RARP - Single Port vs. Multi-Port?

[adventure4me]

I’m tiptoeing toward a decision for RARP, deciding between a couple very highly regarded surgeons. One recommends a single-port, the other multi-port. Any thoughts from the community about pros/cons for single-port vs. conventional multi-port DaVinci procedure??

[Tall_Allen]

Hard for me to understand why you would opt for surgery with EPE, possible bladder neck invasion, and possible seminal vesicle invasion. This has a high probability of leaving you permanently incontinent and certainly impotent, without curing you, IMO.

I assume you've talked to radiation oncologists specializing in SBRT.

Single port vs multiple port is of no consequence.

[adventure4me in reply to Tall_Allen]

Thank you for the counterpoint, this is exactly why I posted here. My profile is perhaps a bit overstated/misleading regarding the MRI's. MRI #1 (February) was read by 3; one noted possible extracapsular, other 2 did not. One noted possible bladder neck invasion, other 2 did not. In Feb, 2 consultations with radiologists and 2 with urologist/surgeons, they all pretty much said there is almost certainly nothing escaped, comments in the reports perhaps slightly cya and due to pirads 5. Radiologists and Urologists also reviewed MRI themselves.

My instinctive thoughts back then (at initial diagnosis in February and initial personal research) were toward radiation as many on this forum seem opposed to surgery and PCRI videos which are useful, if slightly aggressive for/against Dr. Scholtz favored/disfavored treatments. Both this forum and PCRI are greatly appreciated and helpful.

Noteworthy in my case are significant urinary issues, AUA score 20-25 depending on my mood when I fill out the questionnaire. I did indeed see 2 highly-rated radiologists (one at COE, one at highly rated non-profit system), both radiologists took great time to go through my case and possible radiation options. Both said that SBRT is not for me due to urinary issues, as SBRT is more irritative than traditional more frequent/smaller dose. They also both said that radiation as-is would almost certainly lead to substantial decline in already-aggravation urinary function. They also both suggested I would need a turp/holep before radiation. Ultimately both professional, dedicated, experienced radiologists politely suggested that I am a better case for surgery than radiation. (although both radiologists and both surgeons suggested AS at that time due to all gleason 6)

I do not understand how surgery would result in a "high probability of leaving you permanently incontinent and certainly impotent, without curing you". Both surgeons said my surgery would be bilateral nerve sparing, and possibly veil-sparing, but indeterminate until the actual surgery. Both surgeons are cautiously optimistic that my case would be on the better end of side effects of incontinence and ED. But it's surgery of course, and the risk is always there.

Thank you again for the reply, I will indeed review and reconsider.

[Tall_Allen in reply to adventure4me]

I said those things based on your profile that states ECE, SVI, and bladder neck invasion. If you are confident that is not the case, RP may be a good option. Only 35% of previously potent men retain their potency after nerve-sparing prostatectomy. Erectile function is usually much reduced even in those who retain some potency.

[Hiker64 in reply to adventure4me]

My RO told me the very same thing. With my tumor located in the base of my prostate (which is actually near the bladder) that radiation would not make my urinary issues any better and would likely make them worse. I had chronic prostatitis for almost 30 years. He recommended surgery for me and that is what I did. On the positive side my urinary issues are gone, ED is not any worse than before the surgery, and the final pathology showed I actually had Gleason 8 cancer instead of Gleason 3+4. It did take over 2 years for the ED to completely recover though. On the negative side my PSA has slowly started to rise again which is not surprising since I also had positive margins. RO is waiting for it to reach 0.1 before starting salvage radiation. Hope this helps!

[adventure4me in reply to Hiker64]

Thank you for sharing your situation, sounds like it's going about as well as it could be, it seems that recurrence at some point is not uncommon. it sounds like you have gotten relief from long-standing urinary issues, I hope for the same if I indeed elect surgery. Thankfully your side-effects are on the good end of the spectrum! Thanks again.

[Justfor_]

This is purely speculative from my part, as it doesn't come from any real info.

Many, including myself, have developed hernias around the belly button as this port is the largest in the multi-port scenario. From this port the prostate gland is finally removed, hence its dimensions. I fear that in the single port scenario this will be even larger leading to a higher probability of inflicting a hernia. You can investigate the diameter of the two trocars (fitting pieces) of either option to check if my fear is substantiated.

