Single port robotic assisted reconstructive urologic surgery—with the da Vinci SP surgical system

Abstract

Background:
Single port (SP) robotic assisted laparoscopic surgery was approved by the FDA for urologic surgery and clinically available in 2018. This new robotic system enables a camera and 3 separate instruments, with fully wristed motions, to be placed through a single 25 mm port. This system was designed to perform complex surgery in narrow deep spaces making it very suitable for complex urinary tract reconstruction surgery. This paper will describe our early experience of using the SP system for several types of urinary reconstruction procedures and will present our lessons learned, surgical philosophy to using the SP and early data. As with all new technologies, there is an associated learning curve and nuances to be discovered and overcome.

Methods:
The da Vinici SP™ surgical system was acquired and delivered to at our institution in January 2019. Five high volume robotic urologic surgeons at our institutions underwent certification with the da Vinci SP™ and have been adding this technology into their armamentarium. Almost all cases were recorded for quality improvement initiatives and evaluated with the goal of creating standard operating procedures in terms of access, steps of procedure and minimizing pit falls. Data from all patients undergoing SP urinary tract reconstruction that were entered into our prospective institutional database were reported.

Results:
From 1/2019 to 8/2019 we have performed 71 urologic SP cases with the SP of which 18 were for urinary tract reconstructive procedures. These cases included 15 pyeloplasties, 1 buccal mucosa ureteroplasty, 1 ureteral implant and 1 repair of vesico-vaginal fistula. This paper outlines our standard operating procedures for table positioning, port placement, access and surgical steps for these complex SP cases. Our early data suggests that use of the SP system for urinary reconstruction is safe and reproducible.

Conclusions:
The SP robotic surgical system has the potential to be used for nearly all robotic urologic reconstructive procedures. Advantages include a superior cosmetic result and ability to access all surgical quadrants without re-docking or repositioning. Limitations include no near infrared fluorescence imaging, smaller working space and slightly increased difficulty with retraction. We believe these obstacles will be overcome with time and experience. The da Vinci SP™ surgical system, in our initial experience, appears to be as safe and effective as its multiport counterpart for reconstructive surgeries.

Full text

Transl Androl Urol 2020;9(2):870-878 | http://dx.doi.org/10.21037/tau.2020.01.06
© Translational Andrology and Urology. All rights reserved.
Original Article on Robotic-assisted Urologic Surgery
Single port robotic assisted reconstructive urologic surgery—with
the da Vinci SP surgical system
Mubashir Shabil Billah, Michael Stifelman, Ravi Munver, Johnson Tsui, Gregory Lovallo,
Mutahar Ahmed
Hackensack University Medical Center, Hackensack Meridian School of Medicine at Seton Hall University, NJ, USA
Contributions: (I) Conception and design: M Stifelman, MS Billah; (II) Administrative support: M Stifelman; (III) Provision of study materials or
patients: M Stifelman, R Munver, G Lovallo, M Ahmed; (IV) Collection and assembly of data: MS Billah, J Tsui; (V) Data analysis and interpretation:
MS Billah, M Stifelman; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.
Correspondence to: Mubashir Shabil Billah, MD; Michael Stifelman, MD. Hackensack University Medical Center, Hackensack Meridian School of Medicine
at Seton Hall University, 30 Prospect Ave, Hackensack, NJ 07601, USA. Email: msb274@njms.rutgers.edu; michael.stifelman@hackensackmeridian.org.
Background: Single port (SP) robotic assisted laparoscopic surgery was approved by the FDA for
urologic surgery and clinically available in 2018. This new robotic system enables a camera and 3 separate
instruments, with fully wristed motions, to be placed through a single 25 mm port. This system was
designed to perform complex surgery in narrow deep spaces making it very suitable for complex urinary
tract reconstruction surgery. This paper will describe our early experience of using the SP system for several
types of urinary reconstruction procedures and will present our lessons learned, surgical philosophy to using
the SP and early data. As with all new technologies, there is an associated learning curve and nuances to be
discovered and overcome.
Methods: The da Vinici SP™ surgical system was acquired and delivered to at our institution in January
2019. Five high volume robotic urologic surgeons at our institutions underwent certication with the da
Vinci SP™ and have been adding this technology into their armamentarium. Almost all cases were recorded
for quality improvement initiatives and evaluated with the goal of creating standard operating procedures in
terms of access, steps of procedure and minimizing pit falls. Data from all patients undergoing SP urinary
tract reconstruction that were entered into our prospective institutional database were reported.
Results: From 1/2019 to 8/2019 we have performed 71 urologic SP cases with the SP of which
18 were for urinary tract reconstructive procedures. These cases included 15 pyeloplasties, 1 buccal mucosa
ureteroplasty, 1 ureteral implant and 1 repair of vesico-vaginal fistula. This paper outlines our standard
operating procedures for table positioning, port placement, access and surgical steps for these complex SP
cases. Our early data suggests that use of the SP system for urinary reconstruction is safe and reproducible.
Conclusions: The SP robotic surgical system has the potential to be used for nearly all robotic urologic
reconstructive procedures. Advantages include a superior cosmetic result and ability to access all surgical
quadrants without re-docking or repositioning. Limitations include no near infrared uorescence imaging,
smaller working space and slightly increased difculty with retraction. We believe these obstacles will be
overcome with time and experience. The da Vinci SP™ surgical system, in our initial experience, appears to
be as safe and effective as its multiport counterpart for reconstructive surgeries.
Keywords: Reconstruction; pyeloplasty; ureteral reimplantation; ureteroplasty; vesicovaginal stula
Submitted Sep 16, 2019. Accepted for publication Nov 11, 2019.
doi: 10.21037/tau.2020.01.06
View this article at: http://dx.doi.org/10.21037/tau.2020.01.06
878

