Single port robotic assisted reconstructive urologic surgery-with the da Vinci SP surgical system

A multimodal virtual vision platform as a next-generation vision system for a surgical robot

Robot-assisted surgery platforms are utilized globally thanks to their stereoscopic vision systems and enhanced functional assistance. However, the necessity of ergonomic improvement for their use by surgeons has been increased. In surgical robots, issues with chronic fatigue exist owing to the fixed posture of the conventional stereo viewer (SV) vision system. A head-mounted display was adopted to alleviate the inconvenience, and a virtual vision platform (VVP) is proposed in this study. The VVP can provide various critical data, including medical images, vital signs, and patient records, in three-dimensional virtual reality space so that users can access medical information simultaneously. An availability of the VVP was investigated based on various user evaluations by surgeons and novices, who executed the given tasks and answered questionnaires. The performances of the SV and VVP were not significantly different; however, the craniovertebral angle of the VVP was 16.35° higher on average than that of the SV. Survey results regarding the VVP were positive; participants indicated that the optimal number of displays was six, preferring the 2 × 3 array. Reflecting the tendencies, the VVP can be a neoconceptual candidate to be customized for medical use, which opens a new prospect in a next-generation surgical robot.

Single-port robot-assisted pyeloplasty using the da vinci SP system versus multiport pyeloplasty: Comparison of outcomes and costs

OBJECTIVE

To investigate the feasibility of single-port (SP) robotic pyeloplasty by comparing perioperative outcomes with those of multiport (MP) robotic pyeloplasty.

MATERIALS AND METHODS

We reviewed the data from patients who underwent robot-assisted pyeloplasty for ureteropelvic junction obstruction (UPJO) at a single tertiary institution between March 2016 and May 2022. Radiographic and symptomatic improvements were assessed 3 months postoperatively. Propensity score matching was performed for age, sex, body mass index, and hydronephrosis grade.

RESULTS

Of the 15 S P-pyeloplasty and 28 MP-pyeloplasty cases, 14 from each group were matched using 1:1 matching. The SP group had shorter console and operative times without significant differences. Blood loss was lower in the SP group than in the MP group (p = 0.019). The length of hospital stay, opioid use on the operative day, and pain score at discharge did not differ between the two groups. The mean cost for surgery was higher in the SP group than in the MP group (p < 0.001). The mean cost of hospitalization was comparable between the two groups (p = 0.083). The cosmetic numerical rating scale scores were significantly higher in the SP group (p = 0.014). Symptoms improved in all patients, and the radiographic improvement rates were 92.9% in the SP group and 100% in the MP group.

CONCLUSION

SP-pyeloplasty showed cosmetic benefits, lower blood loss, operative time, and console time compared with MP-pyeloplasty. In patients who underwent surgery for UPJO for the first time, SP surgery can show comparable outcomes when compared to MP surgery.

Surgical Technique and Perioperative Outcomes Following Single-Port Robotic Adrenalectomy: A Single Institutional Experience

Objective: To describe a single institution's experience with single-port robotic adrenalectomy (SP-RA) and report perioperative outcomes. Materials and Methods: This is a retrospective, single-center study of adult patients who underwent SP-RA between January 2019 and April 2022 by a single surgeon using an IRB-approved institutional database. Patient demographics, perioperative data, surgical pathology, and postoperative outcomes were assessed. Results: Nineteen patients were identified who underwent SP-RA by a single surgeon over the period reviewed. One patient underwent bilateral SP-RA for bilateral adrenal masses, totaling 20 SP-RA procedures performed. Mean operative time was 80.7 ± 22.9 minutes and mean length of stay was 33.1 ± 27.9 hours. Two minor complications (Clavien-Dindo Collapse

Key Words

• adrenal
• minimally invasive surgery
• robotics
• single-port

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MESH Headings

• Adult
• Humans
• Adrenalectomy/methods
• Robotic Surgical Procedures/methods
• Retrospective Studies
• Robotics
• Adrenal Gland Diseases
• Laparoscopy/methods

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Affiliation(s)

