Abstract
Radical prostatectomy as a procedure has gone through different phases during its history. 1 Surgical technique has gone through a great evolution moving from open to laparoscopy to robotics. Something curious happened though when it comes to the anatomic approach. In the days of open prostatectomy, the “founding fathers” of urology were performing the procedure through the extraperitoneal (EP) approach for a good reason: the prostate is an EP organ. More than evidence, it was common sense-based medicine. Eventually, laparoscopy emerged and all of the sudden urologists faced a problem: the need for space. Learning the laparoscopic technique was difficult enough, 2 but doing it in a nutshell was almost impossible. Therefore, the vast majority of urologists starting laparoscopy moved from an open EP to a laparoscopic intraperitoneal (IP) approach.
It was a conscious trading of unquestionable and established benefits for a new less invasive technique. Patient positioning changed from flat supine to steep Trendelenburg, increasing the systemic side effects of a long procedure. 3 The peritoneal cavity was violated on purpose, making bowel function return a new postoperative problem that was almost nonexistent before. Any other postoperative complications such as urinary leakage or bleeding became a major problem because of the switch of a contained small space with a big open cavity. 4 Another, new, relative contraindication was raised: previous extensive intra-abdominal surgery. Urologists had to start dealing with the general surgeon's curse: adhesions and bowel-related postoperative complications. 5 In addition, the chances of postoperative abdominal hernia were naturally increasing. 6
On the bright side, the IP approach enabled (in theory) urologists to perform more extended pelvic lymphadenectomies (the curative value of which is still to be established to these days) and lymphoceles (again in theory) should not have been a problem anymore because of the peritoneal reabsorption. Unfortunately, the community eventually learned that pelvic lymphadenectomy with rigid nonarticulate instrument was extremely difficult and that in real life, lymphoceles were still happenings despite the IP approach. 7 But, we were being less invasive.
The advent of robotic surgery pushed the IP approach even more. The need of triangulation on the target with three and eventually four robotic arms made the need for space an even bigger factor to avoid conflicts outside or inside the abdomen. The EP approach, despite its peculiar benefits, seemed doomed forever. Some heroic urologists tried to keep it alive. 8 The multiport robotic EP approach was shown to be feasible but with major limitations, including limited space available for robotic arms movements, which inevitably led to clashing inside and outside the patient and a steep learning curve. Another criticism was the pelvic lymphadenectomy: due to the limited lateral movement of the arms, performing a proper dissection of iliac and obturator lymph nodes for a standard template could be challenging. In addition, the need of developing the EP space to accommodate the lateral robotic trocars can often cause small peritoneal breaches, which as a consequence can impair the efficiency of the procedure.
The single-port (SP) platform, the most recent evolution of robotic prostatectomy, has helped overcome the limitations of the EP approach, making it more feasible and potentially more popular. Being able to deliver a flexible camera and three articulated instruments through a central infraumbilical 3 cm incision virtually eliminates the clashing and the limitations associated with the multiport platform. The lateral dissection of the peritoneum at the beginning of the procedure is not required anymore and as a consequence peritoneal breaches are extremely rare. A specific feature of the SP called “relocation” allows the entire platform to be moved in any direction around its fulcrum, making the pelvic lymph node dissection efficient and allowing the operator to reach proximally and medially as needed for an extended template. Moreover, the SP platform facilitates the established benefits of an EP approach, such as no need for Trendelenburg positioning, faster bowel function return, contained space to help managing possible postoperative complications, and decreased invasiveness for potentially shorter length of stay and better pain control. 9
Looking back at this long journey of radical prostatectomy, it becomes clear that when it comes to anatomic approaches, we are using technology to travel back to the future. Giving up the EP space was instrumental to introduce new technology (such as laparoscopy and multiport robotics) that required space to function. We can now close the circle and go back to a more natural approach, thanks to newer technology (such as SP robotics) that allows us to work efficiently in a smaller working space.