Current status and future directions of robotic single-site surgery: a systematic review

Initial experience with the new da Vinci single-port robot-assisted platform

OBJECTIVE

To describe our experience in the first cases of urological surgeries performed with the da Vinci single-port robot-assisted platform.

MATERIAL AND METHODS

We performed 5 single-port robot-assisted surgeries (R-LESS) between May and October 2014. We performed 3 ureteral reimplant surgeries, one ureteropyeloplasty in an inverted kidney and 1 partial nephrectomy. The perioperative and postoperative results were collected, as well as a report of the complications according to the Clavien classification system.

RESULTS

Of the 5 procedures, 4 were performed completely by LESS, while 1 procedure was reconverted to multiport robot-assisted surgery. There were no intraoperative complications. We observed perioperative complications in 4 patients, all of which were grade 1 or 2. The mean surgical time was 262minutes (range, 230-300).

DISCUSSION

In our initial experience with the da Vinci device, R-LESS surgery was feasible and safe. There are still a number of limitations in its use, which require new and improved R-LESS platforms.

Current status of robotic single-port surgery

Robotic-assisted laparoscopic surgery in urology is an ever progressing field, and boundaries are constantly broken with the aid of new technology. Advancements in instrumentation have given birth to the era of robotic laparoendoscopic single-site technique (R-LESS). R-LESS however, has not gained widespread acceptance due to technical hurdles such as adequate triangulation, robotic arm clashing, decreased access for the bedside assistant, lack of wrist articulation, continued need for an axillary/accessory port, lack of robust retraction, and ergonomic discomfort. Many innovations have been explored to counter such limitations. We aim to give a brief overview of a history and development of R-LESS urologic surgery and outline the latest advancements in the realm of urologic R-LESS. By searching PubMed selectively for relevant articles, we concluded a literature review. We searched using the keywords: robotic laparoscopic single incision, robotic laparoendoscopic single-site, single incision robotic surgery, and R-LESS. We selected all relevant articles in that pertained to single-site robotic surgery in urology. We selected all relevant articles that pertained to single-site robotic surgery in urology in a table encompassed within this article. The development of the R-LESS procedures, instrumentations, and platforms has been an evolution in progress. Our results showed the history and evolution toward a purpose-built single-port robotic platform that addresses previous limitations to R-LESS. Even though previous studies have shown feasibility with R-LESS, the future of R-LESS depends on the availability of purpose-built robotic platforms. The larger concern is the demonstration of the definitive advantage of single-site over the conventional multiport surgery.

Robot-assisted partial nephrectomy

Partial nephrectomy is the standard treatment for small renal masses. Currently, it is commonly performed using minimally invasive approaches, including laparoscopic and robot-assisted techniques. The aim of the present review is to report the surgical technique of robot-assisted partial nephrectomy in full detail as well as available literature results.

Single-incision robotic colectomy: are costs prohibitive?

BACKGROUND

The feasibility, safety, and costs of single-incision robotic colectomy (SIRC) are not known.

METHODS

A retrospective review was conducted, comparing the initial 29 consecutive SIRC procedures performed to 36 multiport laparoscopic colectomies (MLC).

RESULTS

The groups did not differ significantly on age, body mass index, gender, ASA classification, smoking status, steroid usage or rate of diabetes. Procedure time, conversion rate, infectious complications and length of stay did not differ significantly. The ratio of observed:expected direct hospital costs statistically favoured MLC, although there was no statistical difference between groups for contribution margin, or for observed and expected direct hospital costs.

CONCLUSIONS

These results demonstrate safety and technical feasibility for SIRC in selected patients with short-term outcomes and hospital costs comparable to MLC. Contribution margin remained positive and expected costs exceeded observed for SIRC. Increased costs for SIRC are a concern. The comparable but relatively high mortality in both groups may represent an institutional approach to colectomy where significant comorbidity is not a contraindication to minimally invasive surgery. Copyright © 2015 John Wiley & Sons, Ltd.

An all-joint-control master device for single-port laparoscopic surgery robots

PURPOSE

Robots for single-port laparoscopic surgery (SPLS) typically have all of their joints located inside abdomen during surgery, whereas with the da Vinci system, only the tip part of the robot arm is inserted and manipulated. A typical master device that controls only the tip with six degrees of freedom (DOFs) is not suitable for use with SPLS robots because of safety concerns.

METHODS

We designed an ergonomic six-DOF master device that can control all of the joints of an SPLS robot. We matched each joint of the master, the slave, and the human arm to decouple all-joint motions of the slave robot. Counterbalance masses were used to reduce operator fatigue. Mapping factors were determined based on kinematic analysis and were used to achieve all-joint control with minimal error at the tip of the slave robot.

RESULTS

The proposed master device has two noteworthy features: efficient joint matching to the human arm to decouple each joint motion of the slave robot and accurate mapping factors, which can minimize the trajectory error of the tips between the master and the slave.

CONCLUSIONS

We confirmed that the operator can manipulate the slave robot intuitively with the master device and that both tips have similar trajectories with minimal error.