Benjamin Rudnick Hackensack University Medical Center, Hackensack, New Jersey, USA
Mubashir Shabil Billah Hackensack University Medical Center, Hackensack, New Jersey, USA
Jennifer Nguyen Hackensack University Medical Center, Hackensack, New Jersey, USA
Fahad Sheckley Hackensack University Medical Center, Hackensack, New Jersey, USA
Mutahar Ahmed Hackensack University Medical Center, Hackensack, New Jersey, USA

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Comparing the safety and efficacy of single-port versus multi-port robotic-assisted techniques in urological surgeries: a systematic review and meta-analysis

OBJECTIVE

Comparing the safety and efficacy of single-port (SP) versus multi-port (MP) robotic-assisted techniques in urological surgeries.

METHODS

A systematic review and cumulative meta-analysis was performed using PRISMA criteria for primary outcomes of interest, and quality assessment followed AMSTAR. Four databases were systematically searched: Embase, PubMed, The Cochrane Library, and Web of Science. The search time range is from database creation to December 2022. Stata16 was used for statistical analysis.

RESULTS

There were 17 studies involving 5015 patients. In urological surgeries, single-port robotics had shorter length of stay (WMD = - 0.63, 95% Cl [- 1.06, - 0.21], P < 0.05), less estimated blood loss (WMD = - 19.56, 95% Cl [- 32.21, - 6.91], P < 0.05), less lymph node yields (WMD = - 3.35, 95% Cl [- 5.16, - 1.55], P < 0.05), less postoperative opioid use (WMD = - 5.86, 95% Cl [- 8.83, - 2.88], P < 0.05). There were no statistically significant differences in operative time, positive margins rate, overall complications rate, and major complications rate.

CONCLUSION

Single-port robotics appears to have similar perioperative outcomes to multi-port robotics in urological surgery. In radical prostatectomy, single-port robotics has shown some advantages, but the specific suitability of single-port robots for urological surgical types needs to be further explored.

A prospective study on single-port versus multiport patient-reported surgical outcomes

Introduction

We sought to determine potential patient reported advantages of the da Vinci single-port (SP) robotic system for urological procedures compared with the previous model, the da Vinci multiport (MP) system. The SP model utilizes a single 30 to 40 mm incision rather than multiple 5 to 22 mm incisions. This project aims to prospectively investigate the impact of the novel SP system on patient reported cosmetic and psychometric surgical outcomes.

Methods

We conducted a prospective study of patients who underwent uro-oncologic surgery by three urologists at the University of Illinois Chicago from April to November 2021. Study participants completed a Patient Scar Assessment Questionnaire 20 and 90 days post-procedure. The Patient Scar Assessment Questionnaire is a reliable measure of surgical scars that includes five subscales: Appearance, Symptoms, Consciousness, Satisfaction with Appearance, and Satisfaction with Symptoms. Higher scores represented worse reported outcomes.

Results

On Postoperative Day 20, there were 77 responses (53 SP and 24 MP). Patients receiving SP procedures reported more favourable outcomes in terms of appearance, symptoms, consciousness, and pain medication. On Day 90, there were 37 responses (24 SP and 13 MP). Patients receiving SP procedures reported more favourable outcomes in terms of appearance. No significant differences were seen on Day 90 in terms of pain, medication, symptoms, consciousness, or satisfaction.

Conclusions

This study demonstrates the superiority of the SP in patient reported cosmetic and pain outcomes on short- and long-term follow-up after uro-oncological surgical procedures. Symptomatic and cosmetic advantages are present at the 20 day follow-up, with better scar appearance being significant 90 days after surgery.

Transperitoneal Versus Retroperitoneal Single-port Robotic-assisted Partial Nephrectomy: An Analysis from the Single Port Advanced Research Consortium

BACKGROUND

In the surgical management of kidney tumors, such as in multiport technology, single-port (SP) robotic-assisted partial nephrectomy (RAPN) can be performed using the transperitoneal (TP) or retroperitoneal (RP) approach. However, there is a dearth of literature on the efficacy and safety of either approach for SP RAPN.

OBJECTIVE

To compare the peri- and postoperative outcomes of the TP and RP approaches for SP RAPN.

