Stesura Seveso Archivio Italiano di Urologia e Andrologia 2025; 97(3):13934 1 REVIEW INTRODUCTION Minimally invasive surgery, including laparoscopic and robotic-assisted procedures, has revolutionized surgical practice by offering significant advantages over open sur- gery, including reduced blood loss, shorter hospital stays, faster postoperative recovery and decreased postoperative pain (1). Moreover, minimally invasive radical prostatec- tomy techniques (laparoscopic and robot-assisted) appear to be associated with a lower risk of postoperative inguinal hernia (2), a condition for which radical prosta- tectomy has been identified as a risk factor (3). Despite these advantages, minimally invasive approaches are not devoid of risks, with trocar site hernias (TSH) representing a recognized complication of laparoscopic and robotic surgery (4). TSH, while relatively rare (estimated to occur in 0.2% to 4.8% of cases of laparoscopic and robotic pro- cedures) (5), can lead to severe complications such as bowel obstruction, strangulation or even intestinal perfo- ration requiring bowel resection (5-6). The literature sug- gests that approximately 90% of reported TSH cases develop at trocar sites measuring 10 mm or larger (7). In a literature review, Richards analysed 153 TSH cases among over 31,000 patients undergoing laparoscopic or robotic surgery across multiple surgical fields, including general, gynecologic, and urologic procedures. The study examined four key variables: trocar type (bladed vs. non- bladed), follow-up duration, previous abdominal surgery and trocar size at the hernia site. The findings indicated that bladed trocars increase the risk of muscular layer injury, leading to prolonged healing time and a higher TSH incidence, a conclusion corroborated by Gutierrez et al. (2020) (7, 8). Additionally, Damani et al. in 2020, investigated the impact of trocar insertion angle on TSH risk. However, no strong evidence currently supported trocar angle as a significant etiological factor for TSH development (6). The onset of TSH is highly variable, with reported cases ranging from 1 day to 7 years post- operatively, underscoring the necessity for long-term fol- low-up to fully assess this complication (9). Several stud- ies, including those by Damani et al., Timm et al., and Seveso et al., have demonstrated a positive correlation Background: Trocar site hernia is a recog- nized but often underreported complication of minimally invasive surgery, including robotic-assisted radical prostatectomy. While relatively rare, trocar site hernia can lead to severe complications such as bowel obstruction, strangu- lation, and the need for emergency surgical intervention. Trocar size has been identified as a primary risk factor, with hernias occurring predominantly at sites where 10 mm or larger trocars are used. However, the role of fascial closure is still debated. Methods and Results: A systematic literature review (1992- 2022) identified 21 cases of trocar site hernia in 13 studies. Only 8 papers provided data on the total number of RaRP procedures which were associated to the reported cases of TSH, with 15 cases of TSH identified out of 3,418 RaRP procedures. Statistical analyses were conducted to assess significant risk factors and potential prevention strategies. Specifically, of the 19 cases in which trocar size was explicitly reported, 15 hernias were associated with 12 mm trocars and 4 with 8 mm trocars (p value < 0.001). Fascial closure was not performed in all reported cases involving 12 mm trocars. No significant correlations were found between trocar site hernia incidence and patient-related factors such as age, body mass index, or prior hernias. Additionally, we report a case of trocar site hernia following RARP in a 67-year-old male with a BMI of 33.46 and a history of prior abdominal hernioplasty. The patient developed bowel obstruction on postoperative day 4 due to a hernia at a 12 mm trocar site, requiring emergency laparotomy and bowel resection with end-to-end anastomosis. Conclusions: Given the strong association between TSH and 12 mm trocars, we suggest routine fascial closure at these sites to reduce the risk of postoperative complications. Further studies are necessary to confirm these findings. Additionally, other potential risk factors and mechanisms contributing to trocar site hernia development in patients undergoing Robot-Assisted Radical Prostatectomy should be investigated. KEY WORDS: Port-site hernia; Trocar site hernia; Robot-assisted radical prostatectomy; Surgical compli-cations; Robotic surgery; Prostate cancer; Urology; Surgical technique. Submitted 28 April 2025; Accepted 1 June 2025 Strategies for preventing port-site hernia following robot-assisted radical prostatectomy: A systematic review Pier Paolo Prontera 1, Francesca R. Prusciano 2, Marco