Extraperitoneal Single-Port Robot-Assisted Radical Prostatectomy for a Massive Prostate: A Case Report

Extraperitoneal single-port robot-assisted radical prostatectomy (SP-RARP) using the da Vinci SP system (Intuitive Surgical, Sunnyvale, CA, US) offers a less invasive alternative to multi-port RARP. However, a significant limitation is the system's reduced instrument force, which makes retraction and manipulation of large, heavy organs particularly challenging. As a result, SP-RARP for prostates over 100 g has been considered difficult and is rarely reported. This case highlights the feasibility of extraperitoneal SP-RARP in a patient with a massive prostate by addressing and overcoming this technical limitation. We report the case of a 77-year-old man with bilateral ureteral stones, significant prostatic hypertrophy, and prostate adenocarcinoma (Gleason score 3+3), who underwent extraperitoneal SP-RARP due to urinary retention. The operation lasted 4 hours and 40 minutes, with an estimated blood loss of 450 mL through a 4.5 cm sub-umbilical incision. The prostate weighed 143 g. No intraoperative complications occurred, and the postoperative course was uneventful. SP-RARP for massive prostates (>100 g) remains technically challenging due to the limited retraction force of the single-port system, and successful extraperitoneal cases have not been previously documented. This report demonstrates that, with proper technique, extraperitoneal SP-RARP can be safely and effectively performed even in cases involving significantly enlarged prostates. These findings support the potential expansion of SP-RARP indications in select high-volume cases.