DESIGN, SETTING, AND PARTICIPANTS

This is a retrospective cohort study using data from the Single Port Advanced Research Consortium (SPARC) database of five institutions. All patients underwent SP RAPN for a renal mass between 2019 and 2022.

INTERVENTION

TP versus RP SP RAPN.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

Baseline characteristics, and peri- and postoperative outcomes were compared between both the approaches using χ2 test, Fisher exact test, Mann-Whitney U test, and Student t test.

RESULTS AND LIMITATIONS

A total of 219 patients (121 [55.25%] TP, 98 [44.75%] RP) were included in the study. Of them, 115 (51.51%) were male, and the mean age was 60 ± 11 yr. RP had a significantly higher proportion of posterior tumors (54 [55.10%] RP vs 28 [23.14%] TP, p < 0.001), while other baseline characteristics were comparable between both the approaches. There was no statistically significant difference in ischemia time (18 ± 9 vs 18 ± 11 min, p = 0.898), operative time (147 ± 67 vs 146 ± 70 min, p = 0.925), estimated blood loss (p = 0.167), length of stay (1.06 ± 2.25 vs 1.33 ± 1.05 d, p = 0.270), overall complications (5 [5.10%] vs 7 [5.79%]), and major complication rate (2 [2.04%] vs 2 [1.65%], p = 1.000). No difference was observed in positive surgical margin rate (p = 0.472) or delta eGFR at median 6-mo follow-up (p = 0.273). Limitations include retrospective design and no long-term follow-up.

CONCLUSIONS

With proper patient selection based on patient and tumor characteristics, surgeons can opt for either the TP or the RP approach for SP RAPN, and maintain satisfactory outcomes.

PATIENT SUMMARY

The use of a single port (SP) is a novel technology for performing robotic surgery. Robotic-assisted partial nephrectomy (RAPN) is a surgery to remove a portion of the kidney due to kidney cancer. Depending on patient characteristics and surgeons' preference, SP can be performed via two approaches for RAPN: through the abdomen or through the space behind the abdominal cavity. We compared outcomes between these two approaches for patients receiving SP RAPN, finding that they were comparable. We conclude that with proper patient selection based on patient and tumor characteristics, surgeons can opt for either the TP or the RP approach for SP RAPN, and maintain satisfactory outcomes.

Outcomes of single-port robotic ureteral reconstruction using the da Vinci SP® system

PURPOSE

The da Vinci SP^® robotic system enables three double-jointed wristed instruments and a fully wristed three-dimensional camera to be placed through a single port. This study presents our experience with robot-assisted ureteral reconstruction using the SP system and reports its outcomes.

MATERIALS AND METHODS

Between December 2018 and April 2022, a single surgeon performed robotic ureteral reconstruction using the SP system in 39 patients: 18 underwent pyeloplasty and 21 received ureteral reimplantation. Demographic and perioperative patient data were collected and analyzed. Radiographic and symptomatic improvements were assessed 3 months after surgery.

RESULTS

In pyeloplasty group, 12 patients (66.7%) were female and two patients (11.1%) had undergone previous surgery for ureteral obstruction. The median operative time was 152 minutes, the median blood loss was 8 mL, and the median length of stay in hospital was 3 days. There was one case of a complication involving postoperative percutaneous nephrostomy (PCN). In ureteral reimplantation group, 19 patients (90.5%) were female and ten patients (47.6%) had undergone gynecological surgery that caused ureteral obstruction. The median operative time was 152 minutes, the median blood loss was 10 mL, and the median length of stay in hospital was 4 days. We observed one case of open conversion and two cases of complications (colonic serosal tearing and postoperative PCN after ileal ureter replacement). The radiographic results and symptoms successfully improved following both surgeries.

CONCLUSIONS

Despite adhesion-related complications, the SP system appears to be safe and effective for use in robot-assisted ureteral reconstruction.

Robot-assisted versus open hepatectomy for liver tumors: Systematic review and meta-analysis

BACKGROUND

This meta-analysis was conducted to evaluate the effectiveness and safety of robot-assisted hepatectomy (RAH) versus open hepatectomy (OH) for liver tumors (LT).