871
Translational Andrology and Urology, Vol 9, No 2 April 2020
Transl Androl Urol 2020;9(2):870-878 | http://dx.doi.org/10.21037/tau.2020.01.06
© Translational Andrology and Urology. All rights reserved.
Introduction
Laparoendoscopic single-site surgery (LESS) is a minimally
invasive surgery technique developed in an effort to
minimize port-related complications and reduce recovery
time and postoperative pain while achieving improved
cosmesis (1,2). Due to the highly challenging nature of
this technique even in expert hands, despite demonstrated
feasibility in urologic surgery (3), the adoption of LESS has
not been widespread due to its steep learning curve and the
more recent adoptions of robotic assisted laparoscopy.
The da Vinci surgical system, which is the most
commonly used robotic surgical system to date, first
received FDA approval in 2000 and has since undergone
several iterations as the technology continues to advance.
Intuitive Surgical Inc. released the latest version of the
DaVinci system in late 2018, the da Vinci SP® surgical
system.
The new system uses a single 25 mm trocar to
introduce three, multi-jointed, wristed instruments and
the first ever fully wristed 3D HD camera (4). The new
system allows for excellent internal range of motion which
offers the urologic community a more technically feasible
approach to LESS. The single port (SP) system also
enables dynamic external range of motion which allows
the surgeon to change the target anatomy without having
to redock the robot, remove instruments or change trocar
position. The SP system uses the same surgeon console as
the Da Vinci X and Xi systems that many urologists are
already familiar with allowing surgeons to make a swift
and easy transition to the latest robotics technology. With
the SP surgical system, the issues of loss of triangulation
and the constraints of laparoscopic straight arm surgery in
LESS are addressed (5,6).
The da Vinci SP™ platform is currently available at
a limited number of institutions worldwide. However,
feasibility has already been demonstrated in a variety of
surgeries ranging from pyeloplasty to radical prostatectomy
(7,8). Herein, we describe our experience in using the
da Vinci SP™ in a variety of reconstructive urologic
procedures including pyeloplasty, ureteral reconstruction
and buccal mucosa ureteroplasty, ureteral reimplantation,
and vesicovaginal fistula repair. We offer our techniques,
lessons learned, surgical philosophy and early data. Almost
all cases were recorded for quality improvement initiatives
and evaluated with the goal of creating standard operating
procedures in terms of access, steps of procedure and
minimizing pit falls.
Methods
Access for SP surgery
Access can be obtained via the umbilicus so that the SP
cannula is positioned directly across from the target area
(UPJ, upper and mid ureter) or caudad to the target area
(reimplant, fistula). Occasionally we have used the lower
quadrant along Pfannenstiel line with SP directed cephalad
to target area (pediatric pyeloplasty). Selection of the initial
incision needs to account for a minimum distance of 10
to 25 cm between the end of the cannula trocar and the
target area. This allows for full deployment of the elbow
and wristed joints of the robotic instruments and ability to
operate with the surgical field minimizing collisions. For
the majority of cases we used umbilical access except for the
pediatric pyeloplasty patient and in select adults in which
we have placed our incision along the Pfannenstiel crease.
We have adopted the use of the Mini GelPOINT™
(Applied Medical, Rancho Santa Margarita, CA) (Figure 1).
Use of this device provides the ability to “oat” the trocar
outside the body furthering the distance to the target area
(Figure 1). This technique, of “oating the trocar” can make
instrument exchanges challenging when the trocar is outside
body and we suggest only performing instrument exchange
with trocar intracorporeally. Instrument exchanges
while floating the trocar is akin to instrument changes
on the multiport without the use of a trocar to guide the
instrument into the body. If the camera lens becomes
foggy or bloody during the case, the camera needs to be
removed and cleaned while the trocar is floating. When
reinserting the camera, we recommend the assistant pulls
up on the Alexis retractor or on the patient’s fascia when
reinserting the camera to create space for the camera to be
reintroduced safely and cleanly.
The mini GelPOINT also allows the assistant to place
their trocar through the device aside the robotic trocar. If
utilizing this approach, we recommend that the trocars are
placed through the GelSeal cap prior to attaching the cap
to the Alexis retractor portion of the device. Our preference
is to place two trocars through the GelSeal cap at opposite
ends of the cap. We also avoid placing the SP cannula
through the center of the GelSeal cap for added stability.
Increased distance between the individual trocars allows for
greater mobility and limits instruments clashing.
Some of our surgeons have not had success with the
assistant working through the GelPoint or have preferred
better assistant mobility and have moved to placing a
5 mm trocar in the lateral lower quadrant. When placing

