The da Vinci SP robot was cleared by the Food and Drug Administration (FDA) in November 2018. Due to its short life on the market, studies describing the da Vinci SP (SP) approach to urologic surgery are very recent in the literature. The first study reporting the SP clinical application was described by Kaouk and colleagues, who performed 19 procedures, 11 radical prostatectomies, and 8 nephrectomies. The author reported feasible procedures with no conversions to alternative surgical approaches. Since then, the use of the SP has expanded, and multiple authors have described other applications for several types of urological procedures.
In this scenario, radical prostatectomy (RP) has become the most common surgical procedure performed with the SP robot in most centers, followed by kidney surgery. However, due to limited follow-up time, the long-term outcomes are still unknown for SP patients. In this chapter, we will describe current urologic applications and the available outcomes of the SP platform.
Da Vinci SP settings
Instruments and pedals
The main modification of this platform regards the instrument’s design and articulated scope working simultaneously in only one trocar. Instead of four independent trocars placed in different positions, the SP console has a single port housing three, biarticulated instruments, and flexible scope ( Fig. 2.1 ). This platform was initially built with an extra pedal, named the relocation pedal, used to drive all instruments and scope to different quadrants at the same time ( Fig. 2.2 ). Until now, all studies published in the literature were performed with this pedal configuration. However, the SP had a recent update, which removed the extra pedal and changed the relocation function to a hand command.
Different groups in the literature have described multiple techniques of SP trocar placement for RP and other urologic procedures. Appropriate port placement is necessary to allow the biarticulated instruments to achieve optimal working distance and triangulation. Placing the instruments too close to the surgical site increases internal clashing and restricts the scope visualization. This can be overcome by using the floating trocar during extraperitoneal SP-RARP and kidney surgery, because even with an infraumbilical incision, the trocar position (outside of the body) will provide the appropriate working distance.
Challenges and limitations
After achieving the learning curve with the SP platform, we identified factors that may prove to be challenges during the surgical procedure. The scope and instrument triangulation demand a learning curve in terms of angles and working distances; all arms are connected on the same base and have to work in the same space. The instruments are constantly repositioned during the surgical steps and the flexible scope angles are modified accordingly to provide optimal view and avoid clashing with the other instruments ( Fig. 2.3 ).
The SP instruments have a reduced caliber (6 mm) compared to the XI (8 mm). Therefore this modification affects the capacity of traction, gripping, and dissection. By having a more delicate instrument, this robot is appropriate for selected cases due to its delicate tips and lack of rigid arms to provide traction when needed.
The first studies with the SP console were performed in cadavers using a prototype platform called SP999. Table 2.1 summarizes these preclinical findings. The authors described different types of procedures with no conversions to open surgery or other robotic approach.
|Author||Year||Type of surgery||Number of cases||Type of access||Intraoperative complications||Median operative time (min)|
|Ramirez et al.||2016||Perineal radical prostatectomy||1||Transperitoneal||None||180–240|
|Maurice et al.||2017||Radical nephrectomy||2||Retroperitoneal||None||91.8|
|Maurice et al.||2017||Radical cystectomy+LND||2||Transperitoneal||None||197 and 200|
|Kaouk et al.||2018||Partial prostatectomy||3||Transvesical||None||43|
|Garisto et al.||2018||1||Transperitoneal||None||90|
|Garisto et al.||2018||Port placement for different types of surgeries||14||None||N/A|
|Ng et al.||2019||Radical prostatectomy||1||Retzius||None||146|
|Garisto et al.||2019||Radical cystectomy||1||Perineal||None||185|
|Garisto et al.||2019||Renal transplant||1||Transperitoneal||None||182|
SP applications in urologic surgeries
Kidney and ureters
The SP approach to kidney surgery has also been expanding in different centers, especially using extraperitoneal access. Kaouk and colleagues reported the surgical outcomes for three patients with renal masses who underwent SP partial nephrectomy (PN). No conversions or intraoperative complications were reported in this series. The group described a median operative time of 180 minutes, average ischemia time of 25 minutes, and 180 mL of blood loss (average). One patient had postoperative bleeding and underwent arterial embolization. In a different series, Frang et al. described the SP technique for PN and radical nephrectomy in a cohort of 16 patients with cortical tumors.