METHODS

A computer-based literature search was conducted to identify all randomized or nonrandomized controlled trials of RAH and OH in the treatment of LT from January 2000 to July 2022. Study-specific effect sizes and their 95% confidence intervals (CIs) were combined to calculate the pooled values, using a fixed-effects or random-effects model.

RESULTS

Eight studies were included, with a combined total of 1079 patients. Compared with the OH group, the RAH group was found to involve less blood loss (standardized mean difference [SMD] = -152.52 mL; 95% confidence interval [CI] = -266.85 to 38.18; p = 0.009), shorter hospital stay (SMD = -2.79; 95% CI = -4.19 to -1.40; p < 0.001), a lower rate of postoperative complications (odds ratio [OR] =0.67; 95% CI = 0.47-0.95; p = 0.02), and a lower recurrence rate (OR = 0.42; 95% CI = 0.23-0.77; p = 0.005). However, operative time was longer in the RAH group than in the OH group (SMD = 70.55; 95% CI = 37.58-103.53; p < 0.001).

CONCLUSION

This systematic review shows that RAH is safe and feasible in the treatment of LT.

Single-port versus multiport partial nephrectomy: a propensity-score-matched comparison of perioperative and short-term outcomes

The objective of this study was to compare the perioperative and short-term functional and oncological outcomes of single-port and multiport robotic-assisted laparoscopic partial nephrectomy using propensity-score analysis. We evaluated all patients who underwent robotic partial nephrectomy at our institution between January 2019 and October 2020. Patient demographics, intraoperative data, and postoperative outcomes were collected and analyzed. Propensity-score matching was performed on age, sex, body mass index, prior abdominal surgery, and nephrometry score using the optimal matching method. A post hoc sensitivity analysis was performed to examine the robustness of the results. In total, 48 and 238 patients underwent single-port and multiport robotic partial nephrectomy, respectively. Following propensity-score matching, 48 multiport cases were matched 1:1 to single-port cases. The single-port cohort had lower median opioid use at postoperative day 1 (4.6 vs 9.8 MME, p = 0.0209) and cumulative hospital stay (5.1 vs 9.3 MME, p = 0.0357). Single port also had a shorter median length of stay (1.4 vs 1.6 days, p = 0.0045), although the post hoc sensitivity analysis showed no difference between the groups [- 0.13 (95% CI; - 0.580, 0.315, p = 0.5607). There were no significant differences in operative time, estimated blood loss, ischemia time, transfusions received, or positive margin rates. In conclusion, based on our early experience, single-port robotic partial nephrectomy is a safe and acceptable alternative to multiport robotic partial nephrectomy, providing comparable perioperative and postoperative outcomes while reducing inpatient opioid use.

Technique and perioperative outcomes of single-port robotic surgery using the da Vinci SP platform in urology

OBJECTIVE

To describe surgical technique for single port robotic surgery using the da Vinci SP system and report the perioperative outcomes.

PATIENTS AND METHODS

Between Jan 2019 and Jan 2021, single-port robotic urologic surgeries were performed in 120 patients by a single surgeon. Clinicopathologic data and perioperative outcomes were collected. All surgical procedures were performed with a transperitoneal approach through an umbilical single port. Additional assistant port was used in complex procedures for malignant disease. Surgeries were carried out using both above and below camera position for effective retraction. For reconstructive surgery using intestine, an extra-intracorporeal hybrid method was used. Surgical procedures involving both kidney and pelvis were performed without change of patient position or trocar placement.

RESULTS

Mean age was 62.7 years and 102 patients were male. For oncologic indication, 105 patients underwent surgeries including 66 radical prostatectomy, 25 partial nephrectomy, six radical nephrectomies, five nephroureterectomy and three radical cystectomy with urinary diversion. Fifteen cases with benign indication included four ureterolithotomy, seven uretero/pyeloplasty, three ureteroneocystostomy, and one ileal ureter reconstruction. All surgeries were performed successfully without conversion to other surgical approach. Clavien-Dindo grade III complication occurred in two patients.

