Robotic-assisted radical prostatectomy (RARP) has become a standard minimally invasive surgical treatment for localized prostate cancer, offering improved perioperative outcomes compared to traditional open approaches [1]. With ongoing technological advancements, the transition from multiport robotic systems, such as the da Vinci Xi, to newer single-port (SP) robotic platforms has become an area of significant clinical interest.

The da Vinci SP system, approved by the FDA in 2018, utilizes a single multichannel port with articulating instruments, providing superior intracorporeal maneuverability and enhanced visualization within confined anatomical spaces. However, the transition from multiport transperitoneal RARP (MP-TP RARP) to single-port extraperitoneal RARP (SP-EP RARP) involves a learning curve due to the unique instrument configuration and spatial dynamics of the SP system. Studies suggest that the learning curve for SP-EP RARP is similar to MP-TP RARP and the learning process can be undertaken without compromising safety and oncological outcomes [2].

Recent studies highlight the feasibility and safety of SP-EP RARP, demonstrating favorable perioperative outcomes, including reduced intraoperative blood loss (SP 125.1 vs. MP 215.0 mL), reduced opioid use (SP 14.4% vs. MP 85.1%), shorter hospitalization durations (SP 12.6 vs. MP 31.9 hours), and earlier catheter removal (SP 6 vs. MP 8 days) compared to the MP-TP RARP while maintaining comparable oncological and functional outcomes [3]. Moreover, the integration of minimal apical dissection techniques during SP-EP RARP seeks to preserve critical anatomical structures such as the dorsal venous complex, puboprostatic ligaments, and external urethral sphincter. This approach aims to minimize trauma and promote faster recovery of urinary continence and improved overall functional outcomes [4].

However, transitioning from Xi to SP technology entails specific technical adaptations, and surgeons face a notable learning curve in mastering the nuances of instrument articulation and optimal port placement. Despite encouraging initial clinical experiences, evidence regarding long-term oncological and functional outcomes remains limited.

In this article, we describe our initial experience and technical details transitioning from the conventional transperitoneal RARP with the Xi system to the SP platform for extraperitoneal SP RARP. We provide a step-by-step video (Supplementary Video 1) adhering to the technical aspects of bilateral nerve sparing and minimal apical dissection for early incontinence recovery and preservation of sexual function. We seek to contribute valuable insights into the potential benefits and limitations of adopting this novel surgical approach.

Figure 1. Supplementary Video 1. Following early retrograde neurovascular bundle release and complete prostate resection, amniotic membrane is applied to the prostatic bed to facilitate maximal neurovascular regeneration and optimize functional recovery.

The video shows a 62-year-old man who underwent a SP-EP RARP. The patient is an avid recreational rock climber, presenting for routine medical evaluation during which his serum prostate-specific antigen (PSA) level was found to be elevated at 8.04 ng/mL. His past medical histo ry is significant for two prior falls during climbing activi ties, each requiring helicopter evacuation. One of the inci dents resulted in traumatic brain injury with intracranial hemorrhage, necessitating craniotomy and exploratory laparotomy. He also has a history of peritonitis secondary to a perforated appendix, managed surgically.

Following the abnormal PSA finding, the patient under went multiparametric magnetic resonance imaging, which revealed a PIRADS 5 lesion in the left peripheral zone at the mid-gland level without evidence of extraprostatic ex tension. Subsequent transrectal ultrasound-guided prostate biopsy confirmed localized prostatic adenocarcinoma with a Gleason score of 7 (3 + 4). The clinical stage was deter mined to be cT2N0. In light of the patient’s oncologic pro file and surgical history suggesting a hostile intra-abdomi nal environment, he elects to undergo robot-assisted radical prostatectomy.

The patient is positioned in the supine position, and later a Trendelenburg position for robot docking. We make a 3 cm infraumbilical midline incision to access posterior to the rectus fascia, with blunt finger dissection allowing en try of the balloon dissector (Spacemaker™ balloon dissector [PDB Balloon Kidney, Covidien, Dublin, Ireland]). The da Vinci^® SP Access Kit is used for a floating dock technique. For the insufflation system, the valveless AirSeal^® (ConMed, Utica, NY, USA) is used. Additionally, one 12 mm assistant port is placed 8–10 cm laterally for suction and H-lock.

The operation commences with the camera positioned at the 12 o’clock position and the Cadiere forceps placed at 6 o’clock to aid in the development of the space of Retzius and dissection of the anterior bladder wall. From this point, the procedure is carried out similarly to the conven tional MP-TP RARP or SP-TP RARP [5]. Once adequate space is established, the Cadiere forceps are swapped to the 9 o’clock arm (bipolar) to elevate the Foley catheter and later the prostate.

