Using a Single-Port Robotics Platform for Kidney, Upper Tract Surgery: Novel Approaches

The da Vinci Single Port (SP) robotics platform was cleared for use by the US Food and Drug Administration (FDA) in May 2018.¹ Subsequently, the SP access port kit was developed and received FDA approval in 2020. The kit facilitates improved surgical dynamics in a wide variety of urologic cases, including radical prostatectomy, partial nephrectomy, and radical nephrectomy.¹

Part 1 of our series on the da Vinci SP robotics platform focused on the lower urinary tract and featured experts who were exploring its use in prostatectomy and transvesical surgery, including transvesical simple prostatectomy. In part 2 of this series, I review some of the latest techniques and most creative applications of the SP platform that US surgeons are currently using for kidney and upper urinary tract surgery.

In the last 6 years, several documented reports have demonstrated how the SP platform can improve patient outcomes. The 3 main recurring benefits are shorter hospital stays, reduced blood loss, and improved cosmesis resulting from the need for just one entry site.

One of the earliest reports on the SP platform in kidney surgery was published by LaMattina et al on the topic of single-site SP robotic donor nephrectomy.² According to the authors, single-site donor nephrectomy had been shown to have equivalent outcomes to traditional donor nephrectomy, as well as improved cosmetic outcomes for the donor, lower rates of postoperative pain, and fewer complications. In this series, the SP platform was used successfully to perform 3 donor nephrectomies while maintaining low rates of blood loss and a respectable operative time of 82 minutes of console time per case. The authors were already using single-site surgery in a laparoscopic approach, so they did not find the SP platform provided substantial cost savings. Still, their study validated the idea that the SP platform may be used for routine kidney surgery.

In the domain of ureteral surgery, various surgical groups began publishing reports of their experiences as well. One early report by Steinberg et al³ showed the viability of the SP platform by demonstrating its uses in ureteral reimplantation, ureterolysis, and ureteral reconstruction. The authors reported no need to convert to traditional laparoscopy, multiport surgery, or open surgery. All patients were treated successfully without complications and with appropriate discharge timing, demonstrating the early viability of the platform in ureteral surgery.

Recently, authors have gone even further by comparing retrospective multiport data against more recent single-port data. Gu et al compared traditional multiport robotic pyeloplasty with single-port robotic pyeloplasty in a meta-analysis comprising 179 patients.⁴ The authors demonstrated that the SP pyeloplasty approach facilitated a significant reduction in postoperative pain (P=.03), as well as improved cosmetic appearance for patients. Furthermore, there was no difference in operative time, blood loss, or complications when compared with the multiport approach.

One of the primary benefits of the SP platform is its low profile and ability to navigate into smaller anatomic regions. As all urologic organs are retroperitoneal organs, the ideal surgical approach would be to avoid transperitoneal access altogether in order to avoid risk to peritoneal organs, prevent hernia formation, intra-abdominal scar formation and other benefits.

Recently, Pellegrino et al popularized the low flank retroperitoneal access technique, which they called supine anterior retroperitoneal access (SARA).⁵ With the SARA technique, the SP robotic platform can be used to complete a wide variety of renal and upper urinary tract surgical treatments. In their article, the authors described the use of the SARA technique for 12 patients undergoing robot-assisted partial nephrectomy and 2 patients undergoing pyeloplasty. Two patients also underwent radical nephrectomy and nephroureterectomy, respectively, demonstrating the viability of the SARA approach for the removal of larger organs as well.

Within the partial nephrectomy cohort, the authors found that 83% of patients met criteria for discharge the same day. Furthermore, rates of blood loss and operative time were well within the range for traditional multiport transperitoneal approaches. The findings from this study and others suggest that the SP platform has a significant role to play in the further regionalization of surgery. It may accelerate the transition of such surgical procedures to outpatient surgeries.

Lastly, the SP robotic platform is being investigated in the realm of renal transplantation. Several authors have documented its ability to assist with donor nephrectomy; however, many groups of surgeons are now investigating the technical benefits of single-site robotic renal transplantation. In a recent series from the Cleveland Clinic, researchers successfully utilized the platform for 12 patients undergoing renal transplantation.⁶ None of the 12 patients suffered complications, and creatinine on follow-up demonstrated normal graft function. These data are in line with other large trials that have found that robot-assisted renal transplantation is noninferior to traditional open renal transplantation,⁷ despite having longer cold ischemia and total ischemia times.

The future of the SP robotics platform and robotics innovation as a whole will depend on the development of further specialized robotic instruments and the creative introduction of existing platforms into a wider range of urologic procedures and patient populations. Incorporating artificial intelligence in surgical planning and live surgery may augment the surgical experience, allowing surgeons to deliver even more minimally invasive surgery with better outcomes.

Read Part 1 of Dr. Saji’s series on the da Vinci SP robotics platform, focused on the lower urinary tract and transvesical simple prostatectomy.

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. da Vinci SP® Surgical System (including SP Access Port Kit) K202571. Intuitive. Accessed August 20, 2023. https://www.accessdata.fda.gov/cdrh_docs/pdf20/K202571.pdf
2. LaMattina JC, Alvarez-Casas J, Lu I, et al. Robotic-assisted single-port donor nephrectomy using the da Vinci single-site platform. J Surg Res. 2018;222:34-38. doi:10.1016/j.jss.2017.09.049
3. Steinberg RL, Johnson BA, Cadeddu JA. Ureteral reconstruction using the DaVinci SP robotic platform: an initial case series. J Endourol Case Rep. 2019;5(2):60-63. doi:10.1089/cren.2018.0115
4. Gu L, Li Y, Li X, Liu W. Single-port vs multiple-port robot-assisted laparoscopic pyeloplasty for the treatment of ureteropelvic junction obstruction: a systematic review and meta-analysis. J Endourol. 2023;37(6):681-687. doi:10.1089/end.2023.0064
5. Pellegrino AA, Chen G, Morgantini L, Calvo RS, Crivellaro S. Simplifying retroperitoneal robotic single-port surgery: novel supine anterior retroperitoneal access. Eur Urol. 2023;84(2):223-228. doi:10.1016/j.eururo.2023.05.006
6. Kaviani A, Eltemamy M, Zeinab MA, et al. Single port robot-assisted kidney transplantation: extraperitoneal approach. Urology Video Journal. 2022. doi:10.1016/j.urolvj.2022.100177
7. Patil A, Ganpule A, Singh A, et al. Robot-assisted versus conventional open kidney transplantation: a propensity matched comparison with median follow-up of 5 years. Am J Clin Exp Urol. 2023;11(2):168-176. PMID: 37168935