Review: Development of Single-Port Robotic Surgery in Urology

The dominant robotic surgery platform used in North America is the da Vinci Surgical System manufactured by Intuitive Surgical, headquartered in Sunnyvale, California. The da Vinci Surgical System is designed to allow surgeons to perform minimally invasive surgical procedures from a console.¹ It consists of an ergonomically designed surgeon’s console, a patient cart with four robotic arms, a high-performance 3D vision system, and proprietary EndoWrist™ articulating instruments. It provides the surgeon with precision, dexterity, and control during surgery, with the ability to execute 1-2 cm incisions versus longer incisions.

In 2000, the da Vinci Surgical System became the first robotic surgical platform to be cleared by the FDA for use in general laparoscopic surgery.² FDA clearance was based on a review of clinical studies of safety and effectiveness, including a study that showed that using the Da Vinci Surgical System in 113 patients who underwent surgery for gallbladder or reflux disease was as safe and effective as standard laparoscopic surgery with 132 patients.¹

The Increasing Use of RARPs

Since the first approval of the da Vinci Surgical System, its use has rapidly expanded to a range of surgical procedures in general, cardiac, colorectal, gynecologic, head and neck, thoracic, and urologic surgery. In 2000, it was estimated that more than 8.5 million procedures were performed using 5989 da Vinci Surgical Systems in 67 countries around the world, and that a surgeon began a procedure using a da Vinci Surgical System every 25.4 s.¹ Its biggest impact has been in urologic surgery, particularly for robot-assisted radical prostatectomies (RARPs) in the US, Europe, Australia, China, and Japan.³ In the US, in 2003, less than 1% of surgeons performed a RARP in preference to open or laparoscopic surgery, but by 2014, RARP accounted for around 90% of all RPs nationwide.

The widespread adoption of RARP reflects a consensus among urologic surgeons that the robotic approach is more straightforward and associated with less blood loss and less morbidity, Early studies showed promising long-term outcomes with few perioperative complications.⁴ Although few studies have compared perioperative and postoperative outcomes with open radical prostatectomy (ORP), laparoscopic RP (LRP), and RARP, a recent study found that RARP was associated with fewer acute and chronic postoperative complications than ORP or LRP.⁵

In general, oncologic outcomes are  considered to be similar with all approaches.⁶ An extensive body of literature supports the association of superior oncologic outcomes with high-volume hospitals and high-volume surgeons, but has found no difference between ORP, LRP, and RARP.⁷ Severe urinary incontinence may be experienced by up to 5% of patients undergoing RP, whichever technique is utilized, but the vast majority of patients achieve continence. Nerve-sparing approaches used in RARP are particularly associated with a favorable impact on postoperative urinary continence. Erectile function has also been reported to be improved with RARP, likely due to the enhanced utility of a nerve sparing approach and the fact that with RARP, production of testosterone remains unaffected. LAP-01, a recent randomized, patient-blinded trial of LRP vs RARP, demonstrated superior urinary continence and erectile function at three months postoperatively for RARP.⁸

Impact of the da Vinci Platform

The da Vinci single port (SP) platform received FDA approval in May 2018 for use in urologic surgery after initial FDA clearance in April 2014.⁹ The da Vinci SP system included three multi-jointed, wristed instruments and the first da Vinci fully wristed 3D HD camera. For urologists, the da Vinci SP platform represents the next step in minimally invasive surgical treatment options for prostate cancer, potentially decreasing morbidity associated with RP. A recent meta-analysis that compared the da Vinci SP and standard multiport platforms demonstrated greater benefit for the single-port platform with lower blood loss and shorter operation time and hospital stay, but no differences in complications.¹⁰

In addition to its impact on RP surgery, use of the da Vinci Surgical system has increased in a number of other urologic diseases. In renal surgery it has been utilized successfully for both oncologic and non-oncologic uses such as RP, partial nephrectomy, pyeloplasty for urinary tract obstruction, and urinary tract reconstruction.

