The re-discovery of alternative access to the pelvic fossa: the role of the single-port robotic platform

4.1 Introduction

The advent of robotics in medicine has generated new avenues in surgical care. Robotic platforms provide surgeons with enhanced visualization and improved degrees of freedom of intraoperative movement and articulation. Urology has consistently been at the forefront of robotics adoption worldwide, as operating within the pelvic fossa is the quintessential application for the marriage of technology and surgery.

Before robotics was widely adopted in pelvic surgery, there was a natural, gradual transition in operative approaches, first from open to laparoscopic, then to the laparo-endoscopic single-site surgery (LESS) era, and finally to the present, with the introduction of robotic laparoscopy. LESS was initially developed with the goal of expediting postoperative recovery, reducing pain, and enhancing cosmesis. In the past decade alone, all major urological procedures were implemented using LESS with subsequent improvement and evolution. Despite this, interest in LESS declined due to a steep learning curve and significant technical challenges of a smaller workspace when compared against standard laparoscopic approaches.

The introduction of the da Vinci surgical robotics platform (Intuitive Surgical, Inc., Sunnyvale, California, United States) paved the way for a modern reintroduction of LESS. Kaouk and colleagues reported on their initial clinical series of robotic LESS (R-LESS) in 2009 utilizing a da Vinci Model S. Despite improving upon the range of motion with suturing and dissection over traditional LESS, R-LESS surgeons continued to face limits on motion and instrument clashing in and outside the operative field.

Surgeons have always been eager to refine their technique and reduce patient morbidity. To this end, each iteration of the da Vinci robot has further reduced preceding technical limitations, enhanced surgical efficacy, and spurred the creation of new surgical techniques. It is in this vein that the da Vinci single-port (SP) platform was developed, receiving US Food and Drug Administration approval in May 2018 and facilitating the conversion of many high-morbidity inpatient surgeries into outpatient procedures with equivalent outcomes and a drastically improved quality of life.

In this chapter, we discuss the application of the SP platform in the context of alternative access into the pelvic fossa, with a focus on applications targeting the prostate, bladder, and ureters ( Table 4.1 ).

Table 4.1

Single-port robotic surgical approaches into the pelvic fossa.

Access	Procedures studied	Port placement	Comments
Transperitoneal	Radical and simple prostatectomy Radical cystoprostatectomy & pelvic exenteration Partial cystectomy Ureteral reimplantation Kidney transplantation	2 cm above umbilicus 5 cm above umbilicus 2 cm above umbilicus 5 cm above umbilicus Periumbilical incision	– Wide operative space – Trendelenburg position – Does not require lithotomy positioning unless access to vagina (for pelvic exenteration) is desired
Extraperitoneal	Radical prostatectomy	2 cm below umbilicus	– Supine position – Does not require Trendelenburg position – Limited pelvic lymph node dissection – Avoids intraperitoneal insufflation
Perineal	Perineal prostatectomy	Perineal semilunar	– Lithotomy position – Does not require Trendelenburg position – Useful in those with complex abdominal surgical history or restrictive lung disease
Transvesical	Radical and simple prostatectomy	Suprapubic	– Limited pelvic lymph node dissection – Facilitates concurrent cystolitholapaxy – Pneumovesicum limits systemic CO ₂absorption
Retzius-sparing	Radical prostatectomy	2 cm above umbilicus

cm , centimeters.

4.2 The evolution of the robotic surgical approaches to the pelvic fossa

The da Vinci surgical robotics platform is the most widely used among the robotic platforms available on the market. It was made commercially available in 1999 as a 3-arms system that rivaled the traditional laparoscopic approaches of the time. After modifying the original platform in 2003 with adding a fourth arm, the da Vinci Model S. augmented the surgical experience in 2006 with high-definition optics (720 px) and a simplified set-up process that facilitated the surgical access. In 2009, the Si further enhanced the quality of the intraoperative visualization with even higher-definition optics (1080 px) and offered the integrated support of fluorescence by the availability of infra-red cameras, introduced more complex instrumentation, and improved educational access to surgeons, fellows, and residents with the potential for a dual-console support, networking, and an accompanying surgical skills simulator. The Xi capitalized on this growth with 3D-optics, the ability to dock the side-cart alongside a supinated patient via a rotating boom, and offered uniform port sizes to further optimize the camera and the port placement.

In 2018, single port surgery emerged as the next advance in robotic laparoscopy via the SP platform. The SP utilizes a single, multichannel port from which three working multijointed instruments and a high-definition camera emerge. From a surgeon’s perspective, single-port surgery further broadens the operative horizon by reducing the number of required ports, reducing the risk of incisional hernias, extending surgical access to more areas of the body (such as narrow-access transoral, transanal, perineal, and extraperitoneal applications). Moreover, it can potentially be employed in an even younger age group with reduced morbidity.