Optimal pain management for radical prostatectomy surgery: what is the evidence?

BACKGROUND

Increase in the diagnosis of prostate cancer has increased the incidence of radical prostatectomy. However, the literature assessing pain therapy for this procedure has not been systematically evaluated. Thus, optimal pain therapy for patients undergoing radical prostatectomy remains controversial.

METHODS

Medline, Embase, and Cochrane Central Register of Controlled Trials were searched for studies assessing the effects of analgesic and anesthetic interventions on pain after radical prostatectomy. All searches were conducted in October 2012 and updated in June 2015.

RESULTS

Most treatments studied improved pain relief and/or reduced opioid requirements. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis and consensus recommendations.

CONCLUSIONS

This systematic review reveals that there is a lack of evidence to develop an optimal pain management protocol in patients undergoing radical prostatectomy. Most studies assessed unimodal analgesic approaches rather than a multimodal technique. There is a need for more procedure-specific studies comparing pain and analgesic requirements for open and minimally invasive surgical procedures. Finally, while we wait for appropriate procedure specific evidence from publication of adequate studies assessing optimal pain management after radical prostatectomy, we propose a basic analgesic guideline.

Da Vinci single site© surgical platform in clinical practice: a systematic review

BACKGROUND

The Da Vinci single-site© surgical platform (DVSSP) is a set of single-site instruments and accessories specifically dedicated to robot-assisted single-site surgery.

METHODS

The PubMed database from inception to June 2015 was searched for English literature on the clinical use of DVSSP in general surgery, urology and gynecology.

RESULTS

Twenty-nine articles involving the clinical application of DVSSP were identified; 15 articles on general surgery (561 procedures), four articles on urology (48 procedures) and 10 articles on gynecology (212 procedures). All studies have proven the safety and feasibility of the use of DVSSP. The principal reported advantage is the restoration of intra-abdominal triangulation, while the main reported limitation is the lack of the endowrist.

CONCLUSIONS

Da Vinci systems have proven to be valuable assets in single-site surgery, owing to the combination of robot use with the dedicated single-incision platform. However, case-control or prospective trials are warranted to draw more definitive conc lusions. Copyright © 2015 John Wiley & Sons, Ltd.

Next-generation robotic surgery--from the aspect of surgical robots developed by industry

At present, much of the research conducted worldwide focuses on extending the ability of surgical robots. One approach is to extend robotic dexterity. For instance, accessibility and dexterity of the surgical instruments remains the largest issue for reduced port surgery such as single port surgery or natural orifice surgery. To solve this problem, a great deal of research is currently conducted in the field of robotics. Enhancing the surgeon's perception is an approach that uses advanced sensor technology. The real-time data acquired through the robotic system combined with the data stored in the robot (such as the robot's location) provide a major advantage. This paper aims at introducing state-of-the-art products and pre-market products in this technological advancement, namely the robotic challenge in extending dexterity and hopefully providing the path to robotic surgery in the near future.

Robotic single-site versus laparo-endoscopic single-site surgery for adnexal tumours: a propensity score-matching analysis

BACKGROUND

The aim of this study was to compare the surgical outcomes of robotic single-site (RSS) and laparo-endoscopic single-site (LESS) surgery for adnexal tumours and evaluate the feasibility of RSS surgery.

METHODS

RSS surgery was performed using the da Vinci Single-Site® surgical platform and LESS surgery using a single multi-channel port system. Surgical outcomes were compared between RSS (n = 20) and LESS (n = 228) after 1:4 propensity score matching.

RESULTS

After the propensity score matching, the RSS group showed longer operating times than the LESS (91.1 vs 66.1 min; p = 0.001). While the LESS showed 1.3% of major complication rates, the RSS group had no perioperative complication. For the LESS, 2.5% of patients needed additional port insertion.

CONCLUSIONS

The RSS surgery for adnexal tumours could be performed safely without complications or additional port insertion. Although it showed a longer operating time, further experience and technical refinements will continue to improve operative results. Copyright © 2015 John Wiley & Sons, Ltd.

Single-Site Robotic Cholecystectomy: Reverse-Port Technique

This study aims to introduce an alternative technique for effective single-site robotic cholecystectomy (SSRC) using a reverse port.Proper exposure of Calot's triangle is critical for safe laparoscopic cholecystectomy. Current robotic surgical systems are useful for single-site cholecystectomy. However, in exposing Calot's triangle, the gallbladder is usually retracted in a medial and upward direction, resulting in a narrow triangle. This intraoperative view is a major obstacle to safe laparoscopic cholecystectomy.From October 2013 to October 2014, 55 consecutive patients underwent SSRC by a single surgeon at Yonsei University Severance Hospital. Initially, 5 patients underwent the original robotic single site cholecystectomy technique, and the remaining 50 patients underwent robotic single site cholecystectomy using our reverse port technique.There were no differences between the SSRC-O (original port) group and the SSRC-R (reverse port) group in terms of patient age (P = 0.244), body mass index (P = 0.503), and pathologic conditions of the gallbladder (P = 0.841). Total operation time (132.6 vs 99.12 min; P = 0.009), actual dissection time (51.6 vs 30.28 min; P = 0.001), and console time (84.4 vs 50.46 min; P = 0.001) were all significantly shorter in the SSRC-R group. Mean intraoperative blood loss was minimal in both groups (20 vs 12.4 mL, P = 0.467), and bile spillage occurred in 2 patients of the SSRC-R group. There was one case of laparoscopic conversion in the SSRC-R group.The reverse port technique described in this study successfully widened Calot's triangle and improved the safety of the current robotic surgical system for single-site robotic cholecystectomy.