872 Billah et al. SP robotic assisted reconstructive urologic surgery with the Da Vinci SP surgical system
Transl Androl Urol 2020;9(2):870-878 | http://dx.doi.org/10.21037/tau.2020.01.06
© Translational Andrology and Urology. All rights reserved.
the assistant through the same incision as the robot, the
assistant’s mobility is restricted such that rigid suction, clip
appliers and other instruments are of limited use. On a case
by case basis and surgeon preference, a 5mm trocar can be
placed to improve mobility and utility of the assistant port.
Finally, we often use the miniGelPOINT to introduce
a remote operated suction irrigation device (ROSI, VTI
New Hampshire). This allows the surgeon to have a exible
suction/irrigation system in the operative eld at all times,
that can be grasped easily with a robotic instrument.
We prefer to have the assistant control the suction and
irrigation function through a foot pedal (Figure 2) (9).
For all cases we have used the 5 mm Airseal trocar placed
either through the GelPOINT or as an assistant port as this
provides stable pneumoperitoneum and allows us to run
the pneumoperitoneum at 10–12 mmHG, Decreasing the
pneumoperitoneum may potentially further decrease post-
operative complications (10).
Pyeloplasty
Pyeloplasty was one of the first cases we transitioned to
the SP robot. Ureteropelvic junction (UPJ) obstruction
often affects younger patients who seek improved cosmetic
outcomes. Pyeloplasty also requires a limited operative eld
which suits the SP robotic system and our institution has a
vast experience with robotic multiport pyeloplasty (11,12).
Similar to our initial reports of robotic assisted pyeloplasty
for UPJ obstruction the approach to SP robotic assisted
pyeloplasty continues to be via a transperitoneal approach.
A B
Figure 1 (A) Mini GelPOINT oated to increase distance and (B) trocar in GelPoint and not oated.
Figure 2 Remotely Operative Suction Irrigation System external set up and intraoperative use during pyeloplasty (Source: VTI Vascular
Technology).

