Applications of single-port robotic platforms in urology: an overview


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.

Figure 2.1

Biarticulated instruments seen inside the SP trocar.

Figure 2.2

Relocation pedal.

Port placement

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 ).

Figure 2.3

Cadiere, bipolar, and scissors positioned during the seminal vesicles dissection.

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.

Preclinical studies

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.

Table 2.1

Preclinical studies.

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
Lymphadenectomy 2
Maurice et al. 2017 Radical nephrectomy 2 Retroperitoneal None 91.8
Partial nephrectomy 4 100
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

  • Transperitoneal intracorporeal

  • Ileal conduit

1 Transperitoneal None 90
Garisto et al. 2018 Port placement for different types of surgeries 14

  • Transperitoneal

  • Retroperitoneal

  • Transvesical

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.


RP is the most common procedure performed with the SP robot ( Fig. 2.4 ). The outcomes in the current literature are presented in Table 2.2 .

Figure 2.4

Transperitoneal SP robotic-assisted radical prostatectomy.

Table 2.2

Current literature reporting radical prostatectomy.

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

  • 46

  • 52

  • TPR

  • EPT

  • None

  • None

  • 15% (Clavien1 and 2)

  • 11% (Clavien1 and 2)

201 NA 117 27
Covas Moschovas et al. 2020 26 TPR None None 121 85 50 11
Kaouk et al. 2020

  • 8

  • 52

  • TPR

  • EPT

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

  • 45

  • 5

  • TPR

  • EPT

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

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Jun 26, 2022 | Posted by in UROLOGY | Comments Off on Applications of single-port robotic platforms in urology: an overview

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