Laparoendoscopic single site surgery versus conventional laparoscopy for transperitoneal pyeloplasty: A systematic review and meta-analysis

We aimed to review studies comparing the outcomes of the laparoendoscopic single site (LESS) pyeloplasty with those of conventional laparoscopic pyeloplasty (CLP). A systematic review of the literature was performed according to the PRISMA (preferred reporting items for systematic reviews and meta-analysis) criteria. The methodological quality of the studies was rated according validated scales. The level of evidence (LE) was reported as described by the Oxford criteria. Preoperative demographic parameters and perioperative outcomes between the two surgical techniques were assessed. A meta-analysis of the included studies was performed. A total of 5 studies were elected for the analysis, including 164 cases, 70 (42.6%) of them being LESS and 94 (57.4%) being CLP. Four studies were observational retrospective comparative studies (LE: 3a-4); one was a prospective randomized controlled trial (LE: 2b). There was no significant difference in age, body mass index, gender, side and presence of the crossing vessel, between the groups. There was no significant difference regarding the operative time (weight mean difference [WMD]: −7.02; 95% confidence interval [CI]: −71.82–57.79; P = 0.83) and length of hospital stay (WMD: 0.04; 95% CI: −0.11–0.20; P = 0.58), whereas the estimated blood loss was statistically lower for LESS (WMD: −16.83; 95% CI: −31.79–−1.87; P = 0.03). The postoperative use of analgesic favored the LESS group but without reaching statistical significance (WMD: −7.52; 95% CI: −17.56–2.53; P = 0.14). In conclusion, LESS pyeloplasty offers comparable surgical and functional outcomes to CLP while providing the potential advantages of less blood loss and lower analgesic requirement. Thus, despite being more technically challenging, LESS pyeloplasty can be regarded as a minimally invasive approach for patients seeking fewer incisional scars.

Single-incision robotic colectomy (SIRC): Current status and future directions

By combining laparo-endoscopic single-site surgery (LESS) techniques with the da Vinci robotic platform, single-incision robotic colectomy (SIRC) aims to further minimize incision-related complications and improve cosmetic outcomes from the current standard of care, laparoscopic colectomy. While there is limited literature on SIRC, all available reports suggest SIRC to be a safe and feasible procedure in terms of perioperative outcomes. Future research should focus on further clarification of proposed benefits of SIRC such as cosmetics, ergonomics, incidence of incision-related complications, and long-term oncologic outcomes.

Two-Port Approach Compared to Standard Laparoscopic Radical Cystectomy

BACKGROUND AND OBJECTIVES

Two-port laparoscopic radical cystectomy (LRC) using a multichannel platform through the umbilicus and one additional 10-mm in the right iliac fossa has been recently described. We compare the perioperative and early results of this technique with a cohort of patients simultaneously treated in our institution with four-port LRC and a 7 to 10 cm midline incision.

MATERIALS AND METHODS

A matched-pair study comparing perioperative outcomes, postoperative visual analog pain scale (VAPS), and morbidity of two-port (n=30) and four-port (n=30) LRC. Preoperative and perioperative data analyzed and compared included demographics, type of urinary diversion, operative time, blood loss, transfusion requirements, decrease in serum hemoglobin, operative complications, analgesic needs, length of stay, number of nodes removed, and other pathologic information. Complications in the first 3 months were evaluated according to the Clavien-Dindo classification.

RESULTS

There was no significant difference between the two groups regarding patient age, gender, body-mass index, American Society of Anesthesiologists (ASA) score, Charlson comorbidity index, tumor stage, percent of positive nodes, positive margin rate, number of nodes retrieved, proportion of neobladders, secondary carcinoma in situ, incidental prostate cancer, or need of systemic chemotherapy. Median operative time was 20 minutes higher in the two-port procedure, but this difference was not statistically significant (p=0.2). Estimated blood loss and differential hemoglobin change were lower in the two-port technique (each p=0.03), but no difference was detected regarding the intraoperative or postoperative transfusion rate. Length of hospital stay was also equivalent. Differences were not observed either in the number or severity of complications. VAPS at days 2, 3, and 5 was significantly lower for two-port LRC (p<0.01).

CONCLUSIONS

Two-port LRC performed through an umbilical platform and an accessory 10-mm port seems technically equivalent to standard four-port LRC. Perioperative outcomes regarding hospital stay and complications are tantamount. Diminished blood loss and, especially, less postoperative pain favor the reduced-port approach in this complex urologic minimally invasive procedure.

