We aim to describe an innovative technique, its challenges, and the oncological outcomes of multi-port trans-vesical robotic radical prostatectomy in patients with localized prostate carcinoma using the da Vinci Xi surgical system.

To date, we have performed this innovative technique on eight patients (n = 8). Four underwent the trans-vesical transabdominal approach, while four underwent the transvesicoscopic approach. The prostate volumes of these patients were 76cc, 70cc, 20.5cc, 22cc, 30cc, 34cc, 56cc, and 50cc, respectively.

In the conventional trans-vesical technique, the prostate was accessed transabdominally after bivalving the urinary bladder. In the transvesicoscopic technique, a pneumovesicum was created using a 12mm intravesical port, placed under direct vision with cystoscopic guidance. Subsequently, three 12mm robotic ports were inserted. The surgical steps were nearly identical in both methods and included, Posterior bladder neck dissection, Vas deferens and seminal vesicle dissection, Posterior dissection, Anterior bladder neck and prostate dissection, Pedicle and neurovascular bundle dissection, Posterior reconstruction and urethrovesical anastomosis. The specimen was retrieved in an endo-bag through a separate skin incision.

The mean age of the patients was 63 years, with a mean preoperative PSA level of 20.5 ng/mL. The average operative time was 288 minutes, with a mean estimated blood loss of 85 mL. The median hospital stay was 4 days, and the median duration of Foley catheterization post-surgery was 21 days. All four patients achieved early continence following catheter removal. Histopathological examination of the resected specimens revealed negative surgical margins in all cases.

Both the trans-vesical transabdominal and transvesicoscopic techniques are viable options for patients with localized carcinoma of the prostate. These approaches offer the precision of Retzius-sparing robotic surgery with additional advantages, particularly in challenging cases such as those with a large median lobe or post-TURP conditions, where ureteric orifice identification is crucial. The expedited return to urinary continence without compromising oncological efficacy has led to increased adoption of these techniques in our clinical practice.