Skip to main content

Single-Port Robotics

The da Vinci SP platform (Intuitive Surgical; FDA 2018, CE 2024) has reopened a dimension of reconstructive urology that the original multiport robot had closed off: where to make the incision, and through which anatomic space. An SP cannula delivers a flexible 3D endoscope and three wristed articulating instruments through a single ~2.5 cm port, which means the surgeon can choose the anatomic corridor (transvesical, retroperitoneal, extraperitoneal) and place the incision for cosmesis (periumbilical) or for exposure (LAA, SARA, mini-Pfannenstiel) independently. This page catalogs the SP-specific incision sites, the approaches they enable, and the outcomes that have been reported.

See also: Platforms & Manufacturers, Reconstructive Applications, Incisions & Closure.

The SP Platform​

The da Vinci SP (single-port) system replaces multiple 8 mm multi-port arms with a single 2.5 cm cannula that delivers:[1][5][6][8]

  • A flexible, articulating 3D camera (no longer a straight stick endoscope)
  • Three wristed 6 mm articulating instruments with elbow-and-wrist kinematics
  • A software-driven "navigator" that displays real-time instrument positioning within a schematic of the working space

The articulating-elbow geometry is what enables single-incision work with triangulation — the instruments deploy distal to the cannula and cross the target in an inverted-triangle configuration, not the linear-instrument collision geometry of conventional SILS.

Incision Sites​

SP incision location is no longer a cost-of-access decision — it is a clinical one, determined by the anatomic target, the desired working space (peritoneal vs retroperitoneal vs extraperitoneal vs transvesical), and cosmesis.[1][2][3][4][5]

Periumbilical​

  • Location: through or adjacent to the umbilicus.
  • Best cosmesis of any SP site. In a prospective study of 111 patients, periumbilical SP incisions had significantly lower scar-consciousness and bother scores than other SP sites or multiport (OR 0.08, 95% CI 0.01–0.38).[5] Cosmetic advantage is most pronounced in patients under 40.
  • Typical use: transperitoneal pyeloplasty, partial nephrectomy, upper-tract procedures where central access is ergonomic.
  • Representative outcomes for SP pyeloplasty via periumbilical access: mean OR time 166 min, minimal EBL, median LOS 21 h, non-opioid analgesia only.[3]

Mini-Pfannenstiel​

  • Location: 2–3 cm transverse incision in the suprapubic skin fold, 2–3 cm above the symphysis.
  • Hidden in the natural skin fold — excellent cosmesis, favorable for bilateral upper-tract access via inframesocolic corridor.
  • Typical use: pyeloplasty (especially bilateral), pelvic reconstructive procedures.[3]

Midline Suprapubic​

  • Location: 3–3.5 cm vertical midline suprapubic incision.[6][10]
  • Typical use: transvesical approach to the prostate and pelvis — radical prostatectomy, simple prostatectomy, partial prostatectomy, PLND.[6][7][8][9]

Low Anterior Access (LAA)​

  • Location: 2–3 cm oblique incision parallel to the external oblique muscle, one-third of the distance between the ASIS/iliac crest and the umbilicus — approximately at McBurney's point.[11][13]
  • Unique capability: provides simultaneous access to peritoneal and retroperitoneal spaces through a single incision, allowing the surgeon to transition between approaches without repositioning or redocking.[11][12][13]
  • Typical use: partial nephrectomy, pyeloplasty, radical nephroureterectomy, radical nephrectomy, ureteral reimplantation, and at least ten other documented procedures.[13]

McBurney / Supine Anterior Retroperitoneal Access (SARA)​

  • Location: 3 cm at McBurney's point (right side) or the mirror position on the left.[4]
  • Position: supine (not lateral decubitus) — eliminates position-related nerve and pressure injuries.
  • Access technique: muscle dissection, finger-develop retroperitoneal space, then SP access port insertion. Dissection reveals the psoas, then ureter, lower pole, and hilum.
  • Typical use: retroperitoneal partial nephrectomy, pyeloplasty, radical nephroureterectomy, ureteral stenosis repair.

