(UroToday.com) In this plenary session, Dr. Jeffrey Cadeddu, Dr. Jihad Kaouk, and Dr. Li-Ming Su elaborated on the specific advantages and disadvantages of the multiport (MP) and single port (SP) robotic platforms in performing prostatectomies in hopes of delineating one’s superiority over the other. Of note, Dr. Cadeddu and Dr. Kaouk, who were both arguing counterpoints, have experience with both robotic platforms.
To better understand the current state of robotic technology, Dr. Su emphasizes the importance of revisiting the history of surgical advancements in the field of prostatectomies, with the first radical perineal prostatectomy performed by Dr. Hugh Young in 1908 at John Hopkins Medical Center. In 2001, Dr. Clement-Claude Abbou borrowed a MP Da Vinci robot from cardiac surgery and performed the first-ever robot-assisted prostatectomy. With the advent of the SP platform in 2014, Dr. Kaouk has since spearheaded its clinical development at Cleveland Clinic Medical Center pushing the idea of minimally invasive surgery to new limits through “key-hole” surgery.
In the past era in which open radical prostatectomy (ORP) was the gold standard treatment for prostate cancer, outcomes were traditionally measured in terms of cancer control, continence, and preservation of sexual function. Understandably, with the evolution of technology, outcomes by which we measure surgical success have also evolved to include perioperative morbidity in the context of overall costs associated with each surgery. Dr. Su also highlights the need for these outcomes to be easily replicated across all robotic users, MP or SP.
To begin his argument in favor of the MP system, Dr. Caddedu begins with stating the reasons MP robot assisted prostatectomies are the gold standard regimen for prostate cancer when compared to ORP:
- Less blood loss
- Less postoperative pain
- Shorter hospital stays
- Similar oncologic outcomes
- Similar or superior functional outcomes (i.e., sexual function, continence)
These benefits in combination with the fact that SP robot assisted proctectomy is more costly than its MP counterpart and has a steep learning curve begs the question, “why should we adopt such a technology? What oncologic and/or functional value does it bring?”. In a study by Thompson et al (2014), it was shown that sexual function and incontinence outcomes post-SP RARP surpassed those of ORP at 99 and 182 RARPs, respectively, underlining the intimidating learning curve associated with newer systems.1 Dr. Caddedu further raised the point that MP RARP, similar to SP surgery, can result in opioid free pain management. In a recent ERAS randomized control study evaluating ketorolac, acetaminophen, and ibuprofen, only ~7% of patients required post-operative opioids with more than 65% of patients reporting < 3 pain on a Likert scale.2 Moreover, MP RARP has also been successfully performed in an outpatient setting with one multi-institutional study of 358 patients demonstrating a 96% same-day discharge rate with a 3 % re-admission rate. Amongst these patients, there were no major complications and no needed transfusions.3
To end his talk, Dr. Caddedu concludes with the idea that the MP robotic platform is a one-stop shop for minimally invasive RARP with fewer costs than its SP counterpart. He poses the question “Do we need a new robot or do we need better technique to improve patient outcomes” with examples of novel MP techniques that have already proven to be advantageous, including the following:
- Rocco Stitch
- Anterior Suspension
- Posterior Urethral Suspension
- Bladder Neck Sparing
- Membranous Urethral Length Sparing
- Retzius Sparing (Earlier continence recovery using Retzius sparing RARP compared to conventional RARP)1
To begin his counterpoint, Dr. Kaouk highlights that the question is not whether the SP platform surpasses the MP platform or whether one incision is better than multiple, but rather how we can utilize a “low-profile robot with the ability to regionalize surgical dissection and overall surgery” in select patient populations to improve patient outcomes, more specifically patients with “hostile abdomens” (i.e., multiple abdominal surgeries – bowel resections, laparotomies, kidney transplant). It is also of note, the SP robot’s ability to operate in a variety of approaches such as transperitoneally, extraperitoneally, transvesically, retzius, and perineally. 
