol 2021;79:393-404. [Crossref] [PubMed]
49. Kim JE, Kaldany A, Lichtbroun B, et al. Single-Port Robotic Radical Prostatectomy: Short-Term Outcomes and Learning Curve. J Endourol 2022;36:1285-9. [Crossref] [PubMed]
50. Pettenuzzo G, Ditonno F, Cannoletta D, et al. Pelvic Lymph Node Dissection: A Comparison Among Extraperitoneal Single-port and Transperitoneal Multiport Radical Prostatectomy-A Single-center Experience. Eur Urol Open Sci 2024;67:69-76. [Crossref] [PubMed]
51. Anthony NCF, Peter CKF. Patients with Previous BPH Surgery. In: Ren S, Nathan S, Pavan N, et al. editors. Robot-Assisted Radical Prostatectomy: Advanced Surgical Techniques. Cham: Springer; 2022:343-5.
52. Gupta NP, Singh P, Nayyar R. Outcomes of robot-assisted radical prostatectomy in men with previous transurethral resection of prostate. BJU Int 2011;108:1501-5. [Crossref] [PubMed]
53. Tugcu V, Atar A, Sahin S, et al. Robot-Assisted Radical Prostatectomy After Previous Prostate Surgery. JSLS 2015;19:e2015.00080.
54. Patel SR, Kaplon DM, Jarrard D. A technique for the management of a large median lobe in robot-assisted laparoscopic radical prostatectomy. J Endourol 2010;24:1899-901. [Crossref] [PubMed]
55. Patel VR, Thaly R, Shah K. Robotic radical prostatectomy: outcomes of 500 cases. BJU Int 2007;99:1109-12. [Crossref] [PubMed]
56. Smith JA Jr, Chan RC, Chang SS, et al. A comparison of the incidence and location of positive surgical margins in robotic assisted laparoscopic radical prostatectomy and open retropubic radical prostatectomy. J Urol 2007;178:2385-9; discussion 2389-90. [Crossref] [PubMed]
57. Ou YC, Yang CK, Chang KS, et al. Prevention and Management of Complications During Robotic-assisted Laparoscopic Radical Prostatectomy Following Comprehensive Planning: A Large Series Involving a Single Surgeon. Anticancer Res 2016;36:1991-8. [PubMed]
58. Zhang X, Ma X. Large Median Lobe: Robot-Assisted Radical Prostatectomy (RARP). In: Ren S, Nathan S, Pavan N, et al. editors. Robot-Assisted Radical Prostatectomy: Advanced Surgical Techniques. Cham: Springer; 2022:325-7.
59. Rehman J, Chughtai B, Guru K, et al. Management of an enlarged median lobe with ureteral orifices at the margin of bladder neck during robotic-assisted laparoscopic prostatectomy. Can J Urol 2009;16:4490-4. [PubMed]
60. Sarle R, Tewari A, Hemal AK, et al. Robotic-assisted anatomic radical prostatectomy: technical difficulties due to a large median lobe. Urol Int 2005;74:92-4. [Crossref] [PubMed]
61. Ahdoot M, Lebastchi AH, Turkbey B, et al. Contemporary treatments in prostate cancer focal therapy. Curr Opin Oncol 2019;31:200-6. [Crossref] [PubMed]
62. Herrera-Caceres JO, Nason GJ, Salgado-Sanmamed N, et al. Salvage radical prostatectomy following focal therapy: functional and oncological outcomes. BJU Int 2020;125:525-30. [Crossref] [PubMed]
63. Bhat KRS, Covas Moschovas M, Sandri M, et al. Outcomes of Salvage Robot-assisted Radical Prostatectomy After Focal Ablation for Prostate Cancer in Comparison to Primary Robot-assisted Radical Prostatectomy: A Matched Analysis. Eur Urol Focus 2022;8:1192-7. [Crossref] [PubMed]
64. Barret E, Harvey-Bryan KA, Sanchez-Salas R, et al. How to diagnose and treat focal therapy failure and recurrence? Curr Opin Urol 2014;24:241-6. [Crossref] [PubMed]
65. Thompson JE, Sridhar AN, Shaw G, et al. Peri-operative, functional and early oncologic outcomes of salvage robotic-assisted radical prostatectomy after high-intensity focused ultrasound partial ablation. BMC Urol 2020;20:81. [Crossref] [PubMed]