Lattarulo 1, Gianluigi Califano 3, Francesco Di Bello 3, Claudia C. Ruvolo 3, Simone Morra 3, Angelo D’Elia 1, Angelo Porreca 4, Luca Di Gianfrancesco 4, Filippo Marino 4, Giulia Marino 5, Francesco Saverio Grossi 1 1 Department of Urology, “S.S. Annunziata” Hospital, Taranto (TA), Italy; 2 Department of Urology, Hospital “Valle D’Itria”, Martina Franca (TA), Italy; 3 Department of Neurosciences, Reproductive and Odontostomatologic Sciences, University of Naples “Federico II”, Naples, Italy; 4 Department of Urology, Humanitas Gavazzeni Hospital, Bergamo (BG), Italy; 5 Department of Precision and Regenerative Medicine, Ionean Area, Taranto (TA), Italy. DOI: 10.4081/aiua.2025.13934 Summary Archivio Italiano di Urologia e Andrologia 2025; 97(3):13934 P.P. Prontera, F.R. Prusciano, M. Lattarulo, et al. 2 between previous abdominal surgery and TSH occur- rence (6, 8, 9). This correlation is likely due to the weak- ening of previous trocar sites during subsequent laparo- scopic procedures, as the current standard practice does not require fascial closure for trocar sites up to 8 mm in diameter. However, further research is needed to confirm this hypothesis. Damani et al. reported a lower TSH risk for trocar sites smaller than 8 mm, whereas Seveso et al. found no statistically significant difference in TSH rates between 5-mm trocar sites with or without fascial closure (6-10). Furthermore, Seveso et al. noted an increased inci- dence of TSH with bladed trocar use, reinforcing the potential influence of trocar type on hernia development. Nonetheless, TSH cases have also been documented in patients where bladeless trocars were used, suggesting that additional risk factors may contribute to hernia for- mation (10). Several patient-related and technical factors have been investigated in TSH development. Patient- related factors include increased intra-abdominal pres- sure, obesity, chronic cough, diabetes, smoking, wound infection, chemotherapy and malnutrition. Technical fac- tors include trocar insertion angle, bladed versus radially expanding trocars, pneumoperitoneum induction, port placement, operative duration, specimen extraction site and fascial closure techniques. Notably, an increased inci- dence of TSH has been observed in obese and bariatric patients, likely due to elevated intra-abdominal pressure and greater pneumoperitoneum volumes (11). TSH is classified as an incisional hernia occurring at the trocar site following minimally invasive surgery (12). The most widely recognized risk factor for TSH is trocar size, as highlighted by Swank et al. and Owens et al. (13, 14). Robotic-assisted radical prostatectomy (RaRP) is now the standard surgical approach for eligible prostate cancer patients requiring surgery. The typical RaRP trocar place- ment configuration consists of six ports: the 8-mm pri- mary camera port was placed 2 to 3 cm at the superior umbilical region. The two 8-mm robotic ports were intro- duced lateral to the rectus muscle and at the level of umbilicus on both sides. An 8-mm robotic port for the fourth arm was placed above the left iliac crest in the mid- axillary line and a second 12-mm port for the assistant was placed in the opposite site. A 5-mm port for the assis- tant was placed between the robotic and camera ports on the right (Figure 1). The prostate specimen is typically extracted through a small laparotomy, extending the camera port incision (15-17). Given the increasing adop- tion of robotic surgery and the associated risk of TSH, this review aims to synthesize current evidence on trocar site hernias in patients underwent RaRP, in order to recog- nized useful strategies to prevent this uncommon but potential severe complication. MATERIALS AND METHODS Literature review The systematic review was conducted in accordance with the PRISMA 2020 guidelines (Figure 2). The literature search was performed using the PubMed and Google Scholar databases, applying the Boolean search terms "trocar hernia" OR "port-site hernia" AND “Robot assisted radical prostatectomy”. The search was restricted to studies published starting from 1992 onwards, which marks the introduction of laparoscopic radical prostatectomy. Prior to this year, the radical prostatectomy procedure was performed exclusively through an open surgical approach. The aim of the review was to identify case reports or case series describing the occurrence of trocar site hernias following laparoscopic or robot-assisted radical prostatectomy. Records were screened by evaluating titles and abstracts, followed by a full-text assessment of potentially eligible stud- ies. Only articles published in peer-reviewed journals and available in English or with an English abstract were considered. Studies were excluded if the described hernia cases were unrelated to radical prostatectomy or if the herniation