873
Translational Andrology and Urology, Vol 9, No 2 April 2020
Transl Androl Urol 2020;9(2):870-878 | http://dx.doi.org/10.21037/tau.2020.01.06
© Translational Andrology and Urology. All rights reserved.
We position the patient in a lateral decubitus position.
In males we prep the phallus into the field to allow
bladder access via cystoscope to check stent position
intra-operatively. In female patients, we either check the
stent after the case is complete or place legs in a modied
lithotomy position with torso in a modied ank allowing
us access to the urethra and to check stent position intra-
operatively.
One important observation is that when approaching
the kidney and upper ureter in these 2 positions the
table should be raised one to two feet higher than with
a multiport approach. The base of the robot where the
instruments attach nearly reaches the floor as the arms
are pointed towards the target anatomy, particularly when
mobilizing the upper pole. If the robot is too close to the
oor, instrument exchange is unnecessarily challenging, and
sterility can be compromised.
Once robot is docked, there are several noticeable
differences between the SP and multiport system in terms
of console surgeon recognition. There is a new robotic
schematic, known as the Navigator, at the bottom of the
screen allowing the surgeon to identify the position of
each instrument in relation to each other and troubleshoot
collisions. The perspective of the Navigator (above, side,
front) can be adjusted to surgeon preference at the console.
Incorporation of this into the surgical procedure is critical
as is using the articulating camera. The camera is the rst
fully elbowed 3D HD camera that can be positioned to a
“cobra” configuration which is when the camera wrist is
elbow is up and the wrist articulated down into the center of
the workspace. The camera icon turns green when in cobra
position. This configuration mimics a 30 degree down
position providing excellent visualization.
In addition, there are now 3 separate ways to control
the camera. The traditional way is to use the camera clutch
pedal to move the camera. An additional method is to
activate the camera adjust feature which moves just the
camera wrist. Camera adjust is activated by depressing the
camera pedal and then twisting your wrist on one hand as
though you are turning the key on a car. Finally, the entire
robot with the camera can be moved in synchrony which is
called relocating.
The camera can be placed in either the 12 or 6 o’clock
position, however for pyeloplasty we exclusively introduce
the camera at the 12 o’clock position. During relocating,
minor adjustments to camera position can be performed
from the console. Our instrument conguration is based on
a right-handed surgeon. For dissection we use a monopolar
scissor in the right hand, bipolar forceps and Cadiere
forceps in the 6 or 9 o’clock position depending on traction
required. Typically, we place the traction instrument
in our 9 o’clock position and the bipolar instrument at
6 o’clock and assign both to the left hand. These are easily
interchanged depending on traction required. We also use
Weck clips to help further retract peritoneum or Gerota’s
fascia to improve exposure of the operative eld. The Weck
clips are applied to the lateral abdominal wall along with the
tissue that needs to be retracted.
After reecting the colon and exposing the renal pelvis,
traction with the Cadiere forceps is through a 6 0’clock
configuration. The renal pelvis and proximal ureter are
dissected from the peri-renal adipose tissue being careful
to avoid stripping ureteral adventitia in order to preserve
blood supply. If performing a redo pyeloplasty, ensure that
a formal ureterolysis is performed and all fibrotic tissue
removed from proximal ureter and pelvis. The single use
scissors are excellent for these tasks.
Multiple techniques exist for performing the pyeloplasty
portion of the procedure, both dismembered and non-
dismembered. We almost exclusively use the Anderson-
Hynes dismembered pyeloplasty due to its versatility,
ability to manage a large hydronephrotic renal pelvis and
transpose ureter anterior to crossing vessel when necessary
(Figure 3). We typically spatulate the ureter with scissors
in a cephalad position and the pelvis with scissor in caudad
position (Figure 3). The, single scissor use prevents need
for a Potts scissor (Figure 3). We use all the same steps to
complete anastomosis with two needle drivers, retraction in
the most cephalad position and 5.0 Vicryl or Monocryl on
an RB-1 needle. For those that choose, a non-dismembered
pyeloplasty may be performed as well using similar surgical
principles as above.
Ureteroureterostomy/buccal mucosa ureteroplasty/ureteral
reimplant
Ureteral strictures are attributed to a variety of causes
including, but not limited to infections, prior surgery,
trauma, and malignancy (13). With the multiport technique
location and port placement strategy was critical and based
on location of stricture. The SP system has simplied our
approach allowing us to exclusively place the SP trocar via
the umbilicus and allow us to easily reach the upper to distal
ureter and provide ability to locate omentum and create
a flap. We advocate the use of the Mini GelPOINT™
for placement of the SP cannula as described above. If

