The studies explored the use of opioids following surgery as well as the risk of incisional hernia.
In this interview, Jihad H. Kaouk, MD, and Nicolas A. Soputro, MD, highlight findings from 2 studies that assessed outcomes with single-port robotic radical prostatectomy.1,2 Kaouk is the director of robotic surgery at the Glickman Urological Institute at Cleveland Clinic, and Soputro is a research fellow at the Cleveland Clinic in Cleveland, Ohio.
Kaouk: We know that robotics has reshaped a lot of the surgeries we do for more than 20 years now. The multi-port robot requires a cut for the camera and 3 cuts for the robot arms, and then at least 1 extra cut for the assistant. Since 2008, a new generation of robot has been in the making, and in 2018, we received the first unit in the United States. The single-port robot is a cannula that is about 2.5 cm in diameter. Through that cannula that requires 1 cut, you can introduce all your instruments; that includes the camera and 3 robot arms. To increase their reach and range of motion, they are double wristed, not just 1 wrist like we know with multiport robotics.
The advantage we took from this new generation robot is to regionalize surgery. It's not at all about multi-port, single-port, 1 cut, multiple cuts; it's not about that. It's about a new tool that is low profile, [and] we want to take advantage of its low profile to go to narrow areas where we can regionalize the surgery to where the disease is. That, in theory, should reflect on less morbidity because we are causing less collateral damage inside the patient.
That's why we elected to apply it to radical prostatectomy, as is the topic of the 2 papers from today. That is to get the 1 cut, introduce the robot, and do the surgery either through the bladder—where the base of the prostate can be immediately visualized—or extraperitoneal. Both ways allow you to stay outside the peritoneal sac. Why is that important? Because then you don't see the bowel, you don't touch the bowel; you're just outside that sac. Particularly for patients who have so much scar tissue from previous surgeries, you don't have to deal with the scar tissue. You're outside that bowel area with scar tissue from previous surgery, so that means less risk of injuries and morbidities and [adverse] effects.
Kaouk: So, this first paper talks about robotic radical prostatectomy toward less or no opioids after surgery. Mind you, these are patients who don't require opioids when they go home. That means we discharged them early. Most of these patients require a hospital stay for a few hours only, not days; usually 4 or 5 hours in the hospital after surgery. Then they go home, they take Ibuprofen or some of the non-steroidal anti-inflammatory medicine and Tylenol [or] Paracetamol–you mix and match. By the next day, the vast majority of the patients don't require anything else.
This has been very exciting because that means our patients can get bowel function quickly [and] they can eat quickly, rather than have the risk of having ileus, meaning slow bowel, after surgery. It can happen 1.) because we handle the bowel when we go transperitoneal, and 2.) because when you give opioids that slow down the bowel [and] cause constipation, that can slow the patient recovery. So, we're excited about this paper that was recently published. And Dr. Soputra has put a huge effort in getting the data together and getting this paper to the finish line.
Soputra: In this paper, we have 420 patients in multi-port transperitoneal radical prostatectomy, 255 patients in the single-port extraperitoneal, and 190 patients in the single-port transfer cycle. The value in this paper is that in the transfer cycle cohort, we can see that 95% of patients were discharged within 24 hours. In terms of opioid consumptions, more than 30% of [those] patients required no opioids with an inpatient stay. This is remarkably higher compared with the 2.1% in the multi-port cohort. Even though patients were discharged a lot quicker in the single-port cohort, a lot of the patients were discharged without any opioid analgesia in the single-port cohort. So, nearly 94% of patients in the single-port transfer cycle cohort required no opioids as compared with 12.1% in the transperitoneal multi-port cohort. Regardless of whether you use opioids as an inpatient or you're discharged home without any opioids, the pain scores at the discharge remained the same.
Kaouk: We were really excited with these outcomes. We are not claiming that you can only eliminate opioid use if you go single-port compared with multi-port. Actually, you can send patients without opioids, and a lot of patients, after you do the multi-port. However, if you use the single port, you will notice that you can do this consistently and frequently without much effort [and] without patient suffering, because you're having 1 cut vs 5 cuts, you're staying extraperitoneal [and] your entire surgical field is as big as a tennis ball around the patient. That's minimum. That allows us to decrease the collateral damage, so it makes sense. Can you still get occasional patients with the multi-port without the opioid necessitation? Yes, you can. But here, we're saying that this route allows to serve more patients without the pain control opioids.
The other thing is the time of hospitalization. A lot of the previous reports that talk about multi-port surgery [and] discharging patients without opioid need, they kept the patient a day or 2 or more in the hospital, while our patients are being discharged within few hours. So, the definition of when they go home without the need for the opioid also varies in the literature. Of course, in 2 days, [or] 48 hours after the procedure, it's routine that the patient will not require opioids, regardless of which approach you do.
Kaouk: We have not only regionalized surgery; we have also regionalized the anesthesia. Typically, general anesthesia [is done] with an endotracheal tube. But because we regionalized the surgery to just within the borders of the bladder, that means we did not need to insulate the abdomen. When you keep the abdomen pressure physiologic, you don't push on the diaphragm. That means you may not want to give the patient a muscle relaxant and attach them to a ventilator. So, we did some cases with epidural anesthesia and the patient awake, and we regionalized the anesthesia to where the disease is. These patients did great and had a very quick recovery.
