2024

Richard E. Link, MD, PhD, discusses the shifting landscape of minimally invasive urologic surgery in the era of single-site robotics. He describes the state of urologic minimally invasive surgery as a “messy toolbox,” with a huge diversity of technologies and techniques currently employed and a lack of consensus.

Dr. Link then ranks approaches based on invasiveness, with robotic single-port (SP) systems being the least invasive. He outlines benefits and drawbacks of various techniques and wonders if there has been a period of stagnation.

He then addresses advantages of the da Vinci SP system, with a softball-sized working envelope and a 360-degree rotation around its axis, its robotic dexterity, its ability to work through small incisions (2.7 cm), and its versatility for multi-quadrant surgery, as well as in working with extraperitoneal, retroperitoneal, and transvesical approaches. He lists disadvantages as well, including cost, scarcity, learning curve, and challenges with large specimens.

Dr. Link contends that development of the SP approach is driving an increase in extraperitoneal approaches (while laparoscopic and robotic advancements drove towards the transperitoneal approaches). He then explains the shift towards the retroperitoneal approach, which is more efficient and timesaving. Dr. Link lists anesthesia advantages of SP, including shorter procedures, lower risk of abdominal entry vascular and organ complications, less pain, and fewer incisions.

Dr. Link then explains that today the SP comprises the vast majority of his radical prostatectomies. He describes the new technology interplay between cost/availability, skills/training, patient benefits, and versatility/speed and acknowledges the tension between a new platform and a technique with which a practitioner is comfortable. Dr. Link predicts that costs will drop, availability will rise, and calls SP “the future.”