Comparison of perioperative outcomes and costs between single-port and standard multiport robot-assisted surgeries in urology

10.1 Introduction

Robot-assisted single-port (SP) surgery, which has been increasingly studied in the past decade, represents an opportunity to advance technology and improve patient outcomes. The da Vinci SP (Intuitive Surgical, Sunnyvale, California, United States) is a purpose-built system that received FDA approval in 2018 and follows years of innovation in institution-specific techniques in robotic-laparoendoscopic single-site surgery (R-LESS). The purpose-built SP da Vinci surgical system has enabled broader adoption of this technology among urologic surgeons. Early studies have supported acceptable perioperative outcomes with use of SP robotics. Patient outcomes with a novel surgical technique should be, at minimum, comparable to the standard of care to justify continued use. Here, we review the existing literature on perioperative outcomes and costs associated with SP urologic surgeries with a focus on comparison to MP surgeries.

10.2 Radical prostatectomy

SP-robot-assisted radical prostatectomy (RARP) is the most extensively studied of the SP urologic procedures, with atleast 23 case series and 9 comparative studies, altogether encompassing over 900 patients. Initial studies demonstrate feasibility and safety of single-site RARP and have since transitioned to assessing differences in patient outcomes based on limited follow-up data ( Table 10.1 ). Although nonstandard approaches to prostatectomy such as perineal and transvesical routes have been explored with SP robotics and shown to be feasible, extra- and transperitoneal RARP remain most popular and comprise the bulk of our discussion.

Table 10.1

Perioperative outcomes of single-port robot-assisted radical prostatectomy.