Sure, this is very selected. It depends if the patient likes it or not, and patients are polarized about it, but it's an option. It becomes a necessity in some diseases like myasthenia gravis; patients who get muscle relaxant can be dangerous in that condition. These patients may be well-served without the general anesthesia altogether. So, this is one project we're working on evaluating and see how we're serving our patients. There's a lot to learn about this narcotic. Minimization—is it because it's a placebo [because] we tell our patients? Is it because of the 1 cut vs multiple? Is it because we are becoming more gentle and minimalist inside the patient when operating? I think it's all the above, but we are evaluating what factor has more weight to give us better results than the others.
Soputro: I think one of the questions that might arise is even though patients following single port transfer cycle and single port extraperitoneal go home earlier, there are no difference following the single port extraperitoneal and transfer cycle within 90 days of the surgery.
Kaouk: So, that probably tells us that avoiding the peritoneum is key. Getting outside the peritoneum and not really handling the bowel is important. For the past 20-plus years doing robotic prostatectomy, we are trained to do it mostly one way, and that's put all the boards in a fan shape, go intra-abdominal, put the patient in a steep angle head down to get the gravity to pull the bowel out of the pelvis so that we can see the prostate area, and then start working. We don't need that if we go extraperitoneal, because the gas bubble pushes the peritoneum and the bowel on the other side away from your field. So, you don't need the gravity; you keep the patient comfortably flat on the operating table. It is increments of small advantages that add up to give an excellent outcome. It's not one thing that you do that's a major step. There are all very tiny steps that one at a time may not be significant, but all together add up to make a significant difference in patient recovery.
Kaouk: So, the second paper we're discussing today is about the risk of incisional hernias after a radical prostatectomy. Incisional hernia means a hernia at the site of surgery. These are triggered by an incision that you needed to do at the time of surgery, and for some reason, it did not heal well, and the bowel bulges out of it and may require another surgery to fix it. This is a main risk when you go transabdominal, because your cut will go from the skin to the fascia and then the peritoneum all the way to where the bowel is sitting. That increases the risk of the hernia. What we found is that in the single-port approach, when you avoid the peritoneal cavity and go transvesical or extraperitoneal, at least, you are not violating the main sac that holds all the bowel together. So, the risk of hernia is significantly less. Actually, in our study, it did not exist. None of the patients had hernias. The only 2 patients that had hernias are patients [in whom] we went transperitoneally.
Because of that finding, we took the advantage of not violating that abdominal wall around the patient bowel to tell the patients that you don't need to wait 6 to 8 weeks without heavy weight lifting. That's why we tell the patients don't do any heavy lifting for 6 to 8 weeks; otherwise, some sutures might cut at the incision area and you might get a hernia. You don't need that anymore, because the risk is negligible. What we tell the patients nowadays in 2 to 3 weeks, you don't have any more limitations. That helped us also get the patients back to work or to their activities [and] move on with their life quicker after surgery, and by that improve their quality of life at the immediate time after surgery. We were very excited about this finding that confirms that we don't need to wait too long with limitations on heavy weight and activities after a single-port extraperitoneal radical prostatectomy.
Soputro: The findings from this paper are very important because it is the first paper that describes a large multi-institute cohort from different surgeons that practice different approaches of single-port robotic radical prostatectomy. One of the most important things that we found is that even though some of the risk factors of incisional hernia following radical prostatectomy is patients with high BMI and previous history of hernia repair, these 2 factors in this paper are higher in the single-port transfer cycle cohort. So, even though people have higher risk of hernia in the single-port transfer cycle cohort, we did not find any incidence of incisional hernia at all based on our study.
Kaouk: And remember, a lot of our patients are heavy. The heavier the patient, the more their risk of incisional hernia. The patients have all kinds of presentations when they come to us. The fact that we did not have any incisional hernia from this approach is significant, because it gives us confidence that our patients can ease up the limitations immediately after surgery.
Kaouk: The field of single port is still new. The first cases clinically here were done in late 2018. So, data is still being accumulated. That's why we established a multi-institutional database, and we call it SPARC, Single Port Advanced Research Consortium. We invite everybody who's doing single port and have minimum follow-up of their patients after the surgery. We would like to keep accumulating the data, validating the results throughout institutes, not just our institute. So far, we have 11 centers involved in the SPARC group, and accumulatively, we have almost 2000 patients. So, we're getting there with bigger amount of data that will give us more clarity and confirm the outcomes and the findings we had in these 2 papers.
Kaouk: I would like to acknowledge our fellows who really did all the work to make these studies possible. Dr. Nicolas Soputra led the work on this paper, and the rest of the team helped him. Roxana Ramos-Carpinteyro, Ethan Ferguson, Jaya Chavali, and Albert Geskin all helped to get this paper. I'm thankful for their effort to get these papers here. Thank you, Urology Times for giving us the opportunity to highlight our work that we're very excited [about], especially because it helps our patients get the quicker recovery.
1. Soputro NA, Ferguson EL, Ramos-Capinteyro R, Chavali JS, Kaouk JH. The transition towards opioid-sparing outpatient radical prostatectomy: A single institution experience with three contemporary robotic approaches. Urology. Published online July 14, 2023. Accessed August 9, 2023. doi:10.1016/j.urology.2023.07.001
2. Soputro NA, Ferguson EL, Ramos-Capinteyro R, et al. Low risk of post-operative hernia following single-port robot-assisted radical prostatectomy: A report from the Single-Port Advanced Research Consortium (SPARC). Urology. Published online July 14, 2023. Accessed August 9, 2023. doi:10.1016/j.urology.2023.07.002