874 Billah et al. SP robotic assisted reconstructive urologic surgery with the Da Vinci SP surgical system
Transl Androl Urol 2020;9(2):870-878 | http://dx.doi.org/10.21037/tau.2020.01.06
© Translational Andrology and Urology. All rights reserved.
one chooses to use an assistant port, other than placed
through gelpoint, we recommend placing the trocar within
the contralateral lower quadrant for distal strictures and
ipsilateral lower quadrant for proximal strictures. This
placement of the assistant trocar in the lower quadrant may
enable more assistant exibility and provide cosmesis as the
incision is hidden within the pant line of most individuals. It
can also be used as a drain location. Patient positioning for
upper and mid ureteral strictures is similar to pyeloplasty
as described above. For distal ureteral reimplant and boari
flap, patient is placed supine with access to the phallus in
men and lithotomy in women for access to the urethra and
bladder.
Instrument choice and conguration is similar to our
pyeloplasty configuration. The Cadiere forceps provide
a balance of grip strength while minimizing tissue
damage and used primarily for traction purposes. The
Cadiere may be assigned to surgeon’s right hand or left
hand and placed anywhere within the trocar based on
surgeon’s requirements. The fenestrated bipolar forcep
is controlled by the surgeon’s left hand for manipulation,
traction, dissection and hemostasis. The monopolar
curved scissor is controlled by the surgeon’s right hand
similar to a pyeloplasty and a multiport approach.
Camera remains at the 12 o’clock position. This
provides a similar feel and muscle memory to a multiport
approach.
Different than a multiport, we nd ourselves changing
and considering optimum instrument position in relation
to traction and mobility during SP ureteral reconstruction
cases and relying on the Navigator to maximize our mobility
and access to the operative field. Changing instrument
positions during different portions of a case can greatly
assist progress. For example, when mobilizing the colon,
we prefer the Caidere in the 6 o’clock position for traction.
While dissecting the ureter, we place the Cadiere in either
the 3 or 9 o’clock position.
Another difference is that when performing complex
ureteral reconstructive procedures with the multiport we
rely heavily on ICG and near infrared imaging to conrm
perfusion to the ureteral anastomosis and when required
the omental flap. The SP lacks the Firefly fluorescence
system which we consider a limitation that we believe will
be overcome shortly with improved SP camera technology.
We have not made any significant changes to the steps
of uretero-urterostomy, buccal mucosa ureteroplasty,
ureteral reimplant, boari flap or technique for omental
wrap (Figure 4) and all have been described previously
(14-20). As highlighted one must be vigilant of instrument
configuration and placement, camera angle, schematic
at bottom of screen, and new relocation pedal. Adjunct
technology including ROSI, weck clips for traction,
Magnetic retractors can all help to facilitate the exposure
and surgery.
Vesicovaginal stula repair
Vesicovaginal stulas occur as the result of pelvic radiation,
infection, malignancy, obstructed labor, or iatrogenic from
prior surgery (21,22). The primary goal of management in
vesicovaginal stulas is achieving healthy mucosa to mucosa
closure with possible interposition of peritoneum or a
graft (23). Our experience with multiport robotic
transperitoneal vaginal fistula repair began in 2007 and have
recently transitioned to SP cases starting 2019. For this
utilization, where the target area is deep in the pelvis, working
A B
Figure 3 (A) Dissection of crossing vessel causing UPJ obstruction and (B) ureteral spatulation.

