Transverse Versus Vertical Camera Port Incision for Patient Satisfaction After Robot‐Assisted Radical Prostatectomy

ABSTRACT

Objective

The aim of the present study was to compare patient satisfaction after robot‐assisted radical prostatectomy (RARP) between transverse and vertical camera port incisions, as assessed by wound pain and camera port–related health‐related quality of life.

Methods

This prospective observational study included 100 consecutive patients who underwent RARP, divided into a transverse incision group (n = 57) and a vertical incision group (n = 43). The primary outcome measure was incisional pain at the camera port used for specimen extraction on postoperative Day 7. Secondary outcome measures included wound satisfaction, particularly at the camera port, assessed using the Derriford Appearance Scale (DAS‐59).

Results

The number of patients who reported wound pain on postoperative Day 7 was significantly higher in the transverse group (n = 11, 19.2%) than in the vertical group (n = 1, 2.3%) (p < 0.001). There was no significant difference in total DAS‐59 scores between the two groups (p = 0.44). Multivariate logistic regression analysis identified body mass index (odds ratio [OR], 9.5; 95% confidence interval [CI], 1.5–188.8; p < 0.01) and incision type (OR, 11.1; 95% CI, 1.7–219.7; p < 0.007) as factors independently associated with wound pain.

Conclusions

In RARP, vertical camera port incisions were associated with less postoperative wound pain and comparable wound satisfaction during the early postoperative period. From the perspective of surgical invasiveness, a vertical camera port incision may therefore be recommended for RARP.

1. Introduction

In radical prostatectomy, including robot‐assisted techniques, treatment success should be evaluated not only by oncological outcomes but also by functional outcomes, especially, postoperative erectile function and urinary continence, which have a substantial impact on patients' quality of life [1, 2, 3]. However, postoperative wound pain and patient satisfaction with the operative scar may also be important factors influencing patients' overall satisfaction after surgery [4].

In the evaluation of body image after laparoscopic sleeve gastrectomy for the management of obesity, health‐related quality of life was not improved in female patients, regardless of postoperative weight loss [5]. These results suggest that body appearance, including the operative scar, may affect the degree of patient satisfaction, even in minimally invasive surgery.

In robot‐assisted radical prostatectomy (RARP), the camera port is usually positioned above the umbilicus, and the choice between a vertical or transverse incision for the camera port depends on institutional or surgeon preference. There is a possibility that a better cosmetic appearance of the surgical wound may be achieved with a transverse incision, as it is oriented parallel to Langer's lines [6, 7]. On the other hand, specimen extraction is technically easier with a vertical incision, as it is oriented parallel to the rectus muscle; however, cosmetic outcomes tend to be inferior with a vertical incision because it is not aligned parallel to Langer's lines.

Although several studies have investigated differences in the incidence of incisional hernia between vertical and transverse incisions after RARP [8, 9], there have been few reports focusing on patient satisfaction with the camera port in RARP. We postulated that patients would perceive transverse incisions as providing better cosmetic outcomes than vertical incisions, and that postoperative wound pain after RARP would be similar between the two incision types. The aim of the present study was to compare patient satisfaction after surgery between transverse and vertical camera port incisions in RARP, as assessed by wound pain and health‐related quality of life related to the camera port.

2. Patients and Methods

The participants in this prospective observational clinical cohort study were 100 consecutive patients who underwent RARP at our tertiary academic hospital between April 2020 and August 2023. The patient cohort was divided into two groups to investigate the impact of skin incision type for the midline camera port on postoperative pain and surgical wound–related quality of life: 57 patients underwent a transverse incision (transverse group), and 43 patients underwent a vertical incision (vertical group). The choice of a transverse or vertical incision was based on physician preference and not on patient‐related factors. No changes were made to the surgical procedure or other procedural aspects during the study period.

All consecutive patients undergoing RARP under the supervision of a single experienced robotic surgeon (N.H.) were considered for inclusion in the present study. N.H. has performed more than 1000 robotic surgical procedures.

The exclusion criteria were as follows:

1. prostate volume > 100 mL on preoperative MRI, because extension of the wound for specimen extraction might be required in cases of large prostate volume; and

2. RARP performed via a retroperitoneal approach, because the wound location differs from that of RARP performed via an intra‐abdominal approach.

The primary outcome measure was the comparison of incisional pain at the camera port used for specimen extraction on postoperative Day 7 (POD7) between the transverse and vertical groups. On POD7, patients were asked whether they had camera‐port incisional pain at the time of assessment, and their responses were recorded as present or absent. The length of hospital stay and the opioid prescription regimen did not differ between the vertical and transverse groups.

Secondary outcome measures included comparison of wound satisfaction, particularly at the camera port, and assessment of whether extension of the camera port incision was required. Perioperative parameters and pathological findings were recorded through a review of electronic medical records. Gleason grade and T stage were evaluated before surgery.

