Hood Technique for Single Port Robot-Assisted Radical Prostatectomy

Abstract

Introduction: The gold standard for surgical management of localized prostate cancer is robot-assisted radical prostatectomy (RARP) in the United States.1 Different techniques and modifications were implemented in the last two decades to enhance the functional outcomes while not compromising the oncological outcomes.2,3 Recently, the Hood technique which emphasizes the preservation of periurethral anatomical structures in Space of Retzius including endopelvic fascia, puboprostatic ligaments, anterior vessels, detrusor apron as well as some detrusor muscle was described using the multiport robotic platform. Since the approval of the da Vinci Single-Port (SP) platform (Intuitive Surgical, Sunnyvale, CA), multiple benefits were reported such as shorter length of stay with higher rates of discharge on the day of surgery, decrease in operation time, postoperative opioid use, and patient-reported pain scores.4 However, the learning curve of the RARP with SP platform remains substantial.5 Herein, we describe our modified hood technique for SP-RARP, which aims to develop a reproducible procedure with a short learning curve, without compromising oncological outcomes, as well as offering durable improved functional outcomes. Methods: All data were prospectively collected into an IRB-approved registry database. A total of 10 consecutive patients with localized prostate cancer underwent transperitoneal SP-RARP by a single high-volume surgeon (D.I.L.). There were no exclusion criteria defined preoperatively. The postoperative status of sexual function was defined by the percentage of erection fullness as the patient-reported ability to have a full and hard erection, and several patient and tumor characteristics as well as perioperative and postoperative outcomes were abstracted. Continence recovery was defined as the patient reported no pads or only one security pad used. Results: The median age was 62.5 (53.5–72.75) and median BMI was 26.25 (24.68–27.58) kg/m2. The median operative time of 10 SP RARP cases was 144.5 (134.3–177.5) minutes and the median console time (n = 7) was 93 (93–110) minutes. The mean estimated blood loss was 50 (50–100) mL. There were no patients with positive surgical margins. No blood transfusions and conversions to open surgery were needed and no perioperative complications occurred. One patient who developed a urinary tract infection was managed with oral antibiotics and one patient needed replacement of the Foley catheter as he went into urinary retention after the first catheter removal on 7-day postop. All patients were discharged home on the same day. There was no readmission during the postoperative 30-days. Early continence rates at 3-months of nine patients reporting their continence status were favorable as 88.9% of patients (n = 8/9) reported using no pads or only one security pad. The median American Urological Association Symptom score of the six patients at 3-months was 5 (4–8.25). The median percentage of the fullness of erection of seven patients at 3-months was 60% (50%–70%). Conclusions: This report demonstrates the Hood technique for SP RARP that is reproducible with a short learning curve, and favorable perioperative, and intermediate functional outcomes which could be safely introduced into a program experienced in multiport RARP. No competing financial interests exist. Patient Consent Statement: Author(s) have received and archived patient consent for video recording/publication in advance of video recording of procedure. Runtime of video: 6 mins 52 secs