It has been said, “Necessity is the mother of invention.” At the University of Florida, we started using the da Vinci single-port (SP) in pediatric patients to increase access to minimally invasive surgery for children in our area. We were finding it difficult to schedule multiport (MP) cases in a timely manner due to shared robotic block time and resources with the adult services. To illustrate how severe the problem was during the pandemic, there were children with completely obstructed kidneys on nuclear renography for whom we could not find operative time inside of 2 months. For these children, the options were to undergo open pyeloplasty, wait for robotic time, or pursue surgery at a farther institution. Meanwhile, our hospital purchased the SP for adult otolaryngology and urology services. This scenario bore imagination, and we acknowledge not every pediatric urologist may find themselves in this situation.

Parikh et al published the first case report describing SP utilization in a pediatric urology patient in March 2021.¹ They describe a technique for SP appendicovesicostomy creation and allude to a case series of 6 pediatric pyeloplasties (the case series for which was later published in August 2023²). In July 2021, Kang et al published the first pediatric SP case series as a cohort comparison between SP and MP outcomes in children.³ The authors presented 15 SP pediatric pyeloplasties and established that, compared to patients undergoing MP pyeloplasty, there were no significant differences in surgical success, hospitalization duration, or postoperative narcotic use between the 2 groups. We published our case series comparing outcomes between SP and MP cohorts in August 2023.⁴ The series included 11 SP pyeloplasty cases. We found no significant differences in hospitalization duration, complication rates, surgical success, or postoperative narcotic use between the 2 groups. Assimilating these reports, it would seem pediatric use of the SP is safe, feasible, and associated with similar outcomes to those of the MP robot.

The institutional experiences highlighted above have led to accepted techniques and strategies to optimize SP robotic surgery in children. One common hurdle is the SP’s need for at least 10 cm working distance between the robotic cannula and target anatomy. This space can be difficult to find in pediatric patients. One adaptation is to utilize a Pfannenstiel incision with “air docking,” where the trocar is floating outside of the body using a laparoscopic gel sleeve. Borrowing from Gargollo’s HIdES (hidden incision endoscopic surgery) approach,⁵ we place a 3-cm incision for the SP cannula in the low midline, directly anterior to the pubic tubercle (Figure). Frainey et al from the Cleveland Clinic described a similar yet higher and off-midline technique in 6 pediatric patients undergoing SP retroperitoneal pyeloplasty.⁶ The floating-dock technique, regardless of incision site, is now commonplace in urology.

Figure. Typical postoperative appearances of single incision used for single-port pediatric pyeloplasty in a 10-year-old boy at 6 weeks postoperatively (A) and a 15-year-old girl immediately postoperatively (B). Reprinted with permission from Smith JM et al, J Urol. 2023;210(2):236-238.⁴

There have been other limitations. We have found the learning curve to be steep, resulting in longer operative times that have improved with additional cases performed. Even with improved operative time as our technique has evolved, concerns for prolonged anesthesia exist and should be considered when attempting to learn this approach.

An SP approach may be beneficial to children with unique urological anatomy or show benefit in specific circumstances. We have described single-incision combined robotic upper tract and open lower tract urinary reconstruction and extirpative extraction.^7,8 Frainey et al from the Cleveland Clinic found the SP approach uniquely useful for a transvesical approach to a vesicovaginal fistula repair in a 9-year-old female with extensive abdominal surgical history and limited transvaginal access.⁹

There may be value to an SP robotic approach in postoperative pain and scar perception. At the World Congress of Endourology, we presented initial data on patient-centered outcomes, including anonymous survey results of 16 families whose children underwent SP surgery.¹⁰ Results suggest families’ view the SP experience similarly to those who undergo MP surgery. Families whose children underwent SP surgery rated their incisions more favorably compared to those undergoing open or MP surgery. There is heterogeneity between these groups, and small sample sizes prohibit statistical analysis; however, for us, these early data imply families and older children may see value in a single, concealed incision.

In conclusion, we began using the SP to increase robotic access for children coming to our combined adult and pediatric center. For urologists in similar environments, using the SP has been shown to be safe and useful in specific cases. An SP approach may provide minor patient-perceived cosmetic advantages over open and MP approaches. Finally, an SP approach may make combined upper and lower tract reconstruction and extirpation as well as extraperitoneal reconstruction more feasible. For pediatric urologists at dedicated, freestanding children’s hospitals, the SP is unlikely to provide value that justifies the cost or learning curve. In our opinion, single-incision robotic surgery warrants continued investigation in appropriate contexts.