occurred in anatomical sites other than the trocar or port site. Records that did not meet these criteria were systematically excluded. No automation tools were used in the selection process, and all stages of screening and data extraction were independently con- ducted by two reviewers, with any disagree- ments resolved through discussion. Through this process, 13 articles were identified and included in the final qualitative synthesis (Figure 2), reporting a total of 21 cases of TSH. The selected studies were divided into two groups: those that reported both the total num- ber of RaRP performed and the number of TSH cases observed and those that only reported the number of TSH cases without mentioning the total number of RaRP performed. Articles explicitly reporting the caliber of the trocar placed at the TSH site were identified, while in the remaining articles, indirect information was Figure 1. Trocar placement for Robot-Assisted Radical Prostatectomy (RaRP). Archivio Italiano di Urologia e Andrologia 2025; 97(3):13934 3 Port-site hernia following robot-assisted radical prostatectomy sought to infer this data (e.g., the anatomical location of the TSH). Data were extracted for the following variables: age, BMI, presence of metabolic diseases, hypertension, chronic medication use, history of prior inguinal or umbilical hernias, timing of TSH onset relative to RaRP, type of initial symptoms (subtle, symptoms without bowel obstruction, bowel obstruction), presence of abdominal bulging at the hernia site upon physical exam- ination, anatomical location of TSH, trocar size, Gleason score, preoperative PSA levels, prostate volume, fascial closure at the RaRP site where TSH occurred, time to resumption of oral intake after RaRP, type of TSH repair (minimally invasive, mini-laparotomy, laparotomy), need for bowel resection and hernia type (Table 1). Some of these factors (presence of metabolic diseases, hyperten- sion, chronic medication use, history of prior inguinal or umbilical hernias, timing of TSH onset relative to RaRP, Gleason score, preoperative PSA levels, prostate volume and time to resumption of oral intake after RaRP) were inconsistently reported by different authors and were therefore not considered suitable for analysis. Statistical analysis Statistical analyses were conducted to evaluate associa- tions between TSH occurrence and various clinical and surgical factors. Descriptive statistics were used to sum- marize patient demographics and surgical characteristics. Associations between categorical variables, such as trocar size, fascial closure, hernia type, and the need for bowel resection, were assessed using the chi-square test or Fisher’s exact test, as appropriate. Relative risk (RR) was calculated to estimate the impact of fascial closure on TSH occurrence. When not directly stated by the study authors, Since the total number of trocars used in each procedure was not consistently reported, we estimated trocar counts based on standard RaRP templates. For each RaRP, we assumed the use of one 12 mm assistant port, three 8 mm robotic ports, one optical trocar, and Figure 2. PRISMA 2020 flow diagram for new systematic reviews which included searches of databases and registers only. Archivio Italiano di Urologia e Andrologia 2025; 97(3):13934 P.P. Prontera, F.R. Prusciano, M. Lattarulo, et al. 4 one 5 mm accessory port. The chi-square analysis on TSH occurrence by trocar size was conducted using only those articles in which both the total number of trocars and their caliber could be directly determined. A p-value < 0.05 was considered statistically significant. The results were interpreted in the context of their clinical relevance, particularly in the prevention and management of TSH in robotic-assisted laparoscopic surgery. Risk of bias A risk of bias assessment was performed using the JBI critical appraisal approach for case series and descriptive observational studies. RESULTS A literature review was conducted using the PubMed and Google Scholar platforms to identify studies describing cases of TSH in patients undergoing RaRP. Studies report- ing cases of TSH in patients undergoing general laparo- scopic surgery or other urological surgeries different from RaRP were excluded. A total of 13 papers were evaluated: 5 case reports, 5 retrospective original articles, 2 combining case reports and retrospective original data, and 1 case report with a literature review. Overall, the reported cases refer to patients who underwent RaRP between 2003 and 2020. In 8 of these articles, it was possible to extract the total number of RaRP procedures performed (3,418 cases) and the number of reported TSHs (15 cases) between 2008 and 2020, resulting in an estimated incidence of 0.44% (5- 6, 15-26). Upon analysis of the included studies, it was found that trocar placement