Single-Port Surgery Changes the Landscape in Prostate Cancer Treatment

Prostate cancer under the microscope: © heitipaves - stock.adobe.com

Robotic surgery has become a standard of care for many patients with prostate cancer, offering several advantages over traditional open surgery.

Robot-assisted laparoscopic prostatectomy (RALP) is now the most common surgical approach for prostate cancer, accounting for a significant majority of procedures. The method is minimally invasive, and smaller incisions lead to less pain, shorter hospital stays, and faster recovery. Robotic technology allows for greater precision and control during surgery.

Studies have shown that robotic prostate surgery generally results in similar cancer control rates to open surgery, with potential benefits in terms of quality of life. Recent advancements in the field include the use of single-port robotic surgery, where the surgeon is able to perform the procedure with only 1 incision compared with multiple incisions. This method offers even quicker recovery.

In an interview with Targeted Oncology^TM, Bertram Yuh, MD, MISM, MSHCPM, urologic surgeon at City of Hope, discussed how single-port robotic surgery has changed treatment paradigms for patients with prostate cancer.

Targeted Oncology: What is single-port robotic surgery, and how does it differ from other forms of surgery in prostate cancer?

Bertram Yuh, MD, MISM, MSHCPM

Yuh: Single-port robotic surgery leverages the same precision, consistency, and effectiveness of robotic surgery through a less invasive means. The primary purpose of robotic surgery is to be less invasive, and single-port is the least invasive of robotic surgeries. For decades, we have been performing robotic surgery with instruments that articulate and have had a lot of great results. Now, we have this ability to utilize instruments that not only are flexible but allow us to squeeze into small areas to be able to achieve angles that we were not able to do before.

Also consider that traditional robotic prostate surgery utilizes 5 to 6 incisions to conduct the operation. Single-port robotic surgery uses just 1 small incision to accomplish this. So, that is the upfront primary difference between these surgery techniques.

What are the benefits of single-port robotic surgery?

The benefits of single-port surgery are around minimizing the invasiveness of the operation. It is also important to understand that we can do most single-port procedures on the prostate through an extraperitoneal approach, which means conducting the operation entirely in the pelvis, where the prostate lies anatomically in the body. This is different than traditional robotic surgery, which is performed through a transperitoneal approach through the abdomen. When you make incisions through the abdomen, it can impact a lot of the other anatomic structures, organs, the intestines, other big blood vessels. Whereas if you do a single-port procedure, you can confine the operation entirely to the pelvis and stay away from and avoid risk to those other organs. To me, that now makes the surgery safer.

There are also more studies there that are being published showing less pain with single-port surgery, higher patient satisfaction, faster recovery, more ability to be able to go home the same day after these types of procedures. Patients also may be able to heal faster and better with a single-port operation.

When it relates to how surgeons perceive the benefits, I think that the big picture is that when the patient benefits, the physician also benefits. Some of the key considerations would also be that overall visualization during the robotic procedure is improved with a single-port procedure, because you are able to harness the capabilities of a flexible camera. This camera can bend in various different directions, so you are able to now see up, down, under, and around and appreciate different angles of the prostate. This allows the surgeon to visualize parts of the prostate differently than they ever could before. This, coupled with the ability to use flexible instruments, allows for precise surgical performance. I think the versatility of the robot stands out in single-port surgery.

In what situations are you most likely to consider surgery for prostate cancer?

While prostate surgery remains the most common treatment used for prostate cancer, the decision to proceed with surgery is always a collaborative discussion with the patient. Ultimately, the decision is highly individualistic, but I would say the patients commonly treated with surgery are men with medium- to high-aggressiveness tumors. Nowadays, most patients with slow-growing cancers tend to observe these cancers without treatment. The metastatic potential is low compared with aggressive cancers. For more aggressive disease, there are risks of progression, risks of metastasis, and we are oftentimes choosing between surgery-based options and radiation-based options. But surgery still tends to be the most common treatment used.

National data shows that younger patients tend to get treated with surgery more often. We also see that these types of patients tend to recover better and more fully after surgery, as compared with patients that are older or less healthy. Nonetheless, I would say that essentially any prostate cancer can be treated effectively with surgery, from those that are slower growing to even those that are aggressive. We have a lot of experience at City of Hope treating patients with very large, bulky, high-stage cancers and still being able to treat them with single-port robotic surgery.

