Page 57 - Read Online

Page 2 of 10 Ditonno et al. Mini-invasive Surg 2023;7:36 https://dx.doi.org/10.20517/2574-1225.2023.62

INTRODUCTION
Nephron-sparing surgery (NSS) represents the standard of treatment for cT1 renal masses. This approach
has seen increasing adoption over the past years, and today, its indications have also extended to include
cT2 renal masses when technically feasible .
[1]

[2]
Robot-assisted partial nephrectomy (RAPN) is becoming de facto the new gold standard in NSS , as it
allows lower intraoperative bleeding and faster post-operative recovery compared to open and laparoscopic
[1]
partial nephrectomy .

The latest advance in the robotic urological field is represented by the Da Vinci Single Port® (SP) system
(Intuitive Surgical, Sunnyvale, CA). Following its initial clinical description , the Da Vinci SP® system was
[3]
approved by the American Food and Drug Administration (FDA) in 2014, the Ministry of Food and Drug
Safety of South Korea in 2020, and Japan’s Ministry of Health, Labour and Welfare in 2022. Its development
aims at minimizing skin incisions and facilitating work in smaller working spaces while preserving the
advantages of robotic instruments. Its safety and feasibility have now been tested in several urological
[4]
procedures, and experience with this platform is growing . The greatest differences between SP and multi-
port (MP) systems consist of a reduced operative field, restrictions in the range of motion of the robotic
arms, shallower instrument depth, and a decreased level of assistance from the bedside assistant .
[5]

[6,7]
Since its approval, an increasing body of literature has emerged on SP RAPN . SP RAPN demonstrated
similar peri- and post-operative outcomes in different reports, with respect to MP RAPN, with a possible
benefit in terms of opioid use . Furthermore, this approach has also been tested in a retroperitoneal
[8]
fashion, proving its safety and feasibility .
[9]
Given the growing interest in this novel approach, this narrative review of the literature aims to address
technical aspects and collect existing evidence about surgical, oncological, and functional outcomes of SP
RAPN.

®
THE DA VINCI SP SURGICAL SYSTEM
The Da Vinci SP® surgical system is composed of a single instrument arm, which encloses four instrument
drives in which to insert the endoscope and three double-jointed articulating robotic instruments.
Instruments enter the patient’s abdomen through a 25-mm multichannel port that accommodates the
12 mm × 10 mm robotic camera, three robotic instruments with 6 mm double-jointed articulation, and a
6 mm extra laparoscopic instrument [Figure 1]. The main difference with Da Vinci MP instruments is the
additional “elbow” joint added to the robotic instruments to maintain the intracorporeal triangulation.
Furthermore, the single incision approach with the single-arm structure allows for possible 360-degree
access, giving this platform the potential to realize one-step multiquadrant surgery.

Technical features of single port partial nephrectomy
The initial experience with SP RAPN was described by Kaouk et al., who investigated the safety and
feasibility of the technique on three consecutive patients treated via a transperitoneal approach. The authors
adopted a transperitoneal approach that resembled the surgical steps performed with the MP approach. An
operative time (OT) of 180 min, a warm ischemia time (WIT) of 25 min, and an estimated blood loss (EBL)
of 180 mL was reported. No intraoperative complications occurred, and one patient required
angioembolization due to post-operative acute bleeding. The pathology report showed negative surgical
margins in all cases. The authors defined the results as promising, acknowledging the presence of a learning
[6]
curve and differences when compared to the MP system, especially in suturing, due to the novel elbow .