4.3 Surgical approaches to the pelvic fossa using the da Vinci SP robot

Fig. 4.1

4.3.1 Transperitoneal approach

The transperitoneal approach to the pelvic fossa is the standard and the most widely used one among all the “urological” approaches ( Fig. 4.2 ).

Via a transperitoneal approach to gain the access to the pelvic fossa, the SP platform has already been employed to perform a variety of major urological surgery, including radical prostatectomy, radical cystoprostatectomy with or without intracorporeal urinary diversion, pelvic exenteration, ureteral reimplantation, and kidney transplant. The principles of the surgical approaches for each of these cases are similar and described as follows. A small 2.5 cm incision is first made above the umbilicus, followed by an additional 5–8 mm incision at the level of the lateral abdominal wall if an assistant port is desired. Once the peritoneal access and the pneumoperitoneum are established, the SP can be used to mobilize the bladder ( Fig. 4.3 ), remove the periprostatic fat, and expose and incise the endopelvic fascia in the traditional fashion.

For radical prostatectomy, the dorsal venous complex (the Santorini plexus) can be identified and managed before the bladder neck is incised; alternatively, a selective ligation of venous sinuses of the plexus can be performed once the apical dissection has been performed. The seminal vesicles and the vas deferens are delivered and the latter is ligated. The prostate is then ligated circumferentially prior to the apical and the urethral dissection, to complete prostatectomy. Finally, the vesico-urethral anastomosis is performed to restore the integrity of the urinary system. This approach provides the most (visually) complete surgical exposure of the pelvic fossa among the discussed approaches. Further, it facilitates the broadest access to the pelvic lymph nodes, allowing for an extended and super-extended lymph-nodes dissection.

The earliest uses of the SP employed the robotic platform in radical prostatectomies via a transperitoneal approach. The first report included two cases that were successfully completed without converting to a traditional robotic or open approach, with an operative time of 40 minutes and without perioperative complications. The approach has also been described in the context of distal ureteral repairs. Kaouk and colleagues discussed the use of the SP in three patients with distal benign ureteral strictures and reported no intraoperative complications. The wide maneuverability of the SP platform provided an adequate range of motion to reach the pelvic fossa without hampering the ability to perform robot-assisted reconstructive surgery.

Turning our focus to the bladder, radical cystoprostatectomy or pelvic exenteration remains the gold standard treatment for muscle-invasive and refractory noninvasive bladder cancers. There was an exponential increase in the use of robot-assisted approaches to radical cystoprostatectomy between 2002 and 2012, starting at 0.7% of all cystectomies to 18.5% in that time. Zhang and colleagues were one of the first to use the SP in radical cystoprostatectomy applications. He described a series of four patients who underwent SP robot-assisted radical cystoprostatectomy with an operative time of 270 minutes and EBL of 250 cc. No intraoperative complications were reported, and all procedures were completed successfully.

Finally, precedent has also been established for use of the platform in robotic-assisted kidney transplantation. Six cases were completed successfully without conversion to an alternative approach, and two of these cases utilized transperitoneal access. With the transperitoneal approach, the cecum and the right colon were medialized. With an extraperitoneal approach (utilized for the remaining four cases and discussed in further detail below), direct access to external iliac vessels was possible. In both approaches, the external iliac artery and vein were dissected. The right anterolateral aspect of the bladder was then prepared for ureteroneocystostomy.

4.3.2 Extraperitoneal approach

Using the SP via an extraperitoneal approach is particularly useful in patients with a prior history of major abdominal surgeries. Moreover, as with the transvesical and the transperineal (discussed in section 4.3.3 . and 4.3.5 ., respectively), the extraperitoneal approach avoids the pitfalls of the pneumoperitoneum and the bowel-related complications (reduced bowel mobilization, decreased likelihood of encountering or causing adhesions, and reduced rates of postoperative ileus). Conversely, the decision to pursue a trans- or an extra-peritoneal approach has consistently leaned towards the former, namely due to the wider working space and the notorious anatomical landmarks.

With the extraperitoneal approach to the pelvis, the prostate is accessed via the anterior rectus fascia. A 2–3 cm incision is made about one fingerbreadth below the umbilicus ( Fig. 4.4 ).

The anterior rectus sheath is incised sharply and dissected. A finger is then used to dissect the preperitoneal space prior to the placement of a SPACEMAKER surgical balloon dissector system (Covidien, Dublin, Ireland). The working area in the Space of Retzius is further maximized by inflating the balloon with 300–400 cc of air under direct visualization. A GelPOINT wound protector and retraction system (Applied Medical, Rancho Santa Margarita, California, United States) is placed into the operative field and secured under the rectus fascia. This is followed by the insertion of a 25 mm SP cannula via the GelPOINT GelSeal cap ( Figs. 4.5 and 4.6 ).