by the various authors was generally consistent with the configuration outlined in the Figure 1, which adheres to the manufacturer's recom- mended setup for the robotic platform. In detail, an 8-mm optical trocar was placed supraumbilically; three additional 8-mm robotic trocars were positioned at a minimum dis- tance of 8 cm from each other (right pararectal, left pararec- tal, and left lateral locations); and two assistant laparoscop- ic trocars were utilized - a 12-mm trocar placed laterally on the right side, and a 5-mm trocar inserted on the right in a triangulated position between the optical trocar and the right pararectal robotic trocar (Figure 1). Due to inconsis- tent reporting across studies, variables such as presence of metabolic diseases, hypertension, chronic medication use, Gleason score, PSA levels, prostate volume, and time to resumption of oral intake were not included in the statisti- cal analysis. Among the 21 described cases of TSH, 16 were classified as “Spigelian” hernias, 3 as incisional hernias at the optical trocar site used for specimen extraction, 1 as a “Richter's” hernia, 1 as a hernia of the vermiform appendix (Table 1). In 13 cases (61.9 %), abdominal bulging was reported; however, this finding was not statistically corre- lated with the presence of bowel obstruction at onset (p- value: 0.52), hernia type (p-value: 0.62), or the need for bowel resection during TSH repair (p-value: 1). To assess the statistical correlation between trocar type and TSH inci- dence, descriptive analyses and chi-square tests were per- formed based on data extracted from the 7 articles that pro- vided information on the total number of procedures. Across all these cases, a total of 15 TSHs were reported: 2 were associated with 8 mm trocars and 13 with 12 mm tro- cars. The authors of these 7 articles explicitly stated the size of the trocar placed at the TSH site. Among the 13 studies included in this review, only two did not directly report the trocar size; however, both provided indirect information (i.e., anatomical location of the hernia site), strongly sug- gesting that the two TSHs described (accounting for 9.5% of the total) were also related to 12 mm trocars (21, 23). The analysis included 8 mm robotic trocars and 12 mm Table 1. Summary of Reported Trocar Site Hernia (TSH) Characteristics of Selected Studies: This table summarizes the characteristics of Trocar Site Hernia (TSH) cases reported in selected studies. Variables include TSH type, bowel re-section, intervention type, fascial closure, trocar size, port site, abdominal bulging, bowel obstruction at onset, symptomatic onset, time of TSH presentation, mean BMI, and mean age. For authors reporting multiple TSH cases, the partial number of variables for each case is indicated in parentheses. Author Ogasa et al., 2020 (16) Mancini et al., 2020 (18) Tobe et al., 2022 (15) Schmocker et al., 2016 (22) Hotston et al., 2009 (19) Damani et al., 2020 (6) Tsu J.H.L. et al., 2013 (20) Singh Wazir J.P. et al., 2021 (21) Jazayeri S.B. et al., 2016 (23) Kang D.I. et al., 2012 (25) Christie M.C. et al., 2016 (17) Chiong E. et al., 2014 (24) Fischer B. et al., 2008 (4) RaRP performed (n°) N/A 1531 N/A N/A 500 N/A 200 N/A N/A 498 38 441 210 TSH reposted (n°) 1 3 1 1 2 1 1 1 1 2 2 4 1 Mean age (range) 56 67 (60-71) 73 66 68.5 (67-70) N/A 75 65 71 59 (52-66) 69 (65-73) 65 (60–70) 64 Mean BMI (range) 25.7 23.43 (20.1-25.7) 22.2 28 N/A N/A N/A N/A N/A 30.6 (29.8-31.4) 26.85 (22.4-31.3) 25.15 (17.9-32) 27 Time of TSH presentation 4 4.5 (1-4) 11 730 5 (1-4) N/A 4 2 3 547 N/A 97.5 (2-335) N/A Symptomatic onset, (n°) Yes Yes (3) Yes Yes Yes N/A Yes Yes Yes Yes Yes Yes N/A Bowel obstruction at onset, (n°) Yes Yes (2), No (1) Yes No No N/A No No No No No No N/A Abdominal bulging, (n°) Yes Yes (2), No (2) No Yes Yes N/A Yes Yes Yes Yes Yes Yes (1), No (3) N/A Port-site Right Pararectal Right Literal (2), Left Lateral (1) Supre-Umbilical Right Literal Right Literal Right Literal Left Lateral Right Literal Right Literal Supre-Umbilical Supre-Umbilical Right Literal N/A Port-dimension (mm) 8 12 (2), 8 (1) 12 12 12 8 8 12 12 12 12 12 12 Fascial closure after RaRP Yes No Yes N/A N/A N/A No N/A Yes Yes Yes No N/A Type of intervervention, (n°) Laparoscopy Open (2), Laparoscopy (1) Open Open Open Open Open Open Laparoscopy Open Open Open Open Bowel resection, (n°) No Yes (1), No (2) Yes Yes Yes (1), No (1) Yes No No Yes (2) No (2) No Yes (1), No (3) No Type of TSH Richter Spigelian Incisional Vermiform Appendix Spigelian Spigelian Spigelian Spigelian Spigelian Incisional Incisional Spigelian Spigelian Archivio Italiano di Urologia e Andrologia 2025; 97(3):13934 5 Port-site hernia following robot-assisted radical prostatectomy laparoscopic trocars. The optical trocar was analysed sep- arately, as it represents the incision site for