Robotic single-site versus laparoendoscopic single-site hysterectomy: a propensity score matching study

Background

The aim of this study was to compare the surgical outcomes of robotic single-site (RSS-H) and laparoendoscopic single-site total hysterectomy (LESS-H) and to evaluate the feasibility of RSS-H in patients with benign gynecologic disease.

Methods

The RSS-H was performed using the da Vinci single-site surgical platform, and the LESS-H using a single multi-channel port system at the umbilicus. Among 467 consecutive patients who had undergone total hysterectomy for benign gynecologic disease, surgical outcomes were compared between RSS-H group (n = 25) and LESS-H group (n = 442) after propensity score matching.

Results

All operations were completed robotically and laparoscopically without conversion to laparotomy, respectively. The RSS-H group had longer operating times and less operative bleeding compared to the LESS-H group. While the LESS-H showed 1.4 % of major complication rate, the RSS-H had no perioperative complication. Even after propensity score matching, the RSS-H still showed longer operating times (170.9 vs 94.1 min, p < 0.0001) and less operative bleeding (median estimated blood loss, 20 vs 50 ml, p = 0.009; mean hemoglobin drop, 1.6 vs 2.0 g/dl, p = 0.038) than the LESS-H.

Conclusions

The RSS-H could be a feasible and safe procedure in appropriately selected patients with benign gynecologic disease, and further experience and technical refinements will continue to improve operative results. Prospective randomized trials will permit the evaluation of the potential benefits of the RSS surgery as a minimally invasive surgical approach.

Spider surgical system versus multiport laparoscopic surgery: performance comparison on a surgical simulator

Background

The rising interest towards minimally invasive surgery has led to the introduction of laparo-endoscopic single site (LESS) surgery as the natural evolution of conventional multiport laparoscopy. However, this new surgical approach is hampered with peculiar technical difficulties. The SPIDER surgical system has been developed in the attempt to overcome some of these challenges. Our study aimed to compare standard laparoscopy and SPIDER technical performance on a surgical simulator, using standardized tasks from the Fundamentals of Laparoscopic Surgery (FLS).

Methods

Twenty participants were divided into two groups based on their surgical laparoscopic experience: 10 PGY1 residents were included in the inexperienced group and 10 laparoscopists in the experienced group. Participants performed the FLS pegboard transfers task and pattern cutting task on a laparoscopic box trainer. Objective task scores and subjective questionnaire rating scales were used to compare conventional laparoscopy and SPIDER surgical system.

Results

Both groups performed significantly better in the FLS scores on the standard laparoscopic simulator compared to the SPIDER.

Inexperienced group: Task 1 scores (median 252.5 vs. 228.5; p = 0.007); Task 2 scores (median 270.5 vs. 219.0; p = 0.005).

Experienced group: Task 1 scores (median 411.5 vs. 309.5; p = 0.005); Task 2 scores (median 418.0 vs. 331.5; p = 0.007).

Same aspects were highlighted for the subjective evaluations, except for the inexperienced surgeons who found both devices equivalent in terms of ease of use only in the peg transfer task.

Conclusions

Even though the SPIDER is an innovative and promising device, our study proved that it is more challenging than conventional laparoscopy in a population with different degrees of surgical experience. We presume that a possible way to overcome such challenges could be the development of tailored training programs through simulation methods. This may represent an effective way to deliver training, achieve mastery and skills and prepare surgeons for their future clinical experience.

The best option: Umbilical LESS radical nephrectomy with vaginal extraction

INTRODUCTION

Umbilical laparoendoscopic single-site (LESS) surgery represents an excellent alternative to laparoscopic or robotic multiport surgery. LESS surgery offers faster recovery, less postoperative pain and optimal cosmetic results. The reusable nature of its instruments also has significant economic advantages.

PATIENT AND METHOD

We present a 34-year-old patient with a solid mesorenal lesion measuring 8 cm in the left kidney treated with pure LESS radical nephrectomy assisted by vaginal extraction of the specimen. The umbilical approach using a single-site multichannel KeyPort (Richard Wolf GmbH, Knittlingen, Germany) with DuoRotate curved instruments allows for minimum crushing and fewer spatial conflicts. Its perfect umbilical adaptation provides a hermetic system. The instrument's double rotation provides considerable movement precision. Vaginal extraction avoids damage to the abdominal wall and the need for widening the umbilical incision.

RESULTS

After the placement of the device and triangulation of the clips, we proceeded to operate on posterior parietal peritoneum. The descending colon was mobilized to access the retroperitoneum and dissect the renal hilum. Hem-o-lok clips were placed on the artery and vein, which were subsequently sectioned. The specimen was inserted into a laparoscopic bag. Under direct vision, we placed a 15-mm trocar through the bottom of the vaginal posterior fornix to facilitate the extraction of the bag's thread. The incision was widened with the fingers, and the specimen was extracted, closing the vagina from the perineum with visualization from the navel. Abdominal drainage was not employed. The surgical time was 180 min. The patient was discharged the following day without needing analgesia. A year later, the patient was disease-free and had no complications.

