The dream of single-incision surgery has been on the mind of surgeons since the inception of laparoscopic surgery. Laparoendoscopic single-site surgery was the first culmination of this technology but came with many challenges that limited its broad appeal and use. The da Vinci SP (single port) Robotic Platform was then introduced in 2018, revolutionizing the landscape of single-incision surgery. The platform enabled multi-articulating arms alongside a camera through a single incision with the same technology platform urologists were already accustomed to with the da Vinci MP (multiport) Xi Robotic Platform.

Figure 1. Incision used for the single-port Ahmed modification. This incision is used to enable concomitant transperitoneal and retroperitoneal surgery for kidney cases, upper tract reconstruction, and adrenal cases.

Figure 2. Intraoperative picture of single-port Ahmed modification incision with single-port robot docked in place with the da Vinci SP access port kit.

As one of the first 10 institutions in the country to adopt the SP robot, our team witnessed the growth and astounding evolution of the platform. In the early days of the SP platform, surgeons tried to imitate the same methods used with the MP platform to limited avail. Early cases used a metal trocar placed directly in the body as currently employed with the Xi. This approach resulted in limited mobility from the restricted working distance of the SP robot. To address this problem, we quickly transitioned to a floating dock system utilizing an Alexis retractor and GelPort mini. This enabled the trocar to sit outside the body and remain movable throughout the case, resulting in enhanced flexibility within the working space. da Vinci was quick to respond to the needs of urologists and introduced the da Vinci SP access port kit, which worked seamlessly with the SP robot and had further advantages over the GelPort mini, including built-in additional instrument trocar sites.

Throughout the following years, the SP platform continued to evolve rapidly and enabled surgeons to utilize new techniques and reintroduce approaches that were previously too early for their time. One good example is the SP robotic-assisted laparoscopic prostatectomy (RALP). The first cases of SP RALPs at our institution were done intraperitoneally in the same manner as performing MP RALP. Quickly, we realized the benefits of an extraperitoneal RALP, which has now become the standard SP approach to RALP across the country. In the most extensive series of SP RALP patients, we have reported the benefits of this approach, such as reduced pain requirements.¹ We had previously performed extraperitoneal RALP more than 10 years ago with the MP platform but quickly returned to a transperitoneal approach as the lateral arms often pierced the peritoneum, nullifying the benefits or making the case impossible. The SP platform has brought back the extraperitoneal approach and its many benefits. With regard to RALPs, the SP system continues to evolve. Aminsharifi et al reported other approaches enabled with the SP platform, including transvesical RALP and transperineal RALP.²

The SP platform has also transformed how our team completes partial nephrectomies. MP partial nephrectomies are typically done transperitoneally, with few surgeons utilizing a retroperitoneal approach because the MP robots have limited ability to work in the small space of the retroperitoneum. One key advantage of the SP platform is to work in small areas. Given this fact, early on, we began performing SP partial nephrectomies transperitoneally using incisions placed either at the umbilicus or the pelvic brim to improve cosmesis.³ These approaches mimicked the MP approach with little change or benefit. For the extraperitoneal approach, we initially docked the robot subcostally at the level of the kidney. But this approach often led to patients developing a bulge at the incision site, likely due to the extended incision disrupting the nerve supply to the intercostal muscles. Therefore, we sought a new approach that would utilize the unique abilities of the SP platform. This led to the introduction of the single-port Ahmed modification (SPAM) approach to retroperitoneal surgeries. In this approach, we placed the incision two-thirds of the distance to the anterior superior iliac spine from the umbilicus (Figure 1). This unique approach changed our practice and enabled us to often perform retroperitoneal and transperitoneal surgery within the same case and same patient as needed. This incision also aligned with the SP robot’s ability to move longitudinally and enabled the hilum to be placed in line with the trocar (Figure 2). This allowed easy access to the hilum for the surgeon and assistant. The SPAM approach has become the de facto standard at our institution and is becoming widely adopted elsewhere. It has many advantages, and we are undergoing a prospective review of the SPAM procedure to better understand the feasibility and reproducibility of this approach for SP partial nephrectomies and other retroperitoneal surgery, including but not limited to adrenalectomy, radical nephrectomy, and upper tract reconstruction.^4,5

The SP robot can perform even the most complex cases in urological surgery. For patients undergoing radical cystectomy, we place a 3-cm incision at the umbilicus. We also utilize NOTES (natural orifice transluminal endoscopic surgery) principles to place the second trocar used for stapling at the vaginal cuff in female patients. Thus, this approach combines the SP platform and NOTES to enable truly single-incision surgery for cystectomy. It is a sight to behold the first time one sees a radical cystectomy with neobladder creation being performed through a 3-cm barely visible incision at the umbilicus. We have published the largest series to date regarding SP radical cystectomy and have found reduced opioid requirements and faster return of bowel function with the SPAM approach.⁶ This is just one example of how SP surgery is changing the field.

The SP platform also enables novel approaches to old surgeries. For example, simple prostatectomies are now often performed transvesically. The robot is docked directly in the bladder, and the bladder is insufflated, thus limiting bleeding and allowing for excellent visualization. This approach combined with a circumferential closure of the prostatic defect has enabled same-day discharge of patients undergoing SP simple prostatectomies. At our institution, the transvesical approach has also enabled new methods to perform cross-trigonal reimplant, ureteral reimplantation, colovesical fistula repair, and vesicovaginal fistula repair.

When the SP platform was first introduced, there were many naysayers about its benefits and broad adoption. As the SP platform has grown and evolved, it has become abundantly clear that the SP platform has a place alongside the MP platform. The SP platform has enabled new incisions, new approaches, and reinvigorated long-forgotten surgeries. The evolution of the da Vinci SP platform has just started and more exciting developments are on the horizon.