Dissection of the vas deferens and seminal vesicles is performed as athermally as possible to minimize nerve damage when nerve-sparing is authorized. After incision of the Denonvilliers’ fascia to access the intrafascial or in terfascial layer of the prostate, the camera and arms are re positioned so that the camera is positioned at 6 o’clock and the Cadiere forceps at 12 o’clock for toggling (camera 30-degree up view). At this point, the camera can be tog gled to an “upside-down” or “bottom-up” position accord ing to surgeon preference. The interfascial plane is further extended distally and laterally for the retrograde early re lease of the neurovascular bundle (NVB).

When the posterior dissection is finished, the camera and Cadiere forceps are swapped to position the camera at 12 o’clock for a 30-degree down view. The endopelvic fas cia is opened close to the prostate. For maximal NVB spar ing, we dissect at the level right beneath the periprostatic vein. Injuries to the vein and resultant bleeding mostly stop without any intervention when the lateral borders of the prostate are totally dissected, and traction of the vein distally and laterally helps minimize bleeding when there is injury to the vein. Hem-o-lok clips are used to control the prostatic pedicles. The apex of the prostate is bluntly dissected to identify the rhabdosphincter lying anterior of the prostate, aiming to maximize the remaining urethral length and periurethral tissues.

The prostate is further mobilized and removed. Vesico urethral anastomosis is performed using a running barbed suture. A drain is placed in the extraperitoneal space, and the incision is closed in layers.

The pathological results were adenocarcinoma, Gleason’s score 7(4 + 3) with extraprostatic extension and invasion into the Lt. seminal vesicles, pT3bNx. Resection margins were clear. After foley catheter removal on post operative day 7, the patient was immediately continent with only mild symptoms of urgency.

The extraperitoneal approach to RARP offers notable advantages, particularly regarding surgical technique and postoperative recovery [3,6,7]. One significant benefit is that extraperitoneal RARP closely mirrors the convention al transperitoneal RARP in surgical steps and instrument maneuvers, resulting in similar learning curves [2]. Sur geons accustomed to the transperitoneal approach can thus transition smoothly without extensive additional training.

A critical adjunct in extraperitoneal RARP is the Air Seal^® valveless insufflation system. Unlike traditional in sufflation methods, AirSeal^® effectively maintains constant pneumopreperitoneum, which is particularly advantageous in the extraperitoneal setting where workspace is limited. Assistant-driven suction can otherwise rapidly collapse this confined space, obscuring vision and complicating dissection. However, surgeons should exercise caution to avoid excessive insufflation pressures, as the limited extra peritoneal space is sensitive to even minimal external ma nipulation, potentially causing rapid spikes in intra-ab dominal pressure. Such pressure fluctuations carry a risk of complications, including air embolism, necessitating careful monitoring and controlled insufflation.

The use of the SP robotic platform further enhances the extraperitoneal RARP approach. A major advantage is that the prostate specimen can be conveniently removed through the initial 3-cm infraumbilical incision, eliminat ing the need for an additional extraction site. Additionally, since the peritoneum is not breached, there is no require ment for peritoneal closure, significantly shortening the overall closure time. Accessing the Retzius space also ap pears more straightforward and quicker in SP extraperito neal RARP compared to traditional methods, further streamlining the procedure and potentially reducing operative times.

The SP platform is particularly suitable for confined working spaces such as the extraperitoneal space, offering improved maneuverability and precision compared to the multiport da Vinci platform. Furthermore, the extraperito neal approach provides significant benefits in patients with hostile abdomens due to previous surgeries or adhesions, as demonstrated in our case. By avoiding entry into the peritoneal cavity, extraperitoneal RARP minimizes the risk associated with adhesiolysis and potential intra-abdominal complications.

Overall, extraperitoneal RARP using the SP platform provides a technically feasible and efficient approach, with distinct advantages that may translate into improved perioperative outcomes and faster patient recovery.

The author has no conflicts of interest to declare.

No external funding was received for this research.

None.

Conceptualization: JHT. Data curation: JHT. Formal analysis: JHT. Investigation: JHT. Methodology: JHT. Project administration: JHT. Resources: JHT. Software: JHT. Supervision: JHT. Validation: JHT. Visualization: JHT. Writing – original draft: JHT. Writing – review & editing: JHT.

Video 1. Following early retrograde neurovascular bundle release and complete prostate resection, amniotic membrane is applied to the prostatic bed to facilitate maximal neurovascular regeneration and optimize functional recovery.