CONCLUSIONS

Umbilical LESS radical nephrectomy with vaginal extraction is feasible in selected cases. The procedure is oncologically safe, avoids scars and facilitates early recovery. From a practical point of view, this approach greatly simplifies natural orifice transluminal endoscopic surgery (NOTES) and enables a minimally invasive equivalent result.

Kinematic Design of a Novel Spatial Remote Center-of-Motion Mechanism for Minimally Invasive Surgical Robot

To deliver more value to the healthcare industry, a specialized surgical robot is needed in the minimally invasive surgery (MIS) field. To fill this need, a compact hybrid robotic wrist with four degrees of freedom (DOFs) is developed for assisting physicians to perform MIS. The main body of the wrist is a 2DOF parallel mechanism with a remote center-of-motion (RCM), which is located outside the mechanism. From the mechanical point of view, it is different from existing 2DOF spherical mechanisms, since there is no physical constraint on the RCM. Other DOFs of the wrist are realized by a revolute joint and a prismatic joint, which are serially mounted on the movable platform of the parallel mechanism. The function of these DOFs is to realize the roll motion and the in-out translation of the surgical tool. Special attention is paid to the parallel RCM mechanism. The detailed design is provided and the kinematic equations are obtained in the paper. Further, the Jacobian matrix is derived based on the kinematic equations. Finally, the paper examines the singularity configurations and implements the condition number analysis to identify the kinematic performance of the mechanism.

Endoscopic simple prostatectomy

INTRODUCTION

Many options exist for the surgical treatment of lower urinary tract symptoms (LUTS) due to benign prostatic hyperplasia (BPH), including transurethral resection of the prostate (TURP), laser surgery, and open adenomectomy. Recently, endoscopic techniques have been used in the treatment of BPH.

MATERIAL AND METHODS

We reviewed clinical studies in PubMed describing minimally invasive endoscopic procedures for the treatment of BPH.

RESULTS

Laparoscopic adenomectomy (LA) and robotic-assisted simple prostatectomy (RASP) were introduced in the early 2000s. These operative techniques have been standardized and reproducible, with some individual modifications. Studies analyzing the outcomes of LA and RASP have reported significant improvements in urinary flow and decreases in patient International Prostate Symptom Score (IPSS). These minimally invasive approaches have resulted in a lower rate of complications, shorter hospital stays, smaller scars, faster recoveries, and an earlier return to work.

CONCLUSIONS

Minimally invasive techniques such as LA and RASP for the treatment BPH are safe, efficacious, and allow faster recovery. These procedures have a short learning curve and offer new options for the surgeon treating BPH.

A state of the art review and categorization of multi-branched instruments for NOTES and SILS

BACKGROUND

Since the advent of Natural Orifice Translumenal Endoscopic Surgery (NOTES) and single incision laparoscopic surgery (SILS), a variety of multitasking platforms have been under development with the objective to allow for bimanual surgical tasks to be performed. These instruments show large differences in construction, enabled degrees of freedom (DOF), and control aspects.

METHODS

Through a literature review, the absence of an in-depth analysis and structural comparison of these instruments in the literature is addressed. All the designed and prototyped multitasking platforms are identified and categorized with respect to their actively controlled DOF in their shafts and branches. Additionally, a graphical overview of patents, bench test experiments, and animal and/or human trials performed with each instrument is provided.

RESULTS

The large range of instruments, various actuation strategies, and different direct and indirect control methods implemented in the instruments show that an optimal instrument configuration has not been found yet. Moreover, several questions remain unanswered with respect to which DOF are essential for bimanual tasks and which control methods are best suited for the control of these DOF.

CONCLUSIONS

Considering the complexity of the currently prototyped and tested instruments, future NOTES and SILS instrument development will potentially necessitate a reduction of the available DOF to minimize the control complexity, thereby allowing for single surgeon bimanual task execution.

A novel locally operated master-slave robot system for single-incision laparoscopic surgery

PURPOSE

Single-incision laparoscopic surgery (SILS) provides more cosmetic benefits than conventional laparoscopic surgery but presents operational difficulties. To overcome this technical problem, we have developed a locally operated master-slave robot system that provides operability and a visual field similar to conventional laparoscopic surgery.

MATERIAL AND METHODS

A surgeon grasps the master device with the left hand, which is placed above the abdominal wall, and holds a normal instrument with the right hand. A laparoscope, a slave robot, and the right-sided instrument are inserted through one incision. The slave robot is bent in the body cavity and its length, pose, and tip angle are changed by manipulating the master device; thus the surgeon has almost the same operability as with normal laparoscopic surgery. To evaluate our proposed system, we conducted a basic task and an ex vivo experiment.

