Since the description of employment of laparoscopic cholecystectomy in the 1980s, urologists have consistently been at the forefront of the advancement of laparoscopic technology and techniques.¹ The goal of continuing to improve surgical outcomes and laparoscopic techniques eventually led to the creation of robotic surgical systems, and in 2000 the da Vinci Surgical System became the first robotic surgery system approved by the U.S. Food and Drug Administration for general laparoscopic surgery. There has been development of additional systems, but the da Vinci is the overwhelmingly dominant system being used.^2,3

Even with use of the multiport da Vinci, surgeons continued attempts to improve morbidity of surgery. Use of robotic systems allowed for R-LESS (robot-assisted laparoendoscopic single-site) surgery as it helped to overcome limitations of LESS (laparoendoscopic single-site), and while still technically challenging was still an improvement over a pure laparoscopic approach due to better vision and better arm/instrument maneuverability.⁴ However there were limitations due to the multiport design of the system, including arm collisions, difficulty triangulating target tissue, inability to use a fourth arm, and difficult access for the bedside assistant.² Nevertheless, this ultimately led to the development of the of da Vinci single-port (SP) surgical system, with the SP robotic platform receiving approval by the U.S. Food and Drug Administration in 2018.

With the da Vinci SP surgical system, all instruments and the camera are placed in a single 25 mm cannula in one of 4 channels located at the 12, 3, 6, and 9 o’clock positions, which helps to maximize work space and minimize arm collisions, which is an improvement over previous LESS and R-LESS procedures.² In addition, instruments have the benefit of an additional joint that can serve as a flexible elbow along with the typical EndoWrist joint. This can help prevent arm collisions as well as negotiate around the target anatomy or difficult to reach locations. The smaller visual field, however, requires adaptation by the surgeon, but the articulation allows for camera angulation of 0° to 30°, which, at least in part, helps offset the limitation.²

As with most minimally invasive options, the goal of an SP robotic procedure would be to reduce postoperative pain, reduce narcotic analgesic use, reduce hospital stay, and reduce the time to return to normal activities, in addition to a better cosmetic outcome. Unfortunately, there are currently limited comparative studies to evaluate this. In addition, as minimally invasive procedures evolve, some of the gains may only be marginal and be more difficult to measure.

Due to the still emerging nature of this technology, current literature is still largely limited to smaller case series and retrospective studies with additional investigation still being needed. More information involving the SP system is associated with its use in radical prostatectomies. Systematic literature reviews have shown that short-term oncologic (ie, positive surgical margins) and functional outcomes as well as safety are similar between SP and multiport systems, while some studies suggest decreased pain and shorter hospital stays.^5-7 In another study involving high-volume surgeons, initial operative times were only slightly longer with the SP system after 3 cases or fewer, suggesting relative ease of adapting to the new system, at least in the context of an experienced surgical team.⁸

Extraperitoneal and transperineal radical prostatectomies have also been shown to be feasible using the SP system and may make access to the prostate somewhat easier than with a typical multiport system given the increased angulation and articulation of the camera and instruments. In a single-institution study there were promising results with regard to initial recovery, complications, and narcotic use.⁹

Additional smaller studies have similarly shown the SP system to be viable with partial and radical nephrectomies, pyeloplasty, simple prostatectomies, and cystectomies.¹⁰ Although larger numbers are needed, current literature reviews again suggest overall surgical complications are likely to at least be comparable to those associated with multiport robotic surgeries in these cases as well.¹⁰

With any new technology, the cost/benefit ratio must always be assessed. Each SP system costs approximately $2 million with instruments costing around $5,000-$7,500 apiece (each instrument having 20-25 uses).² The development of other robotic systems, such as the Telelap ALF-X, REVO-I, and Avatera, may help to lower these costs in the future.

While additional prospective, randomized, controlled trials that also include more long-term outcomes and cost analysis are warranted, SP robotic surgery appears to be an exciting, safe, and feasible alternative to the more traditional multiport robotic-assisted laparoscopic approaches.