Surgical Approaches​

Transvesical​

The transvesical approach is the signature SP innovation — regionalized surgery confined to the disease space, bypassing the peritoneum entirely.[6][7][8][9][10]

Technique:[6][9][10]

  1. 3–3.5 cm suprapubic midline incision.
  2. Open cystotomy.
  3. GelPOINT mini system (or direct percutaneous port) docked into the bladder.
  4. Pneumovesicum (bladder insufflation) in place of pneumoperitoneum.
  5. SP robotic port + 12 mm assistant port + flexible suction through the gel port.
  6. "Floating docking" — the robot is docked directly into the bladder, not the abdomen.

Applications and outcomes:

OperationCasesOR timeEBLLOS
Radical prostatectomy (TV)[6][10]210+120 min (median)70 mL4.4–4.7 h; 92% same-day
Simple prostatectomy (TV, BPH)[7][9]—107–159 min—42–96% same-day
Partial prostatectomy (focal PCa)[8]———100% continent at 6 wk

TV radical prostatectomy continence: 75% continent within 48 h, 85% totally continent within 10 days. Positive margins 15% (all focal). 96.2% discharged without opioid prescription.[6][10]

TV simple prostatectomy at 1 year:[7][9] median IPSS 4, Qmax 21 mL/s, PVR 40 mL, SHIM 20. 3% Clavien 2 complications. No transfusions. Median catheter duration 5 d.

Unique advantages:[6][7][9][10]

  • Avoids the peritoneum entirely.
  • Minimal bowel manipulation.
  • Less steep Trendelenburg required.
  • Direct visualization of the prostate from within the bladder.
  • 360° bladder-mucosal flap reconstruction feasible.
  • No drains or continuous bladder irrigation routinely needed.

Low Anterior Access (LAA)​

The LAA approach is a flexibility play — a single incision that allows the surgeon to enter either the peritoneum or the retroperitoneum and transition mid-case without repositioning.[11][12][13]

Outcomes — LAA partial nephrectomy:[11][12]

  • Mean operative time: 90.5 min
  • Mean EBL: 88.3 mL
  • Warm ischemia (when clamped): 19.4 min
  • Mean LOS: 1.07 d; 77.6% same-day discharge
  • Complication rate: 0% in initial 78-patient series; 5% at 30 days in larger series
  • Conversion rate: 0%

LAA partial nephrectomy achieves significantly shorter hospital stay than standard transperitoneal access — median 10 h vs 24 h.[12]

Supine Anterior Retroperitoneal Access (SARA)​

SARA rescues retroperitoneal surgery from the lateral decubitus position.[4]

  • Patient supine — eliminates lateral-decubitus complications (brachial plexus stretch, peroneal palsy, rhabdomyolysis).
  • Easier setup, fewer positioning-related injuries.
  • Preserves the retroperitoneal advantages: minimal bowel manipulation, low pneumoperitoneum-related physiological stress.
  • Effective across BMI 17–58; safe in high-ASA (75% ASA ≥3 in initial series) populations.

SARA outcomes, 18-patient initial series:[4]

  • Median OR time: 160 min
  • Median WIT: 25 min
  • Median EBL: 105 mL
  • Median tumor size: 35 mm
  • Same-day discharge: 83% of partial nephrectomies
  • Narcotic use at 7 days: 0%
  • Positive margin: 1 of 18 (5.6%)

Transperitoneal (Standard)​

Conventional transperitoneal access via periumbilical or LAA incisions remains the workhorse for SP radical prostatectomy, partial nephrectomy, nephroureterectomy, radical cystectomy with intracorporeal diversion, pyeloplasty, and ureteral reimplantation.[2][14]

SP transperitoneal vs retroperitoneal partial nephrectomy:[14]

  • No significant difference in WIT (727 vs 699 s), console time (68 vs 70 min), EBL, or complications.
  • Equivalent renal function preservation at 90 d.
  • Choice driven by tumor location, prior surgery, surgeon preference, patient anatomy.