Written informed consent was obtained from all patients prior to study participation after explaining the purpose and methods of the study. The study protocol was approved by the Institutional Review Board (IRB) under protocol number [U20‐09‐009] and was conducted in accordance with the ethical principles of the Declaration of Helsinki, ensuring the protection of human subjects and the integrity of the study.

2.1. Sample Size Confirmation

The sample size was determined based on findings from a preliminary feasibility study conducted by Takeda et al. [10]. The sample size estimation was performed for the primary endpoint, defined as the presence of camera‐port incisional pain on POD7. Pain was analyzed as a binary outcome (present vs. absent), with “present” defined as a numerical rating scale (NRS) score ≥ 1 and “absent” defined as an NRS score of 0.

Based on postoperative pain profiles during the first postoperative week reported by Takeda et al.—who evaluated NRS pain scores from POD1 to POD7 at specimen‐extraction incisions extending from the umbilical camera port—and particularly the pain‐at‐rest values on POD7 (0.4 ± 0.6 for periumbilical midline incisions and 0.1 ± 0.3 for Pfannenstiel incisions), we conservatively assumed that 35% of participants in the control group and 10% in the intervention group would report pain on POD7, corresponding to an absolute difference of 25 percentage points.

Assuming a two‐sided α of 0.05, 80% statistical power, and a 1:1 allocation ratio, a chi‐square test comparing two independent proportions (without continuity correction) indicated that 43 participants per group (total n = 86) were required.

2.2. Evaluation of Postoperative Wound Appearance QOL

The Derriford Appearance Scale (DAS‐59) was used to assess psychological and physical distress and the level of dysfunction related to wound appearance [5, 11]. The Japanese translation and validation of this scale were performed by Nozawa et al. [12].

The DAS‐59 generates six measures of psychological distress and dysfunction related to problems of adjustment and appearance. It is a self‐administered instrument comprising 59 items, each rated according to the frequency of experienced symptoms. The questionnaire is designed to comprehensively evaluate both psychological and physical aspects of distress and functional impairment. The DAS‐59 full‐scale score ranges from 8 to 262, with higher scores indicating greater appearance‐related distress and dysfunction rather than objectively poorer cosmetic appearance [13, 14]. The questionnaire was administered at the first outpatient clinic visit after hospital discharge following RARP.

2.3. Operative Technique

All cases underwent RARP using the four‐arm da Vinci Xi surgical system (Intuitive Surgical, Sunnyvale, CA, USA) with an anterior intraperitoneal approach [15]. Briefly, the procedure began with a transperitoneal entry to expose the space of Retzius. Subsequently, the bladder neck was incised to separate the prostate from the bladder, after which the bilateral vasa deferentia were divided and the seminal vesicles were mobilized. The Denonvilliers' fascia was then opened to establish a working plane between the posterior aspect of the prostate and the anterior rectal wall. This was followed by control of the prostatic pedicles and antegrade dissection of the neurovascular bundles, including the apical portion. Finally, the dorsal vascular complex and urethra were divided, and the procedure was completed with vesicourethral anastomosis.

All camera port wound closures were performed by a senior resident under the supervision of a board‐certified urologist. The transverse and vertical incision techniques were identical except for the orientation of the skin and fascial incisions (Figure 1). A 3.0‐cm transverse or vertical incision was made approximately 2.0 cm above the umbilicus, with subcutaneous fat dissected using electrocautery. A standard 12‐mm single‐use blunt‐tip port (Kii Balloon Blunt Tip) was placed as the camera port. After undocking the robot following completion of prostate removal and vesicourethral anastomosis, the specimen retrieval bag was extracted through the camera port site.

FIGURE 1.

Typical postoperative surgical wounds at the camera port. (a) Transverse camera port incision (b) Vertical camera port incision.

The skin and fascial incisions were extended transversely or vertically when specimen removal was not feasible due to prostate size. Wound extension was defined as positive when additional skin and/or fascial incision was required. Fascial closure was performed transversely or vertically using a running suture with polydioxanone.

2.4. Statistical Analysis

All values are presented as means ± standard deviation. The two‐sided Mann–Whitney U test was used to assess differences in continuous variables between the transverse and vertical groups. Multivariate analyses were performed using logistic regression to identify factors associated with wound pain. A p value < 0.05 was considered statistically significant. All analyses were performed using JMP version 14.2.0 (SAS Institute Inc., Cary, NC, USA).

3. Results

The baseline characteristics of the patients are summarized in Table 1. The mean age was 69.9 ± 7.1 years, and the mean body mass index was 23.5 ± 3.1 kg/m². The mean estimated blood loss was 187.6 ± 173.2 mL, and the mean prostate volume was 48.6 ± 20.1 mL. Regarding the completion rate of the DAS‐59 questionnaire, all 100 patients completed all 59 items of the DAS‐59. Therefore, the full completion rate was 100% (100/100), and there were no partially completed questionnaires or missing total scores. The full completion rate was 100% in both the transverse group (57/57) and the vertical group (43/43). The mean total DAS‐59 score was 31.9 ± 28.6.