RESULTS

In basic task experiments, the average object-passing task time was 9.50 sec (SILS cross), 22.25 sec (SILS parallel), and 7.23 sec (proposed SILS). The average number of instrument collisions was 3.67 (SILS cross), 14 (SILS parallel), and 0.33 (proposed SILS). In the ex vivo experiment, we confirmed the applicability of our system for single-port laparoscopic cholecystectomy.

CONCLUSION

We demonstrated that our proposed robot system is useful for single-incision laparoscopic surgery.

Current status of robotic laparoendoscopic single-site partial nephrectomy

Robotic laparoendoscopic single-site partial nephrectomy is increasingly carried out in an attempt to improve the cosmetic outcome of minimally-invasive procedures. However, the actual role of this novel technique remains to be determined. The present article reviews evidence and examines updates of robotic laparoendoscopic single-site partial nephrectomy outcomes reported in more contemporary studies. A comprehensive online systematic search of PubMed, Scopus and Web of Science databases according to Preferred Reporting Items for Systematic Reviews and Meta-analyses criteria recommendations was carried out in January 2014, identifying data from 2008 to 2014 regarding robotic laparoendoscopic single-site partial nephrectomy. The majority of medical evidence to date is based on case reports or retrospective studies. Current studies show that robotic laparoendoscopic single-site partial nephrectomy is a feasible procedure carried out in an acceptable length of operative time, and resulting in a desirable cosmetic outcome and less postoperative pain. However, comparable studies show that robotic laparoendoscopic single-site partial nephrectomy is inferior to the conventional approach, especially with regard to warm ischemia time. Furthermore, the numerous limitations that exist with the utilization of the current commercial single-site devices make robotic laparoendoscopic single-site PN more challenging and more complicated for surgeons compared with conventional procedures. Further significant improvements, along with more studies, are required in order to develop the ideal robotic laparoendoscopic single-site robotic platform and overcome the current limitations. For the time being, robotic laparoendoscopic single-site partial nephrectomy procedures could be applicable in patients with low tumor size and complexity, and should not be routinely applied in all cases.

A novel robotic system for single-port urologic surgery: first clinical investigation

BACKGROUND

The idea of performing a laparoscopic procedure through a single abdominal incision was conceived with the aim of expediting postoperative recovery.

OBJECTIVE

To determine the clinical feasibility and safety of single-port urologic procedures by using a novel robotic surgical system.

DESIGN, SETTING, AND PARTICIPANTS

This was a prospective institutional review board-approved, Innovation, Development, Exploration, Assessment, Long-term Study (IDEAL) phase 1 study. After enrollment, patients underwent a major urologic robotic single-port procedure over a 3-wk period in July 2010. The patients were followed for 3 yr postoperatively.

INTERVENTION

Different types of urologic surgeries were performed using the da Vinci SP Surgical System. This system is intended to provide the same core clinical capabilities as the existing multiport da Vinci system, except that three articulating endoscopic instruments and an articulating endoscopic camera are inserted into the patient through a single robotic port.

OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS

The main outcomes were the technical feasibility of the procedures (as measured by the rate of conversions) and the safety of the procedures (as measured by the incidence of perioperative complications). Secondary end points consisted of evaluating other key surgical perioperative outcomes as well as midterm functional and oncologic outcomes.

RESULTS AND LIMITATIONS

A total of 19 patients were enrolled in the study. Eleven of them underwent radical prostatectomy; eight subjects underwent nephrectomy procedures (partial nephrectomy, four; radical nephrectomy, two; and simple nephrectomy, two). There were no conversions to alternative surgical approaches. Overall, two major (Clavien grade 3b) postoperative complications were observed in the radical prostatectomy group and none in the nephrectomy group. At 1-yr follow-up, one radical prostatectomy patient experienced biochemical recurrence, which was successfully treated with salvage radiation therapy. The median warm ischemia time for three of the partial nephrectomies was 38 min. At 3-yr follow-up all patients presented a preserved renal function; none had tumor recurrence. Study limitations include the small sample and the lack of a control group.

CONCLUSIONS

We describe the first clinical application of a novel robotic platform specifically designed for single-port urologic surgery. Major urologic procedures were successfully completed without conversions. Further assessment is warranted to corroborate these promising findings.

PATIENT SUMMARY

A novel purpose-built robotic system enables surgeons to perform safely and effectively a variety of major urologic procedures through a single small abdominal incision.

TRIAL REGISTRATION

The study was registered on www.ClinicalTrials.gov (NCT02136121).

Robot-assisted single-incision total colectomy: a case report

BACKGROUND

Literature reports shows that robots provide an opportunity for meeting technical challenges associated with Laparo-endoscopic Single Site Surgery (LESS). Following previous success with robot-assisted single-incision right hemicolectomy, this paper reports experience with robot-assisted single-incision total colectomy.

METHODS

Through a single incision around the umbilicus, three robotic ports and a laparoscopic port were placed through the GelPOINT. With one intraoperative redocking of the robot, it was possible to access both right and left sides of the colon. The entire colon was externalized through the GelPOINT and the umbilical incision closed in layers.