specimen extraction and an incisional hernia at this location may have a different pathogenic significance, compared to a hernia occurring through one of the other trocars used during robotic surgery. The chi-square test demonstrated a strong statistically significant correlation between TSH incidence and the 12 mm laparoscopic trocar (χ² = 27.25, p < 0.0001) and the corresponding incidence rates were 3.80 per 1000 for 12-mm ports and 0.20 per 1000 for 8- mm ports. In none of the TSH cases involving the 12 mm laparoscopic trocar was fascial closure at this site described at the end of the RaRP. In all patients, fascial closure was performed at the extraction site (optical tro- car), whereas only one case reported fascial closure at other trocar sites, in which a TSH was observed at an 8 mm trocar site. Among the 21 total cases of TSH, 7 were treated with bowel resection at the time of TSH repair and 14 underwent hernia reduction without the need for bowel resection. No statistically significant differences emerged in terms of bowel resection rates between TSH occurring at the optical trocar site and TSH at other tro- car sites (p-value: 0.92, Chi²: 0.0099). The analysis of the impact of fascial closure on TSH onset, performed using the chi-square test, revealed a statistically significant cor- relation (p-value: 0.00068, Chi²: 11.55, RR: 16). The impact of other factors, such as age, BMI, and history of prior inguinal or umbilical hernias, was also evaluated; however, no statistically significant associations were found (p-values: 0.85, 0.61, 0.60, and 1, respectively). In addition, we report the case of a 67-year-old obese male (BMI 33.46) with a history of multiple prior abdominal wall hernioplasties, who developed bowel obstruction on postoperative day 4 following RaRP. The obstruction was caused by a trocar site hernia at the 12 mm right lateral port site, requiring emergency laparotomy and ileal resec- tion with primary anastomosis. No abdominal bulging was observed prior to symptom onset, and the fascial plane at the 12 mm trocar site had not been closed (Figure 3). Using the JBI critical appraisal approach for case series and descriptive observational studies (27), the included studies were evaluated across eight methodological domains. The overall risk of bias was considered moder- ate, with several domains satisfactorily addressed, includ- ing the presence of clear inclusion criteria, adequate case description, and consistent diagnostic criteria for TSH. However, heterogeneity in the reporting of clinical vari- ables (e.g., BMI, prior hernias, fascial closure) and follow- up duration was noted. Most studies did not discuss internal sources of bias such as selection or measurement bias, and the representativeness of cases may be affected by selective reporting. These limitations underline the need for cautious interpretation of pooled data. DISCUSSION TSH represent a recognized but often underreported and potentially severe complication of minimally invasive sur- gery (5-6), including RaRP. The estimated incidence of TSH after RaRP, according to our results, is 0.44%, close to estimated incidence of TSH after others mini-invasive sur- gery (5). The findings from our literature review, in accor- dance with the case report described, highlight a significant correlation between the use of a 12 mm assistant trocar and the occurrence of TSH, reinforcing the hypothesis that tro- car size plays a critical role in hernia formation (7). Notably, this observation is not limited to patients under- going RaRP but has also been reported in other minimally invasive abdominal procedures, both laparoscopic and robotic-assisted, across various surgical fields, including urology, gynecology and general surgery (7). This broader trend further supports the hypothesis that trocar diameter significantly contributes to TSH development. The type of the trocar is another key factor in TSH pathogenesis. Some studies have shown that the use of bladed (cutting) trocars increases the risk of herniation due to greater disruption of the fascial and muscular layers, leading to prolonged heal- ing time and a higher likelihood of hernia formation (7, 8). However, the insertion angle of the trocar remains a debat- ed factor, as current evidence does not strongly support a Figure 3. Contrast-enhanced CT images: Contrast-enhanced CT images in the arterial phase (A axial plane, B coronal plane, and C sagittal plane) performed at the onset of symptoms for the hernia. The arrow highlights a small defect in the lateral abdominal wall at the right flank, with herniation of an ileal loop at this level and concomitant upstream distension of the small bowel loops, suggestive of mechanical obstruction. Archivio Italiano di Urologia e Andrologia 2025; 97(3):13934 P.P. Prontera, F.R. Prusciano, M. Lattarulo, et