875
Translational Andrology and Urology, Vol 9, No 2 April 2020
Transl Androl Urol 2020;9(2):870-878 | http://dx.doi.org/10.21037/tau.2020.01.06
© Translational Andrology and Urology. All rights reserved.
space is narrow and the operative field is small, the SP has
proven to have all the correct characteristics and functionality.
Like most of our reconstructive procedures the SP is
introduced through a periumbilical incision using a mini-
gelPOINT as described previously. We always place the
patient in dorsal lithotomy position for exposure to the
vagina and urethra. The assistant trocar may be placed
through the miniGelpoint aside the SP trocar which, in
our early experience, is inconsistent and difficult for rigid
suction mobility. Secondary to this difculty we now use the
ROSI (Figure 2) suction which allows for innite angles and
mobility for suctioning purposes as described previously.
Another option is place an assistant trocar inferolateral to
the periumbilical incision on the left or ride side based on
surgeon preference.
The scope is placed at the 12 o’clock position the bipolar
forceps is placed at the 9 o’clock position, the Cadiere
forceps at the 3 o’clock position, and the monopolar curved
scissors at the 6 o’clock position. With this setup, we
have found that instruments do not need to be exchanged
throughout the procedure which reduces operative time.
When suturing with the SP system we utilize the needle
drivers at the 6 and 9 o’clock position. On the multiport
system, when tying knots, the wrist can be held at any
angle and the instruments pulled laterally. One does not
need to consider wrist angle. With the SP system, lateral
movements are limited. To increase lateral distance that the
suture can be pulled, we evert the tips of the needle driver
and pull as far lateral as the SP system enables. This allows
knots to be tied securely and especially important when
closing the vaginal wall.
The major steps of the procedure do not differ from
the multiport approach (24-26). Key elements begin
with finding the posterior bladder and vaginal cuff. The
plane between the vaginal cuff and posterior bladder is
mobilized until the fistula tract is identified. Near the
stula tract, a cystotomy is performed and the stula tract
can easily be seen from within the bladder. The fistula is
then excised and healthy tissue edges from the bladder
mucosa and muscle and healthy vaginal tissue are brought
together. Then mucosa to mucosa closure of the respective
organs is performed in a tension free and watertight
fashion. Interposition can be performed with omentum or
peritoneum. A surgical drain can be brought out through
the initial SP incision.
Some tips include when visualization of bladder closure
is challenging, we have rotated the robotic arm 180 degrees
and placed camera at the 6 0’clock position allowing a
better view and easier closure of the posterior bladder wall.
For harvesting omentum the entire system can be relocated
without changing patient position or redocking the robot
and then used to bring omental flap into position. Early
on we like having an extra assistant in the lateral lower
quadrant to assist with suction, irrigation, traction and
efcient passage of sutures.
Results
We have performed 18 robotic urinary reconstructive
procedure of which 6 had complete information and IRB
Consent (Tables 1,2).
Conclusions
As the boundaries of minimally invasive surgery are
expanded, the introduction of the da Vinci SP™ robotic
surgical system provides the most dramatic advancement in
performing LESS (Figure 5). By providing a platform that
operates similarly to the more widely adopted da Vinci™
multiport platform, the learning curve is drastically reduced.
Figure 4 (A) Suturing buccal mucosa to ureter and (B) tying nal knot after placement of buccal mucosa on ureter. Ureteroscope can be
noted in the lumen of the ureter.
A B

876 Billah et al. SP robotic assisted reconstructive urologic surgery with the Da Vinci SP surgical system
Transl Androl Urol 2020;9(2):870-878 | http://dx.doi.org/10.21037/tau.2020.01.06
© Translational Andrology and Urology. All rights reserved.
Table 1 Single port reconstruction patient characteristics
Pt Sex Height (cm) Weight (kg) BMI Procedure Etiology Stricture length
1 F 170.2 101.6 35.1 Ureteroplasty with buccal graft Impacted Stone 6
2 M 185.4 74.8 21.8 Pyeloplasty Congenital N/A
3 F 165.1 59 21.6 Pyeloplasty Congenital N/A
4 M 177.8 78 24.7 Distal ureterectomy Malignancy N/A
5 F 165.1 80.7 29.6 Pyeloplasty Congenital N/A
6 F 170.2 64.9 22.4 Pyeloplasty and stone Crossing Vessels 1.5
Table 2 Single port reconstruction operating room data
Pt OR Time EBL (mL) ASA score Intra-Op Complications Complications (Clavien 1–5) Need to re-operate?
1 285 20 2 None None No
2 157 50 2 None None No
3 138 70 2 None None No
4 128 10 2 None None No
5 136 15 2 None None No
6 160 25 3 None None No
EBL, estimated blood loss.
Figure 5 (A) As can be seen in the immediate postoperative period, the SP system enables smaller incisions and superior cosmesis, (B)
excellent healing and cosmesis noted at follow-up visit.
A B
Herein, we present our initial experience with the da Vinci
SP™ in urologic reconstructive surgery. Further studies in
outcomes for procedures performed with the da Vinci SP™
may aid in more widespread adoption.
Acknowledgments
Study data were collected and managed using REDCap
electronic data capture tool.
Funding: None.

