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Page 2 of 6 Chen et al. Mini-invasive Surg 2021;5:54 https://dx.doi.org/10.20517/2574-1225.2021.69

INTRODUCTION
Muscle-invasive bladder cancer is an aggressive disease associated with high morbidity and mortality, and is
primarily treated with radical cystectomy with multiple possible avenues for urinary diversion, including the
ileal conduit urinary diversion or the orthotopic neobladder. This is classically done in an open fashion with
the open radical cystectomy (ORC); however, with the increasing popularity of robotic surgery for pelvic
surgery, there is growing interest in robotic-assisted radical cystectomy (RARC) as a minimally invasive
alternative, with the use of the robot for radical cystectomy increasing from 16.7% in 2010 to 25.3% in 2013
[1]
in the United States . The robots typically utilized for RARC include multiport generations of the da Vinci
platform, including the da Vinci SI and XI systems.

The da Vinci single port (SP) robotic system (Intuitive Surgical, Sunnyvale, CA, USA) is the most recent
robotic platform approved by the FDA in 2018 for urological surgery, and was designed with several
modifications to the previously available multi-port robotic systems. The SP system combines the camera
and all instrument arms into a single port, allowing surgery to be performed using a single incision. Other
notable features include a relocation feature that allows the operator to reach all abdominal quadrants by
moving the entire trocar with the attached arm around its fulcrum, and a virtual navigator that provides
real-time monitoring of the relative position of the instruments, even when off the visual field. This allows
for greater control of the instruments and safer positioning. Theoretical advantages of the SP platform over
the multiport include improved cosmesis due to surgery being performed through a single incision. Fewer
incisions also have a theoretical benefit of reduced pain and improved visualization in a narrow space such
as the pelvis. Retrospective studies on robotic prostatectomy have already shown an advantage in terms of
[2,3]
pain scores after surgery and length of stay, with comparable outcomes .
This article illustrates the technique performed utilizing the SP robotic system for the robotic-assisted
laparoscopic radical cystectomy with ileal conduit urinary diversion in a male patient. To date, there are
only three other published papers detailing the use of the SP robot for RARC, and no noninferiority studies
comparing the SP RARC to multiport RARC. We provide a step-by-step technical approach to surgery with
special attention paid to technical modifications from the multi-port technique.

METHODS
We provide a review of our technique for single-port radical cystectomy based on the experience from our
institution. A video of the procedure is available as well. A review of early outcomes has been carried out
through a retrospective analysis of clinical documentation. A systematic review of the literature outcomes
was performed via a broad search of PubMed using the following keywords: da Vinci SP, single port robotic
cystectomy, and radical cystectomy. We included a single patient from our institution, who was chosen
according to standard patient selection for RARC, including the ability to tolerate pneumoperitoneum and
2
steep Trendelenburg, BMI < 30 kg/m , and lack of prior pelvic radiation or trauma .
[4]
Step-by-step surgical technique
Patient positioning and port placement
After induction of general anesthesia, the patient is positioned in the standard positioning for robotic pelvic
surgery, specifically the dorsal lithotomy position with arms tucked, extremities padded and secured, and
the bed in steep Trendelenburg. After the patient is prepped and draped in the normal sterile fashion, a
Foley catheter is placed. A 2.5 cm incision is then made inferolateral to the umbilicus, approximately ⅓ of
the distance between the umbilicus and iliac crest, and the Hasson technique is used to dissect through
layers of fascia to access the abdominal cavity. Of note, this incision is later used as our stoma site for ileal
conduit creation. We then insert an Alexis retractor into this incision site and attach the GelPOINT