	Year	Author	Title	n (R-SP RP)	Operative time (min)	EBL (mL)	# of nodes	LoS (days)	Clavien-Dindo complicatio n ≥2 rate	Pain scale (VAPS), OMEQ, or % pain-free at DC	+ Margin rate	Erectile function	Continence rate (0–1 pads at 12 weeks)
R-LESS	2009	Kaouk et al.	Robotic single-port transumbilical surgery in humans: initial report	1	300	250	NR	1.5	0 (0%)	0 at 1 week	0 (0%)	1 (100%) at 3 weeks	0 (0%) at 3 weeks
	2009	Barrett et al.	Re: Initial complete laparoscopic single-site surgery robotic assisted radical prostatectomy (LESS-RARP)	1	210	300	NR	NR	0 (0%)	NR	0 (0%)	1 (100%)	1 (100%)
	2010	White et al.	Robotic laparoendoscopic single-site radical prostatectomy: technique and early outcomes	20	187.6	128.8	4	2.5	3 (15%)	1.6 VAPS, 22.3 OMEQ	4/17 (23%)	NR	9/11 (81%) at 16 weeks
	2012	White et al.	Robotic laparoendoscopic single site urological surgery: analysis of 50 consecutive cases	20	189.5	142	4	2.7	3 (15%)	1.4	4 (20%)	1 SHIM>=21 at 3 months f/u; 2 at 1 year follow up	18 (90%) at 4 months
	2014	Kaouk et al.	A novel robotic system for single-port urologic surgery: first clinical investigation	11	239	350	4.5	5	3 (27.3%)	NR	2 (18.2%)	1/11 (9%) at 1 year	6/11 (54.5%) at 1 month, 10/11 (91%) at 1 year
	2016	Kaouk et al.	Descriptive technique and initial results for robotic radical perineal prostatectomy.	4	280	62.5	NR	1.4	0 (0%)	NR	3 (75%)	NR	4 (100%) at 6 months
	2017	Tugcu et al.	Single plus one port robotic radical prostatectomy (SPORP); Initial experience.	8	143	45	NR	NR	NR	NR	0 (0%)	NR	6 (75%)
	2018	Mattevi et al.	First case of robotic laparoendoscopic single-site radical prostatectomy with single-site VesPa platform.	1	300	400	NR	NR	0 (0%)	NR	0 (0%)	0 (0%)	0 (0%) at 12 weeks; 1 (100%) at 1 year
	2018	Tugcu et al.	Robotic perineal radical prostatectomy and robotic pelvic lymph node dissection via a perineal approach: the Tugcu Bakirkoy technique.	7	184.1	64.2	NR	2.1	NR	NR	1 (14%)	NR	NR
	2019	Gaboardi et al.	Robotic laparoendoscopic single-site radical prostatectomy (R-LESS-RP) with daVinci Single-Site(R) platform. Concept and evolution of the technique following an IDEAL phase 1.	12	256.2	165	NR	6.54	5 (41.7%)	NR	1 (8.3)	4/5 (80%) IIEF> 17 at mean 1 year f/u	12 (100%) at mean 1 year f/u
Case series	2019	Chang et al.	Single-port transperitoneal robotic-assisted laparoscopic radical prostatectomy (spRALP): initial experience	1	152	100	NR	4	NR	NR	0 (0%)	NR	NR
	2019	Kaouk et al.	Single-port robot- assisted radical prostatectomy: first clinical experience using the SP surgical system	2	140	NR	NR	NR	NR	NR	NR	NR	NR
	2019	Kaouk et al.	Extraperitoneal single-port robot-assisted radical prostatectomy: initial experience and description of technique	10	197.5	143	10.1	0	0 (0%)	NR	5 (50%)	3 (30%) at 12 weeks	2 (20%) at 12 weeks; 5 (50%) at 90 days
	2019	Dobbs et al.	Single-port robot-assisted laparoscopic radical prostatectomy: initial experience and technique with the da Vinci SP platform	10	234	65	NR	1	0 (0%)	NR	2 (20%)	NR	NR
	2019	Ng et al.	Robot-assisted single-port radical prostatectomy: a phase 1 clinical study	20	209	296	8.3	5	3 (15%)	1.9 at 2 weeks	11 (55%)	NR	NR
	2019	Steinberg et al.	Magnet-assisted robotic prostatectomy using the da Vinci SP robot: an initial case series	15	224	198	10.25	1.25	1 (6.7%)	NR	2 (13%)	NR	NR
	2020	Kaouk et al.	Robotic urologic surgical interventions performed with the single port dedicated platform: first clinical investigation.	3	227	83	15	0.67	0 (0%)	NR	NR	NR	NR
	2020	Agarwal et al.	Initial experience with da Vinci single-port robot-assisted radical prostatectomies	49	162	191	7.75	1.25	4 (8.2%)	NR	13 (26.5%)	10 (48%) at 12 weeks	16/21 (76%)
	2020	Kim et al.	Single-port robot-assisted radical prostatectomy with the da Vinci SP system: a single surgeon’s experience	20	245	200	19	7	0 (0%)	NR	7 (35%)	4/7 (57%)	10/10 (100%)
	2020	Kaouk et al.	Single-port robotic urological surgery using purpose-built single-port surgical system: single-institutional experience with the first 100 cases	60	104–281	50–200	5	0.14–2.26	6 (10%)	41 (68.3%) opioid-free pain management	18 (30%)	NR	51.1% at 30 days
