Novel Single-Port Approaches to Traditional Multiport Surgeries

The da Vinci Single Port (SP) robotic surgical system was introduced by Intuitive Surgical, Inc. (ISRG) in 2018 after being approved by the US Food and Drug Administration (FDA) in May of that year.¹ Since its introduction, ISRG has continued to develop improved access instrumentation, and the company has received clearance for the SP platform to be used for a variety of genitourinary disease states. In 2020, the FDA approved the SP Access Port Kit to enhance SP access for several surgical procedures, including radical prostatectomy, pyeloplasty, nephrectomy, and partial nephrectomy.² The SP platform is intended to enable surgeons to perform robot-assisted surgical procedures with the same precision as the traditional multiport techniques that have been developed over the last 20 years.

Since the introduction of the SP platform, many urologists from around the world have attempted different techniques and approaches to traditional multiport robotic surgical procedures, but those techniques present several challenges that need to be addressed before their widespread adoption. One notable challenge is the lack of availability of SP platforms in all hospital systems. According to the latest ISRG investor reports, there are currently 150 total SP deployments compared with more than 7900 multiport robotic systems.³ Furthermore, the SP platform has not yet been approved by the FDA for general surgical procedures, which comprise the largest percentage of robot-assisted procedures performed using da Vinci platforms worldwide.⁴

Since the introduction of the SP platform, 3 general methods have been described for prostatic access and surgery: perineal, transvesical, and extraperitoneal. The transperitoneal approach is not included because a primary benefit of SP surgery is the potential to avoid peritoneal access and facilitate surgical procedures in “hostile” abdomens with significant scarring related to prior surgeries.

The perineal prostatectomy approach dates back to 1867, when Theodore Billroth attempted the procedure for the first time and removed the prostate and all surrounding tissue.⁵ The procedure was then popularized by Hugh Hampton Young at Johns Hopkins Hospital in 1904.⁶ The perineal approach remained widely used until, more recently, Patrick Walsh, also of Johns Hopkins Hospital, pioneered the open retropubic approach. Subsequently, the advent of the laparoscopic and robotic surgery era saw the widespread development of minimally invasive versions of the open retropubic approach.

Despite the advancements in transabdominal techniques (open or robotic transperitoneal), many urologists believe several factors are in need of optimization, including reducing postoperative pain and time to return of bowel function, which can translate to shorter hospital stays.⁷ In an attempt to remedy these issues and develop a modern robot-assisted perineal prostatectomy approach, Kaouk and colleagues demonstrated SP robot-assisted perineal prostatectomy for prostate cancer with promising early continence results in a series of 4 patients.⁸ To further study the functional outcomes of the robot-assisted perineal technique, a Turkish group compared the traditional multiport robotic approach with a perineal approach using a multiport robot and found promising results, including a higher rate of urinary continence at 6 months in the perineal group.⁹ As SP deployments expand, additional data on the efficacy of SP robot-assisted perineal prostatectomy may become available.

Although the perineal approach is currently limited by the availability of SP platforms and the number of surgeons who have experience with SP surgery, the SP platform has been a great boon for urologists in the extravesical and transvesical spaces. Transvesical access and pneumovesicum have enabled surgeons to perform many prostate- and lower urinary tract-related surgeries. In April 2023, the FDA approved the SP platform for transvesical simple prostatectomy (RASP).¹⁰ The approval was supported by favorable operative times, blood loss, a zero percent rate of conversion to open surgery, and a length of hospital stay shorter than 24 hours in most studies.

In addition to RASP, many urologists have investigated the use of the SP platform for radical prostatectomy (RALP). Using the transvesical approach, Kaouk and colleagues demonstrated the viability of transvesical RALP in a series of 10 patients, showing viable rates of urinary continence, complications, and early discharge.¹¹ Following a more traditional approach—akin to the transperitoneal multiport RALP—many authors have reported on the viability of extraperitoneal RALP using the SP platform. Recently, Zeinab and colleagues performed a propensity score-matched study comparing SP extraperitoneal RALP with SP transperitoneal RALP, demonstrating similar rates of complications but a shorter length of hospitalization and higher same-day discharge rates for SP extraperitoneal RALP.¹²

In addition to prostate-directed operations, several authors have reported on the viability of the SP platform in bladder surgery. Tonzi and colleagues demonstrated a novel approach for transvesical bladder diverticulectomy.¹³ Taking this technique further, Garisto and colleagues reported on concurrent distal ureteral reimplantation with transvesical diverticulectomy.¹⁴ The ability of the SP platform to facilitate the direct transvesical access required to perform these traditional multiport transperitoneal techniques enables patients who may have been considered high risk due to prior abdominal surgery to have access to surgical care. Furthermore, since CO₂ insufflation is only required within the urinary bladder, the traditional cardiopulmonary changes and demands of transperitoneal surgery are negated by an SP approach, allowing more patients to qualify for surgery.

As more surgeons who are familiar with the multiport platform gain access to the SP platform, advance existing techniques, and create new ones, it is likely the percentage of SP surgeries will continue to increase. Trainees who are exposed to the SP platform during their residencies and fellowships will likely be eager to utilize the platform to deliver higher-quality and more minimally invasive surgical care to their future patients.

Read Part 2 of Dr. Saji’s series on the da Vinci SP robotics platform, focused on kidney and upper urinary tract surgery.

Akhil Abraham Saji, MD, Fellow at the University of Southern California, is a urologist specializing in minimally invasive surgery and urologic oncology with an interest in technology-driven innovation within health care.

References

1. Intuitive Surgical K173906 501(k) summary. da Vinci SP® Surgical System, Model SP1098, EndoWrist SP™ Instruments, and Accessories. U.S. Food and Drug Administration. May 29, 2018. Accessed August 20, 2023. https://www.accessdata.fda.gov/cdrh_docs/pdf17/K173906.pdf
2. Intuitive Surgical K202571 501(k) summary. da Vinci SP® Surgical System, Model SP1098, EndoWrist SP™ Instruments, and Accessories. U.S. Food and Drug Administration. November 4, 2020. Accessed August 20, 2023. https://www.accessdata.fda.gov/cdrh_docs/pdf20/K202571.pdf
3. Intuitive Surgical, Inc. trended unaudited quarterly and annual condensed consolidated statements of income (GAAP) and other metrics. Intuitive. Accessed August 20, 2023. https://isrg.intuitive.com/static-files/ddf6e6b7-6aa2-4997-980c-7c7c4aeba449
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