Introduction

Robotic-assisted radical prostatectomy (RARP) has become the gold standard surgical treatment for localized prostate cancer in the USA, owing to its decreased complications and early rehabilitation compared to the open approach [1]. Currently, the multiport da Vinci® ** and Si (Intuitive Surgical, Sunnyvale, CA, USA) are the most commonly used platforms for RARP worldwide [2]. Continued advances in minimally invasive surgery (MIS) have led to the introduction of a potentially less invasive platform known as the da Vinci® single port (SP), which was granted FDA approval in November 2018 for urologic procedures [3, 4].

Comparison between these two robotic approaches (SP vs. multiport) on their intraoperative performances, early functional and oncological outcomes has been published [5]. These studies have found SP RALP to be technically feasible and safe with similar perioperative outcomes compared to the **, but the instrument limitations and increased cost of this novel technology must be considered [6]. Some groups have described decreased postoperative pain with increased opportunities for outpatient procedures, while other authors have reported no difference between the SP and multiport postoperative pain [5, 7]. Future reports of long-term outcomes with higher volume of patients will give additional insight regarding the best applications of the SP platform.

In this study, we compared the patient satisfaction describing their perspective on the quality of life following RARP using the SP and ** robotic platforms. As the debate on these modalities would be incomplete without the patient experience, this study aims to assess, with postoperative questionnaire distribution, the patient surgical satisfaction in terms of pain control, ability to return to the daily activity (work or socially), and their surgical experience.

Methods

Study design and primary endpoint

We performed a retrospective study comparing the operative satisfaction and perspectives of two groups of patients who underwent RARP with the ** and SP robot platforms. After a propensity score match (PS), the groups were compared, and the operative outcomes were described previously by our group [5]. In this study, the same patients were interviewed with a questionnaire regarding their postoperative experience in our center. The data was collected according to the Institutional Review Board (approval number 237998-44).

Propensity score matching

The covariates included in the PS were patient demographics (age, body mass index (BMI), Charlson comorbidity index), preoperative Sexual Health Inventory for Men (SHIM) and American Urological Association symptom scores (AUASS), prostate size, prostate specific antigen (PSA), D’Amico risk group, and degree of nerve sparing. The data of 71 consecutive SP patients were matched with 875 ** patients who underwent surgery during the same period (from June 2019 to March 2020). PS analysis used the nearest-neighbor algorithm with a 1:1 ratio without replacement [8]. Covariates with a standardized difference (SDD) of <|0.15| were considered balanced. Finally, two groups of 71 patients were selected for the study.

Surgical Satisfaction Questionnaire (SSQ-8)

The SSQ-8 is a validated eight-item questionnaire that has been used previously to measure satisfaction in urogynecologic surgery. The advantage of this questionary is that it is not condition nor surgery-specific. This questionnaire has a test–retest reliability of 0.80 (P ≤ 0.2) [9]. Responses are recorded on a 5-point Likert scale from 1 = “very unsatisfied” to 5 = “very satisfied” for the first six questions or from 1 = “never” to 5 = “yes” for the last two questions. A higher degree of surgical satisfaction correlates with a higher score. Questions 1 and 2 address the pain subscale; questions 3, 4, and 5 address return to baseline subscale; and questions 6, 7, and 8 address global satisfaction subscale (see Appendix, Fig. 2).

In addition to the eight questions in the SSQ-8, a non-validated question from our institution was added, named (GRI-1). Responses to GRI-1 are reported on a similar 5-point Likert scale to SSQ; all questions are available in Appendix (Fig. 2).

GRI-1: “How satisfied or unsatisfied are you with the number of skin incisions/scars following surgery?”.

Questionnaire distribution

In January 2021, two authors (JN and MM) administered the questionnaire survey over the telephone rather than in person or mail due to the ongoing SARS-CoV-2 (Covid-19) pandemic. A total of 142 patients (71 SP and 71 **) were selected as described in “Propensity score matching”. All 142 patients were randomized via computer algorithm, interviewers only had access to the patient’s name and phone number to ensure the interviewers were blinded to which robotic procedure the patient had (SP or **). Patients were asked at the beginning of the interview not to disclose which robotic platform they had during their surgery.