[adventure4me in reply to Justfor_]

Good point, I'll check it out. Thanks

[allie2020]

I had my RP five years ago and it was multi-port. I was not aware of a single port option at the time. I healed nicely, had an uneventful recovery and am doing very well today. I was 3+4 with a minimal amount of 4. I had a very, very large prostate and dealt with BPH and quite troublesome urinary symptoms for many years. I think I visited nine doctors (Uros, RO's and one MO). I was convinced that radiation would result in my already problematic urinary sypmptoms becoming even worse. I chose a very skilled and experienced surgeon who had performed thousands of RARP's. I was completely continent at the eight week mark and did a lot of penile rehab. which I believe helped me in that department. The urinary symptoms are history and my ultrasensitive PSA's are <.006; I am very happy with my treatment decision. I wish you all the best in your treatment decision. I'm glad you have such a small amount of G4.

[adventure4me in reply to allie2020]

Wow that sounds like a great outcome, very happy for you! My situation is pretty similar and I am consulting with several now, I can only hope for a similar result. Thank you for sharing!

[CPGeek]

My brother had the single port, while I had the multi-port. Both of us have regained full urinary control and, speaking for myself, have pretty normal sexual function. One thing you need to keep in mind is that when the prostate is removed, the surgeon is also removing a sphincter located within the prostate. If you haven't started Kegel exercises, do so well before your surgery date. I find the better alternative is just to orgasm every day. It works the same muscles and is way more enjoyable. An odd issue my brother encountered with his procedure was the gas that is pumped into the surgical site caused his skin to bubble up like bubble wrap and he described the sound of it like bubble wrap popping, but he was left with less internal bruising, which is what I experienced. I had seven incisions with the one for the camera and the other for the removal of the prostate being the largest. My surgeon also inserted a pelvic drain that was a bit hair-raising when removed. They examine the fluid for traces of urine, or so I was told. For about a week or so, I felt like I had been kicked in the guts, or what I imagine every woman of childbearing age experiences every month. I just took Tylenol and kept active. Both of us are now healed, completely in control of our bladders and monitoring our PSAs once a year. My surgery was in May 2020 at the height of the pandemic, just when hospitals were starting up "elective" procedures. Now, it's such a distant memory. I hope you have that to look forward to.

[adventure4me in reply to CPGeek]

Thank you for taking the time to reply, interesting that both siblings had surgery (but not surprising). Sounds like 2 good outcomes after some short-term minor issues, very happy for you. I started Kegels, thank you for the reinforcement of that. Still not committed, but looking more and more like surgery. Thanks again.

[London441]

I’ve had both, since surgery didn’t get it all, as often happens. I experienced permanent incontinence and 80-90% ED despite a world class surgeon at a major center of excellence.

I eventually got a separate surgery for a artificial urinary sphincter for the incontinence, which sounds onerous but works well. Probably wouldn’t have needed that if I hadn’t chosen to follow the RP with radiation based on adverse features post op. SV invasion, positive lymph node.

I chose cancer control over these risks and certainly have no regrets so far as I am doing well so far almost 4 1/2 years later.

Your odds of being left incontinent from surgery are low if you are diligent with your exercises but the ED is another story. Only the most dedicated rehab will give you a shot at being anywhere near your previous function, and your penis will likely be thinner and shorter. Assess how much this means to you. Rosy takes of restoration to previous sexual function after RP are definitely outliers.

[adventure4me in reply to London441]

Hey thank you for the reply. So sorry to hear of your very long journey, hopefully life is enjoyable for you now, finally. And thank you for sharing your less-than-optimal surgery result, I really need to consider there is that risk regardless of best intentions. Thanks again.

[sptill72]

I had a consultation with the head of urology at City of Hope. He performs both single port and multi-port RARP. He said if it was him getting the procedure, he would select multi-port because it gives the surgeon more room to work, which really comes into play if there are any complications. He also stated single port is newer and surgeons have less experience on it. He has performed about 200 on single port and over 2,500 on multi. I ended up going with SBRT at UCLA instead.

[adventure4me in reply to sptill72]

Very good, thank you for the comments, I really appreciate it. I need to find out a bit more about single-port for sure. Hopefully your SBRT is/was successful with minimal side effects.

[Hidden in reply to sptill72]

That makes good sense. I had multi-port as well and after watching video's of the procedure I can see where having extra space and not limiting movement would be of value. Sure, a surgeon that knows what they're doing might not make the mistakes of one trying to use a single port but that's what separates a good RP from a bad RP...the surgeon and the patient. I have no hernia's afterwards (20months) and my scars are barely visible. Hope the SBRT is going well and UCLA is a great institution for sure.