al. 6 significant correlation between trocar angulation and TSH onset (6). Additionally, while our review did not identify a statistically significant correlation between TSH incidence and BMI, some authors have reported a higher TSH inci- dence in bariatric patients, likely due to increased intra- abdominal pressure and greater pneumoperitoneum vol- umes (11). Similarly, patients with a history of prior abdominal surgery appear to be at greater risk, possibly due to pre-existing weaknesses at previous trocar sites (6- 9). However, the limited number of TSH cases observed in our review prevents definitive conclusions regarding these associations, suggesting the need for larger studies to clari- fy the role of BMI and prior surgery in TSH development. An important consideration is the surgical approach itself. TSH is primarily a complication associated with the transperitoneal approach to RaRP, as the peritoneum is breached during trocar placement, facilitating potential herniation through the defect. Conversely, extraperitoneal RaRP, as in the case of extraperitoneal laparoscopic radical prostatectomy (28), eliminates this risk by avoiding peri- toneal penetration altogether, thereby reducing the risk of internal organ herniation. This technical difference may explain the lower incidence of TSH reported with extraperitoneal techniques and warrants more structured comparative studies. Additionally, extraperitoneal RaRP may offer particular advantages in patients at high risk for postoperative hernias, such as those with prior intra- abdominal surgery, obesity, or peritoneal adhesions. This distinction suggests that surgical approach selection may itself be a preventive factor, warranting further comparative studies to evaluate the impact of transperitoneal versus extraperitoneal RaRP on TSH incidence. Given the multi- factorial nature of TSH, an integrated preventive strategy should include: careful selection of trocar type and size, routine fascial closure, and a tailored approach based on patient-specific risk factors. Moreover, surgical approach selection, transperitoneal vs. extraperitoneal, should be considered as a potential modifiable factor when planning prostate cancer surgery in high-risk populations. The sta- tistically significant correlation between TSH incidence and the 12 mm trocar (χ² = 27.25, p < 0.0001) and the statis- tically significant impact of fascial closure on the incidence of TSH (p-value: 0.00068), suggests that fascial closure at this site may be a crucial preventive strategy to prevent the occurrence of TSH after RaRP, especially in bariatric patients and those with a history of prior abdominal sur- gery. Future studies should further investigate these risk factors to refine preventive strategies and optimize patient outcomes in robotic surgery. Limitations This study presents several limitations that should be acknowledged. First, the overall number of TSH cases identified in the literature review is relatively small (n = 21) with only 15 cases were described by authors who also reported the total number of RaRP procedures per- formed and the corresponding trocar size, limiting the statistical power and generalizability of the findings. Second, the review is retrospective and relies on data extracted from previously published case reports and case series, which may be subject to publication bias and inconsistencies in reporting. Third, there is significant heterogeneity among the included studies in terms of study design, data completeness, and follow-up duration, which could affect the accuracy of comparisons and pooled analyses. Several potentially relevant variables, such as metabolic comorbidities, Gleason score, prostate volume, and time to oral intake resumption, were not consistently reported across studies and were therefore excluded from statistical analysis. Consequently, the results and conclusions presented in this manuscript should be interpreted with caution and validated in prospective, multicenter studies with standardized data collection protocols. DECLARATIONS Ethical approval: This study was approved by the Local Ethics Committee of Bari (BA), IRCCS Oncological Institute "Gabriella Serio" (Protocol number: 2112/CEL - Study “PrOPT”). Availability of data and material: The datasets generated and analyzed during the current study are available from the corresponding author upon reasonable request. Competing interests: The authors declare no competing interests. Funding: This research received no specific grant from any fund- ing agency in the public, commercial, or not-for-profit sectors. Authors' contributions: 1: Pier Paolo Prontera - author corre- sponding: Substantial contributions to the conception, design of the work, acquisition, analysis and interpretation of data for the work. Drafting the work, reviewing it