CONCLUSIONS

The da Vinci SP system provides a new robotic surgical platform for single port surgery while maintaining the major features of robotic surgery similar to multi-port surgery. Various single port urologic surgeries can be safely performed with this platform.

Propensity-Score Matched Analysis Between Extraperitoneal Single Port and Intraperitoneal Multiport Radical Prostatectomy: A Single-Institutional Experience

OBJECTIVES

To compare the perioperative results and intermediate-term functional outcomes of single port and multiport robotic-assisted laparoscopic prostatectomy by using a propensity-score analysis.

MATERIALS AND METHODS

We evaluated all patients who underwent robotic prostatectomy by three urologic surgeons at our institution between January 2019 and October 2020. Demographic, intraoperative, and postoperative data were collected and assessed. Patients were matched based on body mass index, Gleason group, and prostate volume using the optimal matching method.

RESULTS

Overall, 98 and 165 patients underwent single port and multiport robotic prostatectomy, respectively. Following propensity-score matching, 98 multiport cases were matched 1:1 to single port cases. The median operative time was lower for multiport (111.5 vs 147.0 minutes, p=0.0000). Single port had a lower median estimated blood loss (50.0 vs 75.0 mL, p=0.0006), pain score on postoperative day 0 (1.0 vs 2.0, p=0.0004), opioid use at postoperative day 1 (0.0 [IQR 0.0-5.0] vs 0.0 MME [IQR 0.0-7.5], p=0.0058), cumulative opioid use (2.0 vs 7.0 MME, p=0.0008), and lymph node yield (4.0 vs 7.0 nodes, p=0.0051). Single port had a greater percentage of men regain full erectile function by 6 months (23.8% vs 4.8%, p=0.002).

CONCLUSIONS

The single port robotic system is a safe option for localized prostate cancer treatment, offering superior pain control and comparable perioperative results and intermediate-term functional outcomes compared to the multiport robotic approach.

Single Port vs Multiport Robotic Pyeloplasty: Propensity-Score Matched Analysis of Perioperative and Follow-Up Outcomes

OBJECTIVES

To compare the perioperative and postoperative outcomes of single port (SP) robotic pyeloplasty and multiport (MP) robotic pyeloplasty using a propensity-score matched analysis.

MATERIALS AND METHODS

We performed a chart review of all patients who underwent SP robotic pyeloplasty from January 2019 to October 2020 and MP robotic pyeloplasty from January 2016 to October 2020. Patient demographics, intraoperative data, and postoperative outcomes were collected and analyzed. Propensity-score matching was performed on sex, body mass index, and history of previous pyeloplasty to adjust for potential baseline confounders. A post hoc sensitivity analysis for operative time was performed to examine the robustness of the results.

RESULTS

In total, 24 and 41 patients underwent sSP and MP robotic pyeloplasty, respectively. Following propensity-score matching, 21 MP cases were matched 1:1 to SP cases. The SP group was shown to have longer median operative times (128.0 vs 88.0 minutes, P = .0411) and shorter follow up time (9.3 vs 18.7 months, P = .0066). In a sensitivity analysis, SP robotic pyeloplasty was marginally associated with increased operative time (95% CI -0.25, 29.72, P = .0540).

CONCLUSIONS

SP robotic pyeloplasty is a safe and acceptable alternative to MP robotic pyeloplasty, achieving comparable perioperative and postoperative outcomes.

Single-Port Robotic Radical Cystectomy with Intracorporeal Bowel Diversion: Initial Experience and Review of Surgical Outcomes

INTRODUCTION & OBJECTIVE

Scant literature is available on surgical outcomes of radical cystectomies on the new single-port (SP) system. This study compares short term outcomes in patients undergoing radical cystectomy with intracorporeal urinary diversion (ICUD) on the multi-port (MP) vs. SP platform.

METHODS

This IRB approved study used a prospective cystectomy database and non-parametric testing including Chi-Squared, Mann-Whitney U, and Fisher Exact tests to analyze all variables stratified by surgical approach.