As stated by Dr. Kaouk, some of these approaches can be finely tuned to optimize certain outcomes. In a recent study by Xu et al (2021), SP transvesical RARP resulted in more continent patients and at a significantly quicker rate than MP surgery via the Retzius sparing and transperitoneal approach.5 Indeed, the SP RARP is also superior to MP surgery in regard to post-operative hospital stay with a higher likelihood of patients being discharged earlier than MP RARP (4 hours vs. 26 hours, respectively) and decreased need for post-operative opioid-based pain management (5.7 mg vs. 16.7 mg, respectively).6 
Lastly, Dr. Kauok counters the argument that SP RARP results in more costly surgery than MP by reminding the audience that this is not the case when accounting for indirect and direct costs such as:
- Disposables
- Instruments
- OR fees
- Pathology
- Pharmacy
- Professional Fees
- Anesthesia
- Preoperative and Postoperative Hospital Stay
Indeed, SP surgery is on par with MP surgery costing $13,512 vs. MP $13, 284 (p = 0.32).7
To summarize, the SP platform offers the following benefits to RARP:
Concluding Remarks:
With the multiport system providing similar oncological and functional outcomes to its SP counterpart, the question still remains whether it is a necessary technology to push the field of minimally invasive surgery for prostate cancer forward rather than focusing on expanding on current surgical techniques. Despite a steep learning curve and uncertainty regarding the financial burden involved with SP RARP, its development is still in the nascent stages and therefore, further studies will be needed to make conclusive statements.
Presented By:
Dr. Li Ming Su, Department of Urology - University of Florida, Gainesville, FL
Dr. Jihad Kaouk, Department of Urology - Cleveland Clinic, Cleveland, OH
Dr. Jeffrey Cadeddu, Department of Urology - UT Southwestern, Dallas, TX
Written By: Rohit Bhatt, Leadership and Innovation Research Fellow, Department of Urology, University of California Irvine, @RohitBhatt_ on Twitter during the 2022 American Urological Association (AUA) Annual Meeting, May 13 - 16, 2022, New Orleans, Louisiana
References
1. Thompson JE, Egger S, Böhm M, Haynes AM, Matthews J, Rasiah K, Stricker PD. Superior quality of life and improved surgical margins are achievable with robotic radical prostatectomy after a long learning curve: a prospective single-surgeon study of 1552 consecutive cases. Eur Urol. 2014 Mar;65(3):521-31. doi: 10.1016/j.eururo.2013.10.030. Epub 2013 Oct 31. PMID: 24287319.
2. Ashrafi AN, Yip W, Graham JN, Yu V, Titus M, Widjaja W, Dickerson S, Berger AK, Desai MM, Gill IS, Aron M, Kim MP. Implementation of a multimodal opioid-sparing enhanced recovery pathway for robotic-assisted radical prostatectomy. J Robot Surg. 2021 Aug 24. doi: 10.1007/s11701-021-01268-7. Epub ahead of print. PMID: 34431025.
3. Ploussard G, Dumonceau O, Thomas L, Benamran D, Parra J, Vaessen C, Skowron O, Rouprêt M, Leclers F. Multi-Institutional Assessment of Routine Same Day Discharge Surgery for Robot-Assisted Radical Prostatectomy. J Urol. 2020 Nov;204(5):956-961. doi: 10.1097/JU.0000000000001129. Epub 2020 May 7. PMID: 32379565.
4. Rosenberg JE, Jung JH, Edgerton Z, Lee H, Lee S, Bakker CJ, Dahm P. Retzius-sparing versus standard robotic-assisted laparoscopic prostatectomy for the treatment of clinically localized prostate cancer. Cochrane Database Syst Rev. 2020 Aug 18;8(8):CD013641. doi: 10.1002/14651858.CD013641.pub2. PMID: 32813279; PMCID: PMC7437391.
5. Xu JN, Xu ZY, Yin HM. Comparison of Retzius-Sparing Robot-Assisted Radical Prostatectomy vs. Conventional Robot-Assisted Radical Prostatectomy: An Up-to-Date Meta-Analysis. Front Surg. 2021;8:738421. Published 2021 Sep 30. doi:10.3389/fsurg.2021.738421.
6. Kaouk et al. Manuscript in Preparation. 2022
7. Lenfant L, Sawczyn G, Kim S, Aminsharifi A, Kaouk J. Single-institution Cost Comparison: Single-port Versus Multiport Robotic Prostatectomy. Eur Urol Focus. 2021 May;7(3):532-536. doi: 10.1016/j.euf.2020.06.010. Epub 2020 Jul 4. PMID: 32631777.