critically for important intellectual content. Final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensur- ing that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; 2: Francesca Romana Prusciano, Francesco Saverio Grossi: Substantial contributions to the conception, design of the work, acquisition, analysis and interpretation of data for the work. Drafting the work, reviewing it critically for important intellectu- al content. Final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensur- ing that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved; 3: Marco Lattarulo, Gianluigi Califano, Francesco Di Bello, Claudia Collà Ruvolo, Simone Morra, Angelo D’Elia, Angelo Porreca, Luca Di Gianfrancesco e Filippo Marino: Substantial contributions to the interpretation of data for the work. Reviewing it critically for important intellectual content. Final approval of the version to be published. Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All authors read and approved the final version of the manu- script. Acknowledgments: Not applicable. Informed consent statement: Informed consent was obtained from patient involved in the study. Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the indi- vidual author(s) and contributor(s) and not of the editor(s). and/or the editor(s) disclaim responsibility for any in-jury to people or property resulting from any ideas, methods, instruc- tions or products referred to in the content. Archivio Italiano di Urologia e Andrologia 2025; 97(3):13934 7 Port-site hernia following robot-assisted radical prostatectomy CONCLUSIONS TSH represent a rare but potentially severe complication of minimally invasive surgery, including RaRP. Our find- ings, supported by a systematic literature review and a case report, confirm a strong correlation between TSH incidence and the use of 12 mm trocars, reinforcing the critical role of trocar size in hernia formation. The absence of routine fascial closure at these trocar sites appears to be a significant risk factor, suggesting that implementing systematic fascial closure could serve as a protective strategy. Additionally, although no statistically significant correlation was found between TSH incidence and patient-related factors such as BMI or prior abdomi- nal surgery, some studies indicate an increased TSH risk in bariatric patients and those with a history of previous laparotomy, likely due to elevated intra-abdominal pres- sure and pre-existing wall weakness. These findings, although not conclusive in our review, underscore the need for further prospective studies to clarify the impact of these factors. Furthermore, while bladed trocars have been associated with a higher risk of TSH due to increased fascial trauma, trocar insertion angle does not currently appear to be a significant contributing factor. Another key consideration is that TSH is inherently a complication of transperitoneal RaRP, whereas the extraperitoneal approach avoids peritoneal penetration, potentially reducing this risk. 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J Endourol. 2012; 26:848-851 26. Liatsikos E, Rabenalt R, Burchardt M, et al. Prevention and man- agement of perioperative complications in laparoscopic and endo- scopic radical prostatectomy. World J Urol. 2008; 26:571-580. Archivio Italiano di Urologia e Andrologia 2025; 97(3):13934 P.P. Prontera, F.R. Prusciano, M. Lattarulo, et al. 8 27. Munn Z, Stone JC, Aromataris E, et al. Assessing the risk of bias of quantitative analytical studies: introducing the vision for critical appraisal within JBI systematic reviews. JBI Evid Synth. 2023; 21:467-471. 28. Grossi FS, Utano E, Minafra P, et al. Oncological and function- al outcomes of extraperitoneal laparoscopic radical prostatectomy: An 18-years, single-center experience. Arch Ital Urol Androl. 2021; 93:268-273. Correspondence Pier Paolo Prontera (Corresponding Author) pierpaolo.prontera@asl.taranto.it Department of Urology, “S.S. Annunziata” Hospital Bruno Francesco, 1 Street - 74010 Taranto (Italy) Francesca Romana Prusciano francescaprusciano@gmail.com Marco Lattarulo marco.lattarulo@asl.taranto.it Angelo D'Elia angelo.delia@asl.taranto.it Francesco Saverio Grossi francescos.grossi@asl.taranto.it Department of Urology, “S.S. Annunziata” Hospital, Taranto (TA), Italy Gianluigi Califano gianl.califano2@gmail.com Francesco Di Bello fran.dibello12@gimail.com Claudià Collà Ruvolo c.collaruvolo@gmail.com Simone Morra simonemorra93@gmail.com Department of Neurosciences, Reproductive and Odontostomatologic Sciences, University of Naples “Federico II”, Naples, Italy Angelo Porreca angelo.porreca@hunimed.it Luca Di Gianfrancesco luca.digian@libero.it Filippo Marino filippo.marino@gavazzeni.it Giulia Marino giulia.marino91@gmail.com Department of Urology, Humanitas Gavazzeni Hospital, Bergamo (BG), Italy