The interviewers confirmed the patient identity and obtained verbal consent for the survey. Patients were made aware at the beginning that participation was completely voluntary. The questionnaire was verbally distributed in English and Spanish, as all patients were English and/or Spanish speakers. All patients were contacted a maximum of three times.

All data collected from survey responses received by the interviewers were documented and sent to an unblinded author who identified which robotic approach (SP or ** group) each patient underwent after data collection. Data was analyzed between the two groups after completion of all interviews.

Surgical technique

Patients having RARP with the multiport da Vinci® ** platform underwent a standard six-port transperitoneal approach with an early retrograde athermal nerve-sparing technique [10]. A similar transperitoneal technique was performed with the da Vinci® SP, while using an additional assistant port as previously described [11]. Postoperative pelvic drains are not placed with either robotic platform.

Postoperative care and follow-up

An Enhanced Recovery After Surgery (ERAS) pathway with multimodal pain management and transversus abdominis plane (TAP) anesthetic block is utilized [12]. Pain is controlled using non-opiate analgesia and the Foley catheter is removed in 5 days.

After the Foley removal, all patients have the first appointments at 6 weeks, and then every 3 months after surgery for the first year. At these appointments, oncologic and functional outcomes are addressed with biochemical recurrence defined as PSA > 0.2 ng/mL in 2 consecutive exams and redistributing SHIM and AUASS questionnaires. We define continence as the use of no pads and potency as the ability to achieve and maintain erections adequate for sexual intercourse (with or without use of phosphodiesterase type-5 inhibitors) [6].

Statistical analysis

Statistical analysis and described data were performed and presented based on established guidelines [13]. Continuous variables are presented as mean ± standard deviation (SD) or median and interquartile range (IQR) while categorical and ordinal variables are described as frequencies and proportions.

Exploratory analysis using the Shapiro–Wilk test of normality found that none of the variables for either surgical modality was normally distributed. Additional review of quantiles supported this, and all questions demonstrated right hand skew. To determine variance, the F test was used and found that the true ratio of variances for all survey questions between the two cohorts was not equal to 1. Two-sided Mann–Whitney U tests were performed for the eight validated SSQ-8 questions and for our institution’s question (GRI-1) as continuous variables, to compare the difference between the ** and SP cohorts. These items are discrete and considered as categorical variables as well, therefore, a Fisher’s exact was used by combining questionnaire responses 1–3 (‘very unsatisfied’, ‘unsatisfied’, ‘neutral’) due to the small sample size in these responses.

A sample size of 94 patients (47 in each cohort) is needed to detect a 20% difference (i.e., answering a ‘5’ vs a ‘4’) in answer response between the two groups, with a two-sided significance of 5% and 80% power. A two-tailed test with P < 0.05 was considered statistically significant. Statistical analysis was performed using R version 4.0.2 (R Foundation for Statistical Computing, Vienna, Austria) and Stata version 16 (Stata Corp., College Station, TX, USA).

Results

Patient demographics

A total of 142 patients (71 SP and 71 **) were included to answer the questionnaires proposed in this study. The preoperative demographics after the 1:1 PS are illustrated in Table 1.

Table 1 Comparison of preoperative parameters of SP and ** group after 1:1 PS matching
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Questionnaire administration

Median postoperative time to administer the questionnaire was 12 months (range 8–19 months). Each patient was called a maximum of three times if initial attempts were unsuccessful, and the average interview time was 4 min. In the ** group, 61 patients completed the entire interview, a response rate of 85.9%. In the SP group, 52 patients completed the questionnaire, a response rate of 73.2%.

Patient satisfaction and perspectives

Distribution of patient responses on the SSQ-8 is illustrated in Fig. 1. On the SSQ-8, questions 1–2 address pain, 97% of ** patients and 98% of SP patients were ‘very satisfied’ or ‘satisfied’ with their pain control following surgery in hospital and 91% and 94% of ** and SP patients were ‘very satisfied’ or ‘satisfied’ once discharged, respectively. Questions 3–5, evaluating quality-of-life following surgery, showed 90% of ** patients and 94% of SP patients being either ‘very satisfied’ or ‘satisfied’ with the time it took to return to their daily activities, work, and exercise. Overall satisfaction with the results of the surgery was 80% and 88% in the ** and SP cohorts, respectively. When asked if the patient would recommend the surgery to a friend, 90% and 96% of ** and SP, respectively, responded ‘yes’ or ‘maybe’. No statistical difference in responses was found between the ** and SP cohorts for the eight SSQ-8 questions (Table 2).