TABLE 1.

Comparison of patient characteristics, operative outcomes, and perioperative subjective parameters between the transverse incision and vertical incision.

Parameters	Transverse group	Vertical group	p
	Mean (±SD or %) or number of patients
Incision	57	43
Age (years)	69.5 (7.8)	70.4 (6.3)	0.96
Diabetes mellitus (n)	16:41	14:29	0.62
Abdominal surgery (yes:no)	20:37	17:26	0.64
Height (cm)	165.9 (5.8)	166.6 (5.6)	0.56
Weight (kg)	65.3 (10.0)	64.9 (11.0)	0.58
Body mass index	23.6 (3.1)	23.2 (3.1)	0.42
PSA (ng/mL)	9.7 (7.6)	9.6 (6.0)	0.81
T stage (T2:≥ T3)	49:8	41:2	0.10
Gleason grade			0.20
Group 1, n (%)	14 (24.6)	6 (14.0)
Group 2, n (%)	16 (28.1)	10 (23.3)
Group 3, n (%)	9 (15.8)	13 (30.2)
Group 4, n (%)	13 (22.8)	10 (23.3)
Group 5, n (%)	4 (7.0)	4 (9.3)
Missing, n (%)	1 (1.8)	0 (0.0)
Console duration (min)	220.9 (51.5)	177.8 (45.4)	< 0.001
Wound‐opening and closing time	72.2 (22.8)	65.2 (24.2)	< 0.05
Estimated blood loss (mL)	205.9 (188.3)	163.3 (188.3)	0.28
Prostate size (mL)	48.1 (20.9)	49.2 (19.3)	0.58
DAS‐59 total score	30.1 (30.1)	34.3 (26.5)	0.44

Abbreviations: DAS‐59, Derriford Appearance Scale 59; PSA, prostate specific antigen.

In comparisons between the transverse and vertical incision groups, no statistically significant differences were observed in age, body mass index, estimated blood loss, prostate volume, or total DAS‐59 score between the two groups (Table 1). In contrast, console time (transverse group vs. vertical group: 220.9 ± 51.5 vs. 177.8 ± 45.4 min, p < 0.001) and wound opening and closure time (transverse group vs. vertical group: 72.2 ± 22.8 vs. 65.2 ± 24.2 min, p < 0.05) were significantly longer in the transverse group than in the vertical group. In addition, wound extension was required significantly more frequently in the transverse group than in the vertical group (p < 0.002; Figure 2A). The number of patients who reported wound pain on POD 7 was also significantly higher in the transverse group than in the vertical group (p < 0.001; Figure 2B).

FIGURE 2.

(a) Association between camera port skin incision type and wound extension. Transverse indicates a transverse camera port incision. Vertical indicates a vertical camera port incision. “Yes” indicates the presence of wound extension. (b) Association between camera port skin incision type and wound pain. Transverse indicates a transverse camera port incision. Vertical indicates a vertical camera port incision. “Yes” indicates the presence of wound pain at the camera port. *p < 0.05; **p < 0.001.

Multivariate logistic regression analyses were performed to identify factors associated with wound pain on postoperative Day 7 (Figure 3). Wound extension, age, body mass index (> 25 kg/m²), prostate volume, and incision type (transverse or vertical) were included as independent variables. Body mass index (odds ratio [OR], 9.5; 95% confidence interval [CI], 1.5–188.8; p < 0.01) and incision type (OR, 11.1; 95% CI, 1.7–219.7; p < 0.007) were independently and significantly associated with wound pain on postoperative Day 7.

FIGURE 3.

Forest plot of multivariable logistic regression for wound on postoperative Day 7. BMI, body mass index.

4. Discussion

Our pre‐study hypothesis was that wound pain at the camera port would be comparable between transverse and vertical incisions, whereas patient satisfaction with the camera port scar, as evaluated by the DAS‐59, would be higher with a transverse incision than with a vertical incision.

However, contrary to our hypothesis, the present study demonstrated that wound pain at the camera port was lower with a vertical incision than with a transverse incision. In addition, multivariate analysis showed that wound pain at the camera port was significantly associated with the direction of the incision (transverse or vertical) and the presence or absence of obesity.

A possible explanation for the lower wound pain associated with the vertical incision is that the incidence of additional incisions for specimen extraction was lower in this group; however, multivariate analysis did not demonstrate a significant association between wound pain and the need for an additional incision for specimen extraction. With regard to obesity, although the thickness of subcutaneous adipose tissue was not evaluated in the present study, strong retraction of the skin and subcutaneous adipose tissue using retractors was often required during camera port placement and wound closure to clearly visualize the anterior rectus sheath, which may have contributed to increased wound pain in obese patients.