RESULTS

The entire procedure took 227 minutes. There was minimal blood loss. The patient was discharged on post-operative day four with no complications. No wound site complications were observed in clinic one week after discharge.

CONCLUSIONS

Robot-assisted single-incision total colectomy is a feasible procedure associated with little increase in operative time.

'Scarless' laparoscopic urologic surgery by the combination of mini-laparoscopic and laparoendoscopic single-site surgery equipment

OBJECTIVE

We evaluated reconstructive and oncological laparoendoscopic single-site surgery (LESS) combined with mini-laparoscopic instruments as standard equipment.

PATIENTS AND METHODS

30 patients underwent reconstructive and oncological LESS: mini-laparoscopic-assisted LESS pyeloplasty (LESS-P, n = 18), mini-laparoscopic-assisted LESS partial nephrectomy (LESS-PN, n = 7) or mini-laparoscopic-assisted LESS radical prostatectomy (LESS-RP, n = 5). Perioperative data were prospectively collected.

RESULTS

The 18 LESS-P cases had operative times ranging between 120 and 180 min (average 147.9 min). Estimated blood loss ranged between 100 and 300 ml (average 202.1 ml). Two patients required additional management for failed reconstruction. LESS-PN was performed in 7 patients with tumor size ranging between 2.5 and 3.8 cm (average 2.7 cm). Average operative time and blood loss were 155 (140-180) min and 321.4 (250-550) ml, respectively. Renal artery clamping took place in 1 case. LESS-RP was performed in 5 patients; average operative time was 156 (140-180) min and average blood loss 196 (100-400) ml. Functional and oncological outcome was directly comparable to laparoscopic radical prostatectomy.

CONCLUSION

The combination of LESS and mini-laparoscopic instrumentation as routine equipment of reconstructive LESS reveals a different perspective for 'scarless' urologic surgery.

Umbilical laparoendoscopic urological surgery with a novel reusable device

OBJECTIVE

The aims of this study were to present cumulative experience with umbilical laparoendoscopic urological surgery using a reusable device and to evaluate outcomes and complications in the first 100 patients.

MATERIAL AND METHODS

Patients undergoing umbilical surgery with the KeyPort system and DuoRotate instruments (Richard Wolf, Knittlingen, Germany) were evaluated prospectively. Demographic, intraoperative and postoperative data were assessed.

RESULTS

Between October 2011 and July 2012, 79 pelvic (66 radical prostatectomy, 10 radical cystectomy, one diverticulectomy, one bilateral orchiectomy, one ureter reimplantation) and 21 renal (seven radical nephrectomy, six partial nephrectomy, five nephroureterectomy, two pyeloplasty, one pyelolithotomy) surgeries were performed through the umbilicus using this platform. Follow-up was 56.7 ± 12.6 weeks (mean ± SD). Mean age was 64.3 ± 10.3 years, body mass index 29 ± 4.6 kg/m(2), operative time 232 ± 106 min and estimated blood loss 260 ± 95 ml. Conversion to standard multiport laparoscopy was not necessary. An accessory port was used in 87 cases to facilitate suturing and conduct drainage extraction. Postoperative complications occurred in 24 cases (six Clavien grade I, 12 grade II, one grade IIIa, two grade IIIb, two grade IVa, one grade IVb). Mean hospital stay was 4.2 ± 4 days. Total transfusion rate was 10%. Mean visual analogue pain scale at day 2 was 2.1 ± 1.3 (0-10). Visual analogue wound satisfaction scale at month 1 was 9.2 ± 0.6 (0-10). No cancer-related events occurred during follow-up. Late complications (4%) were not related to the surgical approach.

CONCLUSIONS

Umbilical KeyPort surgery is technically feasible for a great variety of procedures, both ablative and reconstructive. This access offers adequate surgical outcomes, scarce postoperative pain and security for the patient in the short term. Its reusable nature implies a noticeable economic advantage.

Future robotic platforms in urologic surgery: recent developments

PURPOSE OF REVIEW

To review recent developments at Vanderbilt University of new robotic technologies and platforms designed for minimally invasive urologic surgery and their design rationale and potential roles in advancing current urologic surgical practice.

RECENT FINDINGS

Emerging robotic platforms are being developed to improve performance of a wider variety of urologic interventions beyond the standard minimally invasive robotic urologic surgeries conducted currently with the da Vinci platform. These newer platforms are designed to incorporate significant advantages of robotics to improve the safety and outcomes of transurethral bladder surgery and surveillance, further decrease the invasiveness of interventions by advancing LESS surgery, and to allow for previously impossible needle access and ablation delivery.

SUMMARY

Three new robotic surgical technologies that have been developed at Vanderbilt University are reviewed, including a robotic transurethral system to enhance bladder surveillance and transurethral bladder tumor, a purpose-specific robotic system for LESS, and a needle-sized robot that can be used as either a steerable needle or small surgeon-controlled micro-laparoscopic manipulator.