The SP platform has also been described for treating benign kidney conditions. Heo and colleagues described the outcomes of SP pyeloplasty in three patients with ureteropelvic junction obstruction. The author used the Anderson-Haynes technique in all patients and the transperitoneal approach with no complications or conversions. The entire procedure was performed with only one incision using the GelPOINT to allocate the robotic trocar and eventual suction and assistant. In this scenario, Agarwal et al. described the SP approach to adult pyeloplasty.
SP ureteric reimplantation for benign ureteric stricture was described by Kaouk and colleagues in three patients. The first two procedures used an assistant trocar (SP plus one) and a supraumbilical GelPOINT to house the SP trocar. No intraoperative complications were reported. Hebert et al. also reported a ureteroneocystostomy in one patient with right distal ureteral stricture.
Furthermore, three different procedures were described by Billah and colleagues in six patients. Four patients underwent pyeloplasty, one patient underwent ureteroplasty, and one patient underwent ureterectomy. The author has described feasible procedures with no intraoperative complications.
Finally, the initial experience of SP kidney transplantation was described by Kaouk and colleagues as an alternative for robotic transplantation. The author has described nine cases with no complications and satisfactory renal function during the follow-up.
|Author||Year||Number of cases||Access||Intraoperative complication rates||Postoperative complication rates (Clavien)||Operative time (min)||Console time (min)||Blood loss (mL)||Positive margins (%)|
|Kaouk et al.||2014||11||TPR||None||239||NA||350||18|
|Kaouk et al.||2019||3||TPR||None||None||180–300||NA||50–100||33|
|Ng et al.||2019||20||TPR||None||25% (Clavien 1 and 2)||208||NA||296||55|
|Agarwal et al.||2019||49||TPR or Retzius||None||8.1% (Clavien1)||161||NA||200||28|
|Kaouk et al.||2019||10||RTP||None||None||197||NA||50–400||50|
|Dobbs et al.||2019||10||TPR||None||None||234||189||20–150||20|
|Kaouk et al.||2019||5||TPR||None||25% (Clavien 2)||180–330||NA||50–750||20|
|Dobbs et al.||2019||24||TPR||1 Bowel serosal injury||45% (Clavien 1 to 4B)||191–343||NA||75|
|Kaouk et al.||2019||201||NA||117||27|
|Covas Moschovas et al.||2020||26||TPR||None||None||121||85||50||11|
|Kaouk et al.||2020||None||None||106–281||NA||50–200||30|
|Valero et al.||2020||1||TPR||None||None||256||108||100||0|
|Kim et al.||2020||20||TPR||None||None||200–255||165–210||155–300||35|
|Jones et al.||2020||23||TPR||None||26%||236||NA||50||39|
|Wilson et al.||2020||60||EPT||None||18% (Clavien 3a)||198||NA||179||23|
|Vigneswaran et al.||2020||None||14%||290||230||100||40|
|Covas Moschovas et al.||2021||50||TPR||None||None||118||80||50||14|
|Abaza et al.||2021||59||TPR||NA||NA||NA||NA||NA||NA|
|Covas Moschovas et al.||2021||71||TPR||None||None||114||80||55||17|
|Talamini et al.||2021||20||TPR||1 Bowel serosal injury||20% (Clavien 1–4B)||225||191||20–250||45|
|Lenfant et al.||2021||26||RPP||None||50% (Clavien1–3A)||255||NA||100||65.4|
|Kaouk et al.||2021||20||TVS||None||5% (Clavien 1)||199||119||135||15|