RESULTS

34 patients underwent radical cystectomy with ICUD from 9/1/2019 to 2/8/2021. 20 patients were in the MP cohort, while 14 were in the SP group. Table 1 presents the demographics of both groups and shows no statistically significant differences. Intra- and post-operative as well as pathology data is shown in Table 2. Patients in the SP group had less narcotic use (MP: 25 MME vs. SP: 11.5 MME, p=0.047) and shorter return of bowel function (MP: 3 days vs. SP: 2 days, p=0.032). Operative times were similar between both groups despite having fewer patients undergoing ileal conduit (MP: 85% vs. SP: 50%, p=0.027) in the SP group. In table 3, we list the early short term post-operative follow up data for each group which showed no significant differences between the two groups with an average follow up of 4.9 months for MP and 4.4 months for SP.

CONCLUSIONS

Our initial experience with SP robotic cystectomy and ICUD appears to be safe and an effective alternative to MP cystectomies. A learning curve was involved but the overall transition from MP to SP was smooth. Operative times were similar despite fewer patients undergoing ileal diversion, shorter return of bowel function, and less narcotic use in the SP group. Further studies including longer follow ups with multi-institutional data are underway.

Robotic-assisted genitourinary reconstruction: current state and future directions

With the widespread dissemination of robotic surgical platforms, pathology previously deemed insurmountable or challenging has been treated with reliable and replicable outcomes. The advantages of precise articulation for dissection and suturing, tremor reduction, three-dimensional magnified visualization, and minimally invasive trocar sites have allowed for the management of such diverse disease as recurrent or refractory bladder neck stenoses, and radiation-induced ureteral strictures, with excellent perioperative and functional outcomes. Intraoperative adjuncts such as near-infrared imaging aid in identification and preservation of healthy tissue. More recent developments include robotics via the single port platform, gender-affirming surgery, and multidisciplinary approaches to complex pelvic reconstruction. Here, we review the recent literature comprising developments in robotic-assisted genitourinary reconstruction, with a view towards emerging technologies and future trends in techniques.

Robotic surgical systems in urology: What is currently available?

Robotic assistance in laparoscopic surgery was introduced at the turn of this millennium, marking a milestone in the history of surgery. Urologists were early adopters of robotic technology and the indications of robot-assisted surgery in urology are expanding. Over the last 20 years, the da Vinci surgical system was the dominant system in the robotic surgical market. However, the recent expiration of Intuitive patents has allowed new systems to enter the market more freely. We performed a nonsystematic literature review using the PubMed/MEDLINE search engines. The aim of this review was to briefly summarize the currently available robotic surgical systems for laparoscopic urologic surgery. New surgical devices have already been launched in the robotic market and the da Vinci systems have some competition. The innovation of robotic technology is continuing, and new features such as an open-console design, haptic feedback, smaller instruments, and separately mounted robotic arms have been introduced. A new robotic era is rising, and new systems and technologies enhancing patient care are welcomed.

Applications of the da Vinci single port (SP) robotic platform in urology: a systematic literature review

INTRODUCTION

Robotic surgical technology has evolved to include a new platform specifically designed for the single-port (SP) approach. Benefits of the da Vinci SP are still under investigation. This study aimed to review the urological literature since the first report of the use of the platform.

EVIDENCE ACQUISITION

We performed a systematic literature review of PubMed, Medline, and Web of Science databases on June 15, 2020 searching for all available articles of da Vinci SP use from December 2014 (date of the first clinical report of da Vinci SP in the urology) until June 1, 2020 following the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) Guidelines.

EVIDENCE SYNTHESIS

A total of 43 articles were eligible for inclusion. Ten studies reported different surgeries and techniques on cadavers while the rest described the clinical experience of different groups. We divided our article and tables into preclinical experience with surgery on cadavers, radical prostatectomy (RP) approach, and multiple types of procedures described in the same study.

CONCLUSIONS

The application of da Vinci SP in urologic procedures after five years of the first clinical investigation is feasible and safe. Radical prostatectomy is the most common intervention performed with this robot. Some groups described benefits in terms of less postoperative pain and early discharge, especially with the extraperitoneal approach. However, further studies with larger sample sizes and longer follow-up are awaited.