Partial nephrectomy, a nephron-sparing therapy for localized kidney cancer, aims at complete excision of a suspected cancerous lesion with negative margins while achieving the lowest possible (warm) ischemia time. Benefits compared with radical nephrectomy include reduced overall morbidity with comparable oncologic control^. As use of laparoscopic approaches to partial nephrectomy has increased, urologists have sought to improve on the limitations of laparoscopy, which include a high learning curve attributed primarily to the difficulty of intracorporeal resection of tumor, as well as renorrhaphy.

The introduction of the da Vinci platform for partial nephrectomy was associated with improved outcomes with regard to blood loss, transfusions, complications, hospital stay and kidney function preservation; however, operative time, warm ischemia time, and positive margin rates were similar between robotic and open surgery.¹¹ A recent comparison of robotic partial nephrectomy with the da Vinci  platforms suggested that the minimally invasive nephron-sparing surgery performed with single-port and multiport robotic approaches result in comparable short-term outcomes but that the single-port surgery may be superior with respect to operative time and ability to perform a retroperitoneal approach.¹²

Use of a robotic platform in other types of renal surgery, including upper urinary tract reconstruction surgeries such as pyeloplasty, have also been reported. Common limitations of laparoscopic pyeloplasty, such as learning curve and articulation, were overcome with robot-assisted pyeloplasty. A large meta-analysis that compared robot-assisted laparoscopic pyeloplasty (RALP) and laparoscopic pyeloplasty (LP) in a pediatric patient with pelviureteric junction obstruction (PUJO) reported a significantly higher success rate with RALP, with a significantly shorter duration of hospital stay, as well as lower postoperative complication and reintervention rates.¹³

Robot-Assisted Radical Cystectomy

Although open radical cystectomy (RC) remains the gold standard, minimally invasive approaches are also increasingly used in treatment of the muscle invasive bladder cancer (MIBC).  A novel technique for robot-assisted radical cystoprostatectomy (RRCP) for patients with bladder cancer was described in 2003.¹⁴ The three-step technique, utilizing a six-port approach and the da Vinci Surgical System, was shown in a feasibility study to be “safe, quick, and precise.”¹⁴ Robot-assisted cystectomy was also proposed as an alternative to open RC, with the goal of lowering morbidity while achieving similar oncological outcomes.  The phase 3, non-inferiority RAZOR trial, reported in 2018,¹⁵ provided comprehensive data on the utility of robot-assisted approaches in RC.  Similar rates (72%) of two-year progression free survival were seen with open cystectomy and robot-assisted cystectomy.¹⁵ Robotic surgery was associated with decreased blood loss, reduced blood transfusion rates, and a shorter length of hospital stay, but also longer duration of surgery than open surgery. No significant differences were seen between the two treatment groups in overall and major complication rates or in adverse events.

The utility of the da Vinci SP platform in RC has been explored in comparison with multiport systems. Analysis of data from patients seen at a single center between 2017 and 2020 demonstrated no significant differences in perioperative outcomes, including operative time, estimated blood loss, 90-day complication rates, 90-day readmission rates, and positive surgical margin rates between the two approaches. However, patients undergoing single-port surgery on average had lower lymph node yields than those who underwent multiport the procedure.

The da Vinci platforms will continue to be utilized by urologists to extend the boundaries of minimally invasive surgery. Although their primary use is currently for surgery for major genitourinary malignancies, other uses, including transplant surgery and female urologic surgeries such as sacrocolpopexy are being increasingly reported. High costs (e.g., about US$2 million per system) and an extensive learning curve, remain challenges to be addressed.

Akhil Abraham Saji, MD is a urology resident at New York Medical College / Westchester Medical Center. His interests include urology education and machine learning applications in urologic care. He is a founding and current member of the EMPIRE Urology New York AUA section team.

References

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