Fig. 1
figure 1

Patient questionnaire response (percentage of answered questions x scores from 1 to 5)

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Table 2 Patient satisfaction comparison
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Question GRI-1 revealed 84% of patients in the ** cohort and 98% in the SP cohort were either ‘very satisfied’ or ‘satisfied’ with the number of incisions or scars after surgery, which demonstrated a statistically significant difference (P < 0.001) (Table 2).

Discussion

We report a study of surgical satisfaction among patients undergoing RARP with either the da Vinci® SP or da Vinci® ** a robotic program safely even when laparoscopic experience was limited [21]. A Cochrane systematic review found robotic surgery has led to decreased postoperative hospital stay compared to open surgery [22]. Additionally, RARP advantages include reduced operative time, blood loss, and perioperative morbidity [23]. These advantages have allowed for direct adoption of robotic surgery among open surgeons with two decades of multiport prostatectomy pushing the robotic commercial industry to further optimization.

Moreover, previous studies have found a positive relationship between patient satisfaction and their pain control, recovery to physical activity, and reduction of functional limitations. In our study, satisfaction with pain control was similar between the two cohorts. Both groups of patients returned to their normal activities after surgery without differences between robotic platform used. It is understood that treatment satisfaction is complex and derived from quality-of-life experience and functional changes [24]. Generally, despite the robotic approach, our patients were highly satisfied with the overall results of their surgery.

Previous studies evaluating regret after RARP found correlation of dissatisfaction with outcomes such as urinary and sexual deterioration [25] and interestingly, Sanda et al. [26] found that changes in quality of life (QoL) were also related to overall satisfaction among patients and their partners. While our early outcomes did not demonstrate a difference in continence and potency, these variables were not assessed by our questionnaire, because we need long-term follow-up as our data mature.

Our intention with a non-validated institution question GRI-1: “How satisfied or unsatisfied are you with the number of incision/port/keyholes after surgery?” was to assess the patient’s point of view raised by the robotic surgery community (Does the number of incisions really matter for the patient?) Future studies will aim to further validate this question as it relates to SP platforms. The responses to this question were the only answers found to have a significant difference, and we have found that patients undergoing ** RARP had lower satisfaction rates from GRI-1. Due to the invaluable nature of the patient perspective, a selection of unsolicited comments were grouped according to ** or SP (see Appendix, Table 3). On review of these comments to understand GRI-1 discrepancy; it appears patients in XI group thought they had too many scars, or that some were too painful. It is important to note that cosmetic concerns affect patients differently, and once SP is proven to be equivalent, then counselling the patient on the options will be paramount [27]. Despite this difference, it can be presumed the invasiveness of both procedures is similar from our results of the SSQ-8.

During the study, the interviewers received the dataset with the robotic modality omitted and patients sorted by name. Interviews were conducted in English and Spanish, without the need for translation to another language. It is appreciated that a telephone administered questionnaire may have shortcomings compared to face to face; a study assessed this difference in children and showed little difference and even advantageous with the lack of visual distortions or tension/tension release signs between interviewee and interviewer [28]. Our limitations are the study was retrospective and interviewing patients’ months after surgery introduces recall bias. However, to our knowledge, this is the first study comparing the surgical perspective and satisfaction of patients who underwent RARP with two different robotic platforms.

Conclusion

We found no statistical difference between the groups regarding the answers for SSQ-8 questionnaire; both groups were very satisfied. However, when assessing the number of incision sites with the GRI-1 question, patients who underwent ** described lower satisfaction rates which we hypothesis is due to number of scars. We believe that future studies should consider the patient postoperative perspective when adopting new platforms in order to combine adequate treatment with patient expectations.