	2020	Wilson et al.	Outpatient extraperitoneal single-port robotic radical prostatectomy	60	198	179	NR	0.18	7 (11.7%)≥3	VAPS 2, 37% pain free at DC	23%	1/19 (5.26%) SHIM >19 at 90 days	37 (76%) at 90 days
	2020	Aminsharifi et al.	Predictors associated with a prolonged hospital stay after single-port extraperitoneal robotic radical prostatectomy: a comparative analysis of outpatient versus inpatient care	120	203.2	197.2	NR	0.19	7 (5.8%)	VAPS 2 at discharge	29 (24.2%)	NR	102 (85.0%) at 90 days
	2020	Covas Moschovas et al.	Early outcomes of single-port robot-assisted radical prostatectomy: lessons learned from the learning-curve experience	50	118	50	NR	0.68	0 (0%)	2 VAPS 8 h, 0 at 16 h	7 (14%)	70% at 6–8 weeks	27 (54%) at 4 weeks
	2021	Kaouk et al.	Single-port transvesical robotic radical prostatectomy: initial
Clinical experience and description of technique	20	199	135	NR	0.18	1 (5%)	VAPs 2.5, 0 opioid use at DC	3 (15%)	NR	15 (75%) at Foley removal; 17 (85%) at 10 days
Comparative	2020	Kaouk et al.	Extraperitoneal versus transperitoneal single port robotic radical prostatectomy: a comparative analysis of perioperative outcomes	52 (SP)	201 *	145.7	5 *	0.18	6 (11.5%)	NR	14 (26.9%)	NR	24 (60%)
				46 (MP)	248.2 *	117.6	12 *	1.07 * *	7 (15.2%)	NR	19 (41.3%)	NR	25 (62.5%)
	2020	Saidian et al.	Perioperative outcomes of single versus multi-port robotic assisted radical prostatectomy: a single institutional experience	47 (SP)	255.9	169.2	15.9	1.1	2 (4.3%)	NR	10 (21.3%)	3 (7.9%) at 12 weeks	19 (63.3%)
				48 (MP)	274.7	157.7	15.1	1.4	3 (6.3%)	NR	13 (27.1)	3 (6.7%) at 12 weeks	24/45 (53.3%)
	2020	Huang et al.	Comparison of perioperative and pathologic outcomes between single-port and standard robot-assisted radical prostatectomy: an analysis of a high-volume center and the pooled world experience	26 (SP)	180	100 *	5 *	1	3 (12%)	VAPS 2	6 (23.1%)	NR	NR
				376 (MP)	180	150 * , P =0.04	9 * , P =0.002	1	47 (13%)	VAPS 3	92 (24%)	NR	NR
	2020	Vigneswaran et al.	A comparison of perioperative outcomes between single-port and multiport robot-assisted laparoscopic prostatectomy	50 (SP)	260	100	12 *	1 *	7 (14%)	29 OMEQ, 15 (30%) pain-free POD1 *	20/48 (41.7%)	NR	24 (86%)
				113 (MP)	280	100	14 * , P =0.012	2 * , P =0.002	17 (15%)	28 OMEQ, 13 (12%) pain-free POD1, P =0.004	47/113 (41.6%)	NR	84 (87%)
	2020	Lenfant et al.	Single-institution cost comparison: single-port versus multiport robotic prostatectomy	78 (SP)	198 *	NR	5.18	0.41 *	NR	NR	20 (26%)	NR	NR
				97 (MP)	223 * , P <0.001	NR	5.86	1.48 * , P <0.001	NR	NR	38 (39%)	NR	NR
	2021	Francavilla et al.	Radical prostatectomy technique in the robotic evolution: from da Vinci standard to single port—a single surgeon pathway	40 (SP)	238.5 *	75 *	12	1 *	5 (12.5%)≥3	NR	15 (38.5%)	NR	25/37 (67.6%) at 90 days
				40 (MP)	270.5 * , P <0.01	88 * , P <0.01	9	2 * , P <0.01	5 (12.5%)≥3	NR	21 (52.5%)	NR	27/36 (75.0%) at 90 days
	2021	Abaza et al.	Single-port robotic surgery allows same-day discharge in majority of cases	59 (SP)	170 *	Not reported for each procedure.
				1131 (MP)	155.5 * , P <0.001	Not reported for each procedure.
	2019	Lenfant et al.	Pure single-site robot-assisted radical prostatectomy using single-port versus multiport robotic radical prostatectomy: a single-institution comparative study	100 (SP)	195	190 *	5	0.18 *	12 (12%)	7.5 OMEQ *	24 (24%)	20%	60 (69%) at 12 weeks; 34 (85%) at 1 year
				110 (MP)	190	200 * , P <0.0001	6	1.09 * , P <0.0001	6 (5.5%)	15 OMEQ * , P <0.0001	37%	25%	60 (73%) at 12 weeks; 36 (88%) at 1 year
	2021	Covas Moschovas et al.	Comparing the approach to radical prostatectomy using the multiport da Vinci Xi and da Vinci SP robots: a propensity score analysis of perioperative outcomes	71 (SP)	114 *	55 (78%) under 100 mL *	NR	NR	0 (0%)	VAPS 2.5 at 18 h	12 (17%)	18% at 90 days	68% at 90 days
				71 (MP)	103, P <0.001	36 (51%) * , P =0.002	NR	NR	0 (0%)	2	11 (16%)	28%	56%