Single-port robotic system for prostatectomy ‘has made a huge difference,’ surgeon says

Smilow Cancer Hospital has introduced a new single-port robotic prostatectomy procedure that reduces the number of incisions and may minimize the risk for complications.

The procedure uses the da Vinci SP (Single Port Intuitive Surgical) system, which combines all surgical instruments into one robotic arm. It, therefore, requires only two incisions —one for the robot and the other for assistance.

“The original robot had four arms, which were inserted into the belly of the patient at four different sites,” Isaac Y. Kim, MD, PhD, MBA, professor and chair of urology at Yale School of Medicine and chief of urology at Yale New Haven Hospital, told Healio. “Some have advocated that if we could consolidate it into just one incision, that would be better for the patient, but it’s always been an engineering challenge. So, it’s a credit to Intuitive Surgical that they could come up with a platform that made this feasible.”

Advantages and barriers

Kim is one of only two surgeons currently performing single-port robotic prostatectomy at Smilow, and the procedure is still relatively uncommon. Kim said he is glad to be able to provide appropriate patients with a less invasive surgery and shorter recovery time.

“The most important question is what is the added benefit of this new technology compared to the old one?” Kim said. “In that sense, at least in my practice, it has made a huge difference. With the single port, I feel much more comfortable, because it gives me better control of the space that the robot is sliding through.”

The single-port procedure also offers the advantage of not invading the peritoneal space, which contains the intestines, stomach and liver. In the multiport procedure, the robot enters this space, increasing the risk for complications.

Because the procedure is less invasive, it is also less painful for the patient, and Kim is often able to forgo prescribing postoperative opiates, which has additional patient benefits.

“I’ve been reluctant to send a patient home on the same day with the conventional robot, but certainly with the single port, I have the peace of mind to know that the complications are going to be much less,” he said. “So, I send my single-port patients home on the same day now.”

Kim added that the procedure may not be appropriate for all patients, such as those with metastatic disease.

“One significant part of my practice is patients who have metastatic prostate cancer,” he said. “These patients would need a very wide surgical field, as well as lymph node removal. Single-port surgery is probably not the best platform for them. It’s about recognizing the limitations of the instrument and picking the one that’s best for the patient.”

Cost and surgical training may also prove to be a barrier to widespread use of the single-port procedure, Kim acknowledged.

“There are a few ways to think about this procedure and why it isn’t so widespread,” Kim said. “One is that the platform is expensive. The second is that surgeons will have to dedicate a significant amount of time to learn how to use it, because it’s not a straightforward process. It takes a little bit of effort on the surgeon’s part to learn how to use this new instrumentation.”

Kim said residents at Yale are currently being trained in the single-port procedure and will leave with some idea of how the procedure works. He said while there is certainly a learning curve, it isn’t too steep for those already experienced in robotic surgery.

“As a surgeon, you have to learn how to work within the limitations of the robot,” he said. “It’s not that difficult, though. The surgeon just needs to know how to work around the engineering limitations of the new instrument.”

Kim said he envisions these surgeries utilizing smaller instruments and becoming less invasive in the future.

“If you look at the evolution of surgical technology, this is the way things are headed,” he said. “When I was training, we were told to just make a big incision so we could get all of the instruments into the surgical field. Now, we want to make minimal or small incisions, putting in 8 mm ports. Many in our field anticipate that in the future, we will probably do these surgeries with even smaller incisions or no incisions at all.”

For more information:

Isaac Y. Kim, MD, PhD, MPH, can be reached at Yale Urology, P.O. Box 208058, New Haven, CT 06520-8058; email: isaac.kim@yale.edu.