877
Translational Andrology and Urology, Vol 9, No 2 April 2020
Transl Androl Urol 2020;9(2):870-878 | http://dx.doi.org/10.21037/tau.2020.01.06
© Translational Andrology and Urology. All rights reserved.
Footnote
Provenance and Peer Review: This article was commissioned
by the Guest Editor (Ashok K. Hemal) for the series
“Robotic-assisted Urologic Surgery” published in
Translational Andrology and Urology. The article was sent for
external peer review organized by the Guest Editor and the
editorial ofce.
Conflicts of Interest: The series “Robotic-assisted Urologic
Surgery” was commissioned by the editorial ofce without
any funding or sponsorship. RM: Boston Scientic, Amniox
Medical; MS: Conmed, Ethicon, Intuitive Surgical, Vascular
Technology Incorporated. The other authors have no other
conicts of interest to declare.
Ethical Statement: The authors are accountable for all
aspects of the work in ensuring that questions related
to the accuracy or integrity of any part of the work
are appropriately investigated and resolved. The study
was approved by the Ethics Committee of Hackensack
University Medical Center/Institutional Review Board (IRB
number: Pro 2017-0476) and written informed consent was
obtained from all patients.
Open Access Statement: This is an Open Access article
distributed in accordance with the Creative Commons
Attribution-NonCommercial-NoDerivs 4.0 International
License (CC BY-NC-ND 4.0), which permits the non-
commercial replication and distribution of the article with
the strict proviso that no changes or edits are made and the
original work is properly cited (including links to both the
formal publication through the relevant DOI and the license).
See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
1. Box G, Averch T, Cadeddu J, et al. Nomenclature of
natural orice translumenal endoscopic surgery (NOTES)
and laparoendoscopic single-site surgery (LESS)
procedures in urology. J Endourol 2008;22:2575-81.
2. Gettman MT, Box G, Averch T, et al. Consensus statement
on natural orice transluminal endoscopic surgery and
single-incision laparoscopic surgery: heralding a new era in
urology? Eur Urol 2008;53:1117-20.
3. Autorino R, Cadeddu JA, Desai MM, et al.
Laparoendoscopic single-site and natural orice
transluminal endoscopic surgery in urology: a critical
analysis of the literature. Eur Urol 2011;59:26-45.
4. Intuitive Surgical I. Intuitive Surgical Announces
Innovative Single Port Platform — the da Vinci SP®
Surgical System. Intuitive Surgical [Internet] 2018
[cited 2019 Sep 1]. Available online: http://investor.
intuitivesurgical.com/news-releases/news-release-details/
intuitive-surgical-announces-innovative-single-port-
platform-da
5. Best SL, Donnally C, Mir SA, et al. Complications during
the initial experience with laparoendoscopic single- site
pyeloplasty. BJU Int 2011;108:1326-9.
6. Autorino R, Kaouk JH, Stolzenburg JU, et al. Current
status and future directions of robotic single-site surgery: a
systematic review. Eur Urol 2013;63:266-80.
7. Chang Y, Lu X, Zhu Q, et al. Single-port transperitoneal
robotic-assisted laparoscopic radical prostatectomy
(spRALP): Initial experience. Asian J Urol 2019;6:294-7.
8. Heo JE, Kang SK, Koh DH, et al. Pure single-site robot-
assisted pyeloplasty with the da Vinci SP surgical system:
Initial experience. Investig Clin Urol 2019;60:326-30.
9. Stifelman MD, Mass A. #WCE2014 - The use of a robotic
remotely operated suction/irrigation (ROSI) system
may lead to less post-operative blood loss after robotic
pyeloplasty - Interview [Internet]. World Congress of
Endourology 2014 [cited 2019 Sep 3]. Available online:
https://www.urotoday.com/conference-highlights/global-
congress-on-bladder-cancer-2018/1622-conferences/
wce-2014/wce-2014-trauma-reconstruction/75097-
wce2014-the-use-of-a-robotic-remotely-operated-suction-
irrigation-rosi-system-may-lead-to-less-post-operat
10. Rohloff M, Cicic A, Christensen C, et al. Reduction
in postoperative ileus rates utilizing lower pressure
pneumoperitoneum in robotic-assisted radical
prostatectomy. J Robot Surg 2019;13:671-4.
11. Palese MA, Munver R, Phillips CK, et al. Robot-assisted
laparoscopic dismembered pyeloplasty. JSLS 2005;9:252-7.
12. Niver BE, Agalliu I, Bareket R, et al. Analysis of robotic-
assisted laparoscopic pyleloplasty for primary versus
secondary repair in 119 consecutive cases. Urology
2012;79:689-94.
13. Marien T, Bjurlin MA, Wynia B, et al. Outcomes
of robotic-assisted laparoscopic upper urinary tract
reconstruction: 250 consecutive patients. BJU Int
2015;116:604-11.
14. Stifelman MD. V1820: Robotic Pyeloplasty for the
Treatment of Secondary UPJ Obstruction: Lessons
Learned. J Urol 2007;177:605.
15. Stifelman MD, Hyams ES. V1056: Laparoscopic Doppler