In minimally invasive (laparoscopic or robotic) radical cystectomy, transverse incisions (Pfannenstiel incisions) have been associated with less postoperative pain than vertical incisions (midline incisions) [16]. Although this finding was contrary to our present results, the authors of that study speculated that the reduced pain associated with the Pfannenstiel incision was attributable to the lack of a need for retractors during urinary diversion in this approach. Thus, a common factor influencing postoperative wound pain in both our present study and the minimally invasive radical cystectomy study may be the degree of wound retraction.

Lee et al. demonstrated that, in laparoscopic colorectal surgery, transverse incisions were associated with better quality of life than vertical incisions, as evaluated by the SF‐36 generic health–related quality‐of‐life instrument [17]. In contrast, in the present study, wound satisfaction assessed using the DAS‐59 did not differ significantly between the two groups. One possible reason for this discrepancy is the difference in the timing of wound satisfaction assessment, which was earlier in the present study than in the study conducted by Lee et al. At 1 month after surgery, which was the evaluation time point in the present study, patients who underwent RARP were more likely to be concerned about urinary incontinence and/or erectile dysfunction than about wound appearance. In addition, wound satisfaction may be influenced by sex differences [5]; however, RARP is performed exclusively in male patients.

Several limitations of the present study should be acknowledged. First, wound pain and wound satisfaction were evaluated at only a single time point. In addition, wound satisfaction was assessed during the early postoperative period. Therefore, future studies are needed to clarify wound satisfaction by performing repeated assessments and by evaluating outcomes at later postoperative time points. Second, although no incisional hernias were observed in either group in the present study (data not shown), the reported incidence of incisional hernia after RARP remains controversial [8, 9]. Thus, further studies are warranted to clarify differences in the incidence of incisional hernia between transverse and vertical incisions. Third, camera‐port incisional pain was assessed only on POD7, which may have been too late to capture the earlier peak of acute postoperative pain associated with a small camera‐port incision. However, assessment during the immediate postoperative period might have been influenced by pain from other port‐site incisions, urethral catheter‐related discomfort, and other postoperative factors, making it difficult for patients to distinguish pain specifically attributable to the camera‐port incision. Therefore, POD7 was selected to reduce the influence of these other sources of pain. Fourth, analgesic use after hospital discharge was not evaluated. Because such use may have affected the assessment of camera‐port incisional pain on POD7, its potential influence on our findings cannot be excluded.

In the present study, both console time and wound‐opening and closure time were significantly longer in the transverse‐incision group than in the vertical‐incision group. To examine whether the temporal distribution of the two incision groups could explain these differences, we divided the 100 consecutive patients into the first 50 cases and the subsequent 50 cases. Transverse incisions were performed in 22 of the first 50 cases and 35 of the subsequent 50 cases, whereas vertical incisions were performed in 28 and 15 cases, respectively. Thus, the proportion of transverse incisions was significantly higher in the later period than in the earlier period (70.0% vs. 44.0%; Pearson's χ ² = 6.90, p = 0.009). Although the skills of the bedside‐assistant team and console surgeons may have improved during the later period, the transverse‐incision group nevertheless had longer console time and wound‐opening and closure time. Therefore, the temporal distribution of the two incision groups does not explain these differences, and the reason for the longer console time in the transverse‐incision group remains unclear.

In conclusion, regarding the surgical wound at the camera port in RARP, vertical incisions were associated with less wound pain and showed comparable patient satisfaction with the surgical wound during the early postoperative period. In addition, the duration of port placement and wound closure was significantly shorter with vertical incisions. From the perspective of surgical invasiveness, a vertical incision for the camera port may therefore be recommended in RARP.

Author Contributions

Aiko Fujikawa: investigation. Seiya Yamashita: validation. Ryota Sako: resources. Keisuke Noda: data curation. Yuki Matsuo: software. Toshihiro Zaizen: visualization. Tomoki Shinohara: investigation. Takuya Miyahara: writing – review and editing. Maiko Fujiwara: methodology, data curation. Kazutaka Nakaya: data curation. Nobuhiro Haga: writing – review and editing, conceptualization, methodology, validation, supervision, project administration, writing – original draft, visualization, formal analysis, funding acquisition. Chikao Aoyagi: resources. Akito Iwata: writing – original draft. Masahiko Tachibana: data curation. Riko Yokoyama: data curation. Kosuke Tominaga: visualization. Shintaro Aso: investigation.

Ethics Statement

Approval of the research protocol by an institutional review board: The study protocol was approved by the Institutional Review Board of Fukuoka University (Approval No. U20‐09‐009).

Consent

Informed consent was obtained from all patients.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request.