Conventional LRP was first introduced as a minimally invasive treatment for PCa in 1991 [13], and since then, minimally invasive approaches for PCa treatment have been widely disseminated in an attempt to decrease morbidity [14]. The benefits include smaller incisions, less pain, reduced morbidity and an overall increase in patient satisfaction. With the improvement of the modern technology and the advent of robotic instruments, RARP was promptly applied mainly in the United States and in some developed European countries as the most common extirpative treatment for PCa [15].
Nevertheless, the increased technical effort with a longer robot docking time and the increased cost associated with the robot-assisted operation cannot be ignored. It has been demonstrated that over 10 years, RARP was on average more costly than LRP [16]. Especially in the developing countries such as China, the healthcare resources are in heavy shortage and medical insurance fails to cover the fees on robot-assisted operations. The high cost has also led a number of authorities to question the value of RARP to patients and health care systems. Unfortunately, this unpleasant situation cannot be improved by the surgeons or the hospital itself, but by the economists and politicians. Therefore, the RARP may not be generalizable to the developing countries and community settings. In developing countries such as China, choosing LRP instead of RARP remains common due to the robotic medical expenses that the national health insurance system does not cover. Factually, the standard laparoscopic technique still continues to be practiced in a number of centers in developed countries due to the higher total hospitalization costs of RARP [17, 18].
As for the extensive application of LRP in developing countries, it can be further divided into the conventional four-five port LRP and a more minimally invasive single-port LRP. Single-port LRP is associated with reductions in the number of transcutaneous access points, reducing incision-related complications and improving cosmesis [19]. However, due to a loss of triangulation, small operative space and instrument clashes [20] with some doubtful factors on the safety of the procedure and the extended OT, concentrating the incisions at a single site limits the range of motion and makes visualization difficult, which is a huge challenge even for an experienced laparoscopic surgeon. Gao Y et al. [3] also reported a similar results using single plus one port LRP for PCa, but the obstacles mentioned above were still present. Although some surgeons advocate this technique for the excellent cosmetic outcomes, it is not a key surgical parameter for an operation of RP that is usually performed in an elderly patients population. Delongchamps NB et al. [21] reported that scars generated by RP were not different from the patient point-of-view, and the cosmetic aspect of scars did not seem to be a concern in patients undergoing RP. As a matter of fact, scars indeed had a low impact on overall satisfaction during postoperative patient counseling. Additionally, the increased cost related to the use of disposable elements must also be taken into account when considering the application of this technique.
To overcome limitations, including the extended OT and financial burden of RARP, a narrow operating space with an increased risk of complications of single-port LRP, and a loss of triangulation without efficient cooperation by three unfamiliar surgeons of the conventional port LRP, our team modified the conventional LRP technique and now performs three-port LRP as our first-line treatment for PCa. Ali SG et al [22] has proposed that trocar placement is an important step at the beginning of LRP. Thus, it may affect the continuum of the surgical procedure. As a matter of fact, the extraperitoneal approach is surely not the best approach to use the fourth port extensively due to the limited space. In our views, three-port LRP combines the advantages of lower cost, faster OT, lower complication rates and acceptable incision cosmesis. Using laparoscopic vision, the surgeon can detect certain features that cannot be realized accurately and vividly by the RARP. Furthermore, the three-port equilateral triangle can avoid a narrow space, which is a remarkable disadvantage when executing single-port LRP. As a matter of fact, three-port LRP is the best combination of direct contact with the surgeon’s observations, a spacious cavity and efficient coordination in clinical practice. Only in this situation can the most challenging steps including the suturing ligation of the DVC and urethra-vesical anastomosis be performed well. When compared with the conventional four-five port LRP, other advantages of this approach are heavily emphasized. In three-port LRP, the concept of triangulation implies an instrument positioning schema that provides an optimal relationship between the camera and the working instrument. With the bipolar instrument and the laparoscopic traction forceps both in the surgeon’s hand, this setup can promote accurate retraction and rapid hemostasis. Some important procedures, including traction of the adjacent structures, dissecting the surrounding tissues and promoting hemostasis, can be achieved promptly and efficiently only by the surgeon himself. Three-port LRP is a novel technique based on the conventional LRP that can be easily learned by those who have mastered conventional LRP.
Besides, some professionals might believe that surgeons should strive for use of perineal prostatectomy, which is usually recognized as a minimal invasive procedure with the same advantages and outcomes as laparoscopic and robot assisted procedures yet much cheaper and the most cost-effective. Unfortunately, the disadvantages of this technique cannot be ignored, and the popularization may be severely limited due to these reasons as follows: (1) the narrow space with limited exposure makes hemostasis more difficult; (2) Unclear anatomic vision increases the risks of rectal injury; (3) postoperatively, the functional parameters regarding erectile function and urinary continence cannot reflect a satisfactory outcome compared with LRP and RARP; (4) for some cases, it is impossible to perform extended lymph node dissection in view of the limited space, which will undoubtedly make a negative influence on the tumor stage and disease prognosis.
In Table 2, combining our three-port LRP data with other urologists’ experience, it can be clearly revealed that our mean OT is significantly shorter than that for RARP, single-port and the conventional LRP. As is well known, prolonged OT is associated with an increased risk of complications in PCa patients [23]. Therefore, shortened total OT should be always pursued and it can be effectively achieved in our method after undergoing the learning curve although the OT is more likely to related to the surgeon’s experiences [24, 25]. Likewise, the parameters of EBL, drainage days, hospitalization days and the rates of surgical complications are also superior to the other urologists. Contradiction with the published literature, the data of complications and recovery in our investigation appeared more excellent, which can be explained by three points: (1) a more quick recovery time with less trocar placement and incisions, (2) the risks of faulty operation can be decreased evidently due to the inflexible and excessive traction by an inexperienced and unskilled assistant, (3) the triangle operation in accordance with the human engineering principle makes the surgeons feel more comfortable and reduce the fatigue.
Admittedly, our study has several limitations and our findings must be interpreted in this context. First of all, this study is retrospective and non-randomized, which clearly biases subsequent analysis. Secondly, the experience was obtained purely based on a single high-volume surgeon at a single center, which means that a limited experience may not be reproducible by all surgeons and a larger scale research study requiring collaboration of multiple institutions or even different countries is still needed. Though the short-term results are encouraging in three-port LRP, the oncological and functional outcomes in the long-term follow-up is still not clear. We strongly remain hopeful that long-term follow-up of these patients will provide interesting information that can influence the development of future methods. Despite the limitations of this study, the usefulness of comparing the treatment outcomes of three-port LRP versus conventional LRP and other surgical techniques for PCa will raise further questions and stimulate ongoing debate in the field of PCa surgery. Hence, further study is still necessary to validate and extrapolate this application.