Perioperative outcomes and cosmesis analysis of patients undergoing laparoendoscopic single-site adrenalectomy: a comparison of transumbilical, transperitoneal subcostal, and retroperitoneal subcostal approaches

OBJECTIVE

To compare the perioperative outcomes and cosmetic results for transumbilical (TU), transperitoneal subcostal (TS), and retroperitoneal subcostal (RS) laparoendoscopic single-site surgery (LESS) adrenalectomy (AD).

MATERIALS AND METHODS

An observational study was conducted of patients who were had undergone LESS-AD using a TU (n = 9), TS (n = 17), or RS (n = 16) approach. The perioperative outcomes and comprehensive cosmetic results were analyzed statistically.

RESULTS

The RS-LESS-AD patients were more likely to have an indication for surgery of a right adrenal mass (TU-LESS-AD 11.1% and TS-LESS-AD 5.9% vs RS-LESS-AD 43.8%, P = .016) or partial AD (0% vs 9% vs 87.5%, P < .001). The TU-LESS-AD procedures had a longer median operative time but significantly lower postoperative pain. The median cosmesis rating for the TU-LESS-AD, TS-LESS-AD, and RS-LESS-AD scar photographs was 10, 8, and 9, respectively (P = .010). Only the cosmesis ratings after the photograph viewing were statistically significant across the surgical approaches (9.5 vs 8 vs 9, P = .048). Assuming equivalent surgical complication risks across the approaches, the preference for future TU-LESS-AD, TS-LESS-AD, RS-LESS-AD was 86%, 6%, and 8%, respectively. As the theoretical risk of TU-LESS-AD increased, the preference for TU-LESS-AD decreased and the preference for TS-LESS-AD and RS-LESS-AD increased.

CONCLUSION

LESS-AD is an effective procedure with a high level of cosmesis using a TU, TS, or RS approach. The surgeon's background, patient characteristics, and cosmetic perception must be carefully considered as a part of the entire clinical picture so that LESS-AD can be used for patients who will derive the most benefit.

Changing our view of minimally invasive gynecologic surgery: a review of laparoendoscopic single-site surgery and a report on new approaches

The recent emergence of laparoendoscopic single-site surgery (LESS) has had a great impact on gynecology. As LESS grows in popularity, attention has been paid to the procedure's cosmetic benefits. Although in theory LESS is an ideal approach that leaves no visible scars and improves patients' quality of life, the outcomes are not always ideal according to recently published data. Therefore, alternative approaches, such as mini-laparoscopy, are also becoming more popular. Herein, we review randomized trials studying the benefits of LESS in gynecology and discuss alternative approaches. Finally, we propose the mimic approach as the next generation for non-visible scar surgery.

Robotic laparoendoscopic single-site transumbilical partial nephrectomy: functional and oncologic outcomes at 2 years

OBJECTIVE

To assess the functional and oncologic outcomes of robotic laparoendoscopic single site surgery (LESS) partial nephrectomy with a minimum of 2-year follow-up.

MATERIALS AND METHODS

Thirty-nine consecutive patients who had undergone robotic LESS partial nephrectomy were identified with a minimum of 2-year follow-up. Perioperative data were recorded along with functional and oncologic outcomes. Patient's estimated glomerular filtration rate was determined using the Modification of Diet in Renal Disease formula. A univariate analysis was performed using independent samples t test. Data are presented as medians with interquartile range and counts or frequencies with percentages or proportion.

RESULTS

The median age was 51 (45, 59). The median resected tumor size was 3 cm (2, 3.7), and the median operative time was 185 minutes (135, 237). The median estimated blood loss was 150 mL (70, 150), and the median warm ischemia time was 25 minutes (17, 35). The estimated glomerular filtration rate did not change significantly at 24 month follow-up with a mean decrease of 6.4 mL/minute/1.73 m(2) (-7.5%, P = .22). Renal cell carcinoma was confirmed in 33 patients (85%) with tumor stage pT1a in 26 patients (78%). There was 1 patient with a positive surgical margin. At a median follow-up of 26 months (24, 32), there was no local recurrence and only 1 distant recurrence was detected.

CONCLUSION

This study appears to be the first to report on intermediate term functional and oncologic outcomes after robotic LESS partial nephrectomy. It has shown comparable results with other minimal invasive surgical options.

Recent advances in urologic laparoscopic surgeries: laparoendoscopic single-site surgery, natural orifice transluminal endoscopic surgery, robotics and navigation

Laparoscopic surgery was developed at the end of the 1980s and has been utilized in almost all urologic surgical procedures. It offers the benefits of less invasiveness and earlier recovery than open surgery. The introduction of laparoendoscopic single-site surgery has offered reduced pain and improved cosmetic satisfaction to patients. Scarless nephrectomy has been realized with transvaginal natural orifice transluminal endoscopic surgery in women. The development of surgical robots has decreased the technical difficulty of complicated procedures, shortened the learning curve, and improved perioperative outcomes relative to laparoscopic surgery. Surgical navigation using real-time sonography, augmented reality, fluorescence, or radioisotope images will improve the quality of these surgeries.