How receptive have patients been to the idea of single-port surgery?

Patients are nowadays much more accepting of robotic surgery in general. There used to be more questions raised by patients, but it is now well accepted across the country for robotic surgery to be performed.

From the standpoint of single-port surgery, I have seen some interesting trends. I find many patients, especially in the geographic location that I work in, to be savvy at finding information online. They will watch surgical videos and will go and search websites and look for the latest and greatest technology. I have patients that will specifically seek out single-port robotic surgery. Conceptually, I see patients having this mindset of why they would go through a 6-incision surgery when they could have just 1 incision instead. Several of my patients have even asked to see the robot or to see the surgical videos and are personally very interested in it.

Are there any trends in prostate cancer treatment that you are excited about?

There are a lot of developments and research that I am excited to see. In the surgery space, there is rapid technological advancement. We are seeing new robotic platforms hit the market and seeing robotic technology and instruments become finer and better. Similar to the advancements seen with microchips in computer science, we see miniaturization and more capabilities in robotic technology.

Right now, we are in a fascinating era where robotic technology is developing at a faster pace than we have ever seen before. This will allow us to leverage these technologies to improve upon the surgeries that we are performing. Seeing more robotic companies developing surgical robots at the same time leads to key pieces of technology that will be able to be optimized and then hopefully assimilated to provide the best technology going forward for our patients.

Some of the other things that are interesting would be the genetics and personalization of medicine that continues to develop in the prostate cancer setting. We perform genetic testing, essentially for all our patients with prostate cancer, to be able to understand the genetics of the patient, but also the genetics of various tumors. We obtain a lot of information, some of which we know what to do with and some of which we are trying to figure out. Ultimately, the goal is to be able to use this information to personalize care, to be able to deliver specific treatments to a given patient, to be able to administer targeted medication perhaps in conjunction with surgery or with radiation, to be able to optimize outcomes, and be able to cure more patients.

How do you see the areas of community and surgical oncology coming together to best serve patients?

This relies on a close collaboration between sites and physicians to provide that level of care. Many patients do prefer being treated in the community, closer to their homes, closer to their friends and family. I find that many patients, especially if they are coming for more frequent treatments or visits, prefer to be closer to home, making community sites crucial for this. But when it comes to specialty treatments, like single-port surgery, there are not many places that offer this type of surgery. The academic site may also offer different clinical trials and options. This is where we can maintain these open and smooth lines of communication to optimize the care setting and ask, what are the things that are better done in an academic setting vs keeping care in the community? I think oftentimes there are ways to find that balance, and patients appreciate it when the physician assists in figuring this out on their behalf.

Do you consider there to still be any unmet needs when it comes to surgery for prostate cancer?

Prostate cancer research still lags many other cancers, so there are still a number of unmet needs. One area I would highlight is that we still need better identification of patients that truly require treatment. Over the course of the last 10 to 15 years, we have done much better with this. But the fact is we still oftentimes underestimate patients' cancers at the time of diagnosis, and this uncertainly raises challenges for treatment decision making. Sometimes we end up erring more on the side of more aggressive treatment, because we are unsure of what we are dealing with. Patients are worried their cancer could be worse, and by not treating it, think that they are doing themselves harm. I think that on the biomarker testing side, there is a lot of work being done that will hopefully help us in this. Upfront testing to better characterize tumors is going to be vastly helpful for us. We know that with a lot of our traditional testing we can characterize cancers but not necessarily predict an individual's cancer behavior that well. There is still a lot about the biology of specific cancers that we need to learn more about.

Continuing also on the theme that I brought up earlier, I think improved personalization of treatment is necessary. We know that patients with high-risk prostate cancers, for instance, require multiple treatments at least 50% of the time. If that is the case, how do we determine the optimal treatment path for them? Is it combining medication with surgery? Is it a specific timing or sequence? Those are things that we're still a bit unclear on. I am hoping that as we understand cancers better, we will be able to administer specific medications or treatments in conjunction with other therapies to give patients the best chance of beating their cancer.