878 Billah et al. SP robotic assisted reconstructive urologic surgery with the Da Vinci SP surgical system
Transl Androl Urol 2020;9(2):870-878 | http://dx.doi.org/10.21037/tau.2020.01.06
© Translational Andrology and Urology. All rights reserved.
Technology: Applications in Laparoscopic Pyeloplasty,
Radical and Partial Nephrectomy. J Urol 2007;177:349.
16. Stifelman M, Feliciano J. V860 robotic transmesenteric
pyeloplasty of a pelvic kidney. J Urol 2011;185:e345.
17. Lipkin ME, Shah OD, Stifelman MD. Robotic-assisted
ureteral re-implant and psoas hitch in the treatment of
distal ureteral stricture. J Urol 2008;179:543.
18. Berger AD, Shah OD, Stifelman MD. V488: The Use of
Rotobics in the Management of Mid Ureteral Obstruction.
J Urol 2007;177:163.
19. Korets R, Hyams ES, Shah OD, et al. V485: Robot-
Assisted Laparoscopic Ureterocalicostomy. J Urol
2007;177:162.
20. Fenig DM, Berger AD, Kau E, et al. V752: Robotic-
Assisted Laparoscopic Ureteral Reimplantation. J Urol
2005;173:204.
21. Moses RA, Ann Gormley E. State of the Art for Treatment
of Vesicovaginal Fistula. Curr Urol Rep 2017;18:60.
22. Bodner-Adler B, Hanzal E, Pablik et al. Management of
vesicovaginal stulas (VVFs) in women following benign
gynaecologic surgery: A systematic review and meta-
analysis. PLoS One 2017;12:e0171554.
23. McKay E, Watts K, Abraham N. Abdominal Approach
to Vesicovaginal Fistula. Urol Clin North Am
2019;46:135-46.
24. Agrawal V, Kucherov V, Bendana, et al. Robot-assisted
Laparoscopic Repair of Vesicovaginal Fistula: A Single-
center Experience. Urology 2015;86:276-81.
25. Martini A, Dattolo E, Frizzi J, et al. Robotic vesico-vaginal
stula repair with no omental ap interposition. Int
Urogynecol J 2016;27:1277-8.
26. Kelly E, Wu MY, MacMillan JB. Robotic-assisted
vesicovaginal stula repair using an extravesical
approach without interposition grafting. J Robot Surg
2018;12:173-6.
Cite this article as: Billah MS, Stifelman M, Munver R,
Tsui J, Lovallo G, Ahmed M. Single port robotic assisted
reconstructive urologic surgery—with the da Vinci SP surgical
system. Transl Androl Urol 2020;9(2):870-878. doi: 10.21037/
tau.2020.01.06