The da Vinci single port (SP) robotic surgical system, which made its clinical debut in 2018, represents a significant technological advance in robotic surgery. While it does not fully replace the capabilities of the multi-port system, it represents a potential new approach for several major robotic urological procedures.
Jean Joseph, M.D., the Winfield W Scott Professor and Chairman of the URMC Department of Urology, was one of the first surgeons to utilize the original Intuitive da Vinci system more than two decades ago and has helped pioneer and promote subsequent robotic systems. His leadership in the robotic surgery field has placed him center stage demonstrating live surgeries for colleagues’ viewing at major professional conferences such as the American Urological Association and the North American Robotic Urology Symposium.
Dr. Joseph discussed the differences between the SP and multi-port systems, how surgeons will need to adapt to the system’s controls, the utility and promise of SP, and the factors hospitals should keep in mind if they are considering acquiring an SP system.
Describe the differences between single-port and multi-port robotic surgical systems.
As the name implies, instead of three to five separate incisions, the SP system consists of a single entry into the patient, which accommodates all of the instruments. This has obvious potential benefits for patients, like reduced scarring, less pain and less need for narcotics post-surgery, quicker discharge, and faster recovery. The instruments are smaller in the SP system, which, along with other technological advances, such as improved optics, enhances the precision of the system and enables surgeons to do complex surgeries in more confined spaces.
What is the learning curve for surgeons?
There are differences between the two systems that require training for surgeons to obtain proficiency. For example, the instruments branch out from a single trocar, so the process of triangulating them to the correct position is different. To avoid clashing the instruments, hand placement on the controls is different. The smaller instruments allow for more refined and precise operations, but this alters the dexterity of some instruments—it can be trickier to grasp and hold using an SP compared to a multi-port system.
Expert robotic surgeons can get up to speed on the SP system quickly with training and simulation, something we have experienced here in Rochester and in other high-volume, established robotic surgery centers. Less experienced surgeons will probably need to master the multi-port system before moving on to SP.
Are there conditions in which it appears to deliver better outcomes than multi-port systems?
SP robotic surgery is used for several procedures, such as pyeloplasty, nephrectomies, prostatectomies, cystectomies, and urinary tract reconstruction, and we are exploring its applications in other procedures. Improvements in the tools associated with the SP system also represent potential steps forward in improving outcomes. An example is a recently developed access kit that consists of a balloon that acts as an extension of the abdominal cavity and makes it easier to assess cancer margins.
The question that remains to be answered is the appropriate role of SP robotic systems among the host of technologies at a surgeon’s disposal. It is natural to greet new technologies with excitement. SP robotic surgery represents a significant advance and potentially opens the door to procedures, such as transvesical cystectomies, that are beyond the capability of multi-port systems. At the same time, we need to understand the value SP delivers to our patients and the impact on intraoperative and postoperative outcomes. There are many studies underway seeking to address these questions, but it is clear that SP represents an improvement in cosmetic outcomes, patient satisfaction, post-surgical pain, and recovery.
What advice would you give to institutions that are considering acquiring a single-port system?
As with any new tool, it will take time to assess and ultimately identify its full capabilities. For a high- volume surgical center like ours, SP represents a promising technology that is worthwhile to have in our surgical armamentarium. Our surgeons are working on training models to facilitate the adoption of such new technology. We perform several procedures using the SP, where we previously used the multiport exclusively. For certain procedures, such as simple prostatectomies, the SP robot has become our preferred mode of intervention using the transvesical route.
The use case for SP robotic surgery is constantly evolving and it is worth keeping in mind that while urologists are the primary users of SP robotic surgery system, it also has potential applications in ear, nose, and throat procedures.