Section and Specialty Meetings: Robotic Urological Surgery Takes New Leap with Addition of Single Port Surgery

By: Ash Tewari MBBS, MCh, FRCS(Hon.); Adriana M. Pedraza, MD; Vinayak Wagaskar, MD; Sneha Parekh, MBBS | Posted on: 06 Aug 2021

“If you always do what you always did, you will always get what you always got.” –Albert Einstein

Urologists have always been intrigued to develop newer things, and robot-assisted laparoscopic urologic surgery (RALUS) has been one such field. This turned out to be a game changer and has changed the way the surgery is performed.

RALUS has revolutionized the field of urology over the past 21 years. Today, the da Vinci® Robotic System remains the most commonly used platform for RALUS and is utilized by surgeons in multiple subspecialties. Intuitive Surgical has released 5 da Vinci models including the standard, streamlined (S), S-high definition (HD), S integrated (Si)-HD and Xi systems. As the surgical systems continue to evolve with new technologies, single port (SP) robotic surgical system is another edition in the field that was added in June 2018.1 RALUS has become popular worldwide for a variety of indications in children, adults and elderly.

The Society of Urologic Robot Surgeons (SURS) has one important goal: to train future physicians and educate healthcare providers while pursuing research that will lead to better treatments and outcomes. With this in mind we have developed an interesting program for the AUA meeting on Sunday, September 12 (1:00 pm–6:15 pm). We will start our session with Young SURS, and the best video will be presented by them.

“If I have seen further, it is by standing on the shoulders of Giants.” –Sir Isaac Newton

The next session will be very exciting, and Dr. Menon will start with inaugural talk, “Why I Delve into Robotics,” followed by Dr. Gill and Dr. Thomas, AUA President-elect.

SP robotic surgery is a new venture in subspecialty of robotic surgery, and Dr. Kaouk, who was instrumental in developing the technique, will discuss it followed by other speakers. The session will end with the limitations of the surgery. Robotic radical prostatectomy has always been an area of great interest and will focus on advances in nerve-sparing techniques, 3D-image guided radical prostatectomy and radical prostatectomy in high-grade, high-risk prostate cancer. Similarly, we will have a session encompassing progress on kidney, reconstructive surgery and bladder, and finally we will end our session with the SURS international program.

Figure 1. Narrow tunnel (a modification of hood technique): preservation of anterior structures to achieve better functional outcomes.
Figure 2. Hood technique: anterior structures preservation.
Figure 3. Grade 2 nerve sparing. Levator ani fascia (yellow), lateral prostatic fascia (green) and perivenous layer (blue) are visualized.
Figure 4. Early release of endopelvic fascia in high-risk prostate cancer.

Next, I take an opportunity to present the culmination of my 21 years of efforts in developing robotic radical prostatectomy, which has these major components:

  1. Complete anatomical reconstruction: At the end of procedure, the closer we are to pre-surgical anatomy, the better the functional results would be. It is important to obtain posterior and anterior support to the vesico-urethral junction, combining the principles of Pagano and Rocco as well as reconstructing the anterior attachments of the arcus tendinous and puboprostatic plate to the bladder.2
  2. Hood: In 2010 Bocciardi described the preservation of the space of Retzius, finding better urinary continence outcomes at 1, 3 and 12 months and demonstrating the importance of anterior structures.3 Our novel “Hood” concept and technique is an anterior approach designed to better preserve the anatomical structures surrounding the urethra, the space of Retzius and pouch of Douglas, to facilitate early return of continence. The Hood technique also allows various grades of nerve sparing to occur in an athermal manner, and surgeons could focus on time tested anatomical principles to achieve trifecta (cancer control, urinary continence, sexual function). It is a simple, reproducible, adaptable approach to the anatomical robotic technique of removing prostate cancer (figs. 1 and 2).4
  3. Nerve-sparing techniques: Detailed anatomical knowledge and the introduction of minimally invasive techniques have changed the radical prostatectomy conception. The neural hammock is formed by the proximal neurovascular plate (PNP), the predominant neurovascular bundle and the accessory neural pathways.5 There have been constant efforts to preserve periprostatic nerves; besides different grades of nerve sparing,6 some authors have described novel techniques like the Menon precision prostatectomy, where the seminal vesicle, ejaculatory duct and a 5–10 mm rim of prostate capsule contralateral to the dominant lesion are spared.7 Also, some other authors have focused on seminal vesicle preservation to avoid PNP injury.8 Although the distribution of these periprostatic nerves is complex, a tailored surgery should be offered to every patient based on his clinical characteristics and taking into account grades of nerve sparing in order to achieve proper oncological and functional outcomes (figs. 3 and 4).
  4. Extraperitoneal single-port robotic prostatectomy: It is an alternative technique that has shown feasibility as an outpatient procedure. Kaouk et al have extensively worked on this surgery achieving good short-term oncological and functional outcomes.9 Further followup is needed for this promising technique.

Dr. Ash Tewari (the Principal Investigator in this study and Chairman of Milton and Carroll Petrie Department of Urology at the Icahn School of Medicine at Mount Sinai) owns equity in the form of stock certificates in Promaxo, for which he serves as an advisor. Promaxo is a privately traded company which develops MRI technology with a focus on prostate cancer.

  1. Dobbs RW, Halgrimson WR, Talamini S et al: Single-port robotic surgery: the next generation of minimally invasive urology. World J Urol 2020; 38: 897.
  2. Tewari A, Jhaveri J, Rao S et al: Total reconstruction of the vesico-urethral junction. BJU Int 2008; 101: 871.
  3. Checcucci E, Veccia A, Fiori C et al: Retzius-sparing robot-assisted radical prostatectomy vs the standard approach: a systematic review and analysis of comparative outcomes. BJU Int 2020; 125: 8.
  4. Wagaskar VG, Mittal A, Sobotka S et al: Hood technique for robotic radical prostatectomy-preserving periurethral anatomical structures in the space of retzius and sparing the pouch of Douglas, enabling early return of continence without compromising surgical margin rates. Eur Urol 2020; doi: 10.1016/j.eururo.2020.09.044.
  5. Tewari A, Takenaka A, Mtui E et al: The proximal neurovascular plate and the tri-zonal neural architecture around the prostate gland: importance in the athermal robotic technique of nerve-sparing prostatectomy. BJU Int 2006; 98: 314.e23.
  6. Tewari AK, Srivastava A, Huang MW et al: Anatomical grades of nerve sparing: A risk-stratified approach to neural-hammock sparing during robot-assisted radical prostatectomy (RARP). BJU Int 2011; 108: 984.
  7. Sood A, Abdollah F, Jeong W et al: The precision prostatectomy: “Waiting for Godot.” Eur Urol Focus 2020; 6: 227.
  8. John H and Hauri D: Seminal vesicle-sparing radical prostatectomy: a novel concept to restore early urinary continence. Urology 2000; 55: 820.
  9. Wilson CA, Aminsharifi A, Sawczyn G et al: Outpatient extraperitoneal single-port robotic radical prostatectomy. Urology 2020; 144: 142.