Retroperitoneal (Posterior)​

Traditional posterior retroperitoneal access with lateral decubitus positioning remains viable, though increasingly displaced by SARA.[14][15][16] SP adoption has measurably increased retroperitoneal approach utilization — at one multi-institutional registry, retroperitoneal partial nephrectomy rose from 7.3% pre-SP to 24.8% post-SP, reaching 52.8% of SP partial nephrectomies overall and 75% of SP cases in 2023.[15]

Why SP favors retroperitoneal:[15]

  • Articulating instruments overcome the narrow retroperitoneal geometry that constrains multi-port.
  • Shorter operative times and LOS vs transperitoneal SP.
  • No difference in complication rate.

Extraperitoneal (Non-Transvesical)​

Extraperitoneal access to the space of Retzius — the same space developed for open Pfannenstiel RP — has been adapted for SP radical prostatectomy.[17] Primary use case: patients with extensive intra-abdominal adhesions or contraindications to peritoneal entry. Advantages mirror the transvesical approach: minimal bowel manipulation, less steep Trendelenburg, early bowel function recovery.

Multi-Quadrant Surgery Without Repositioning​

A practical consequence of SP flexibility is that some operations that previously required repositioning or redocking can now be done through a single incision:[1][6][7]

  • Bilateral PLND via single transvesical access.
  • Transperitoneal-to-retroperitoneal transition mid-case via LAA.
  • Access to both obturator fossae from a single transvesical port.

Cosmesis and Recovery — by Incision Location​

Cosmesis ranking (best to worst), based on prospective scar-consciousness and bother scores:[5]

  1. Periumbilical SP — OR 0.08 vs multiport
  2. Lower quadrant (LAA) SP
  3. Midline non-umbilical SP
  4. Multiport

The SP cosmetic advantage is most pronounced in patients under 40.

Recovery by incision site:[5][11][12]

  • LAA — shortest LOS, lowest pain scores, least opioid use.
  • Periumbilical — excellent recovery, non-opioid analgesia typical.
  • Transvesical (midline suprapubic) — fastest continence recovery after RP, >90% same-day discharge.

First-100 SP Experience (Benchmark Distribution)​

From the first 100 SP cases at a pioneering center:[2]

  • Extraperitoneal — 53%
  • Transperitoneal — 37%
  • Transvesical — 10%
  • Pelvic surgery — 86%
  • Retroperitoneal surgery — 14%
  • Completion without conversion — 99% (1 conversion to open for dense adhesions).

SP vs Multi-Port — Aggregate Outcomes​

Systematic review and meta-analysis of SP vs multi-port urologic surgery shows modest but consistent SP advantages:[18]

  • LOS — 0.63 days shorter
  • EBL — 19.56 mL lower
  • Opioid use — 5.86 mg morphine equivalents less
  • OR time and complication rate — equivalent

References​

1. Biasatti A, Soputro NA, Porpiglia F, et al. "The Current Landscape of Single-Port Robotic Surgery in Urology." Nat Rev Urol. 2026;23(3):156–173. doi:10.1038/s41585-025-01081-z

2. Kaouk J, Aminsharifi A, Sawczyn G, et al. "Single-Port Robotic Urological Surgery Using Purpose-Built Single-Port Surgical System: Single-Institutional Experience With the First 100 Cases." Urology. 2020;140:77–84. doi:10.1016/j.urology.2019.11.086

3. Lenfant L, Wilson CA, Sawczyn G, et al. "Single-Port Robot-Assisted Dismembered Pyeloplasty With Mini-Pfannenstiel or Peri-Umbilical Access: Initial Experience in a Single Center." Urology. 2020;143:147–152. doi:10.1016/j.urology.2020.05.041

4. Pellegrino AA, Chen G, Morgantini L, Calvo RS, Crivellaro S. "Simplifying Retroperitoneal Robotic Single-Port Surgery: Novel Supine Anterior Retroperitoneal Access." Eur Urol. 2023;84(2):223–228. doi:10.1016/j.eururo.2023.05.006

5. Raver M, Implicito C, Henrich M, et al. "Does Incision Location Matter? Analysis of Single-Port Cosmesis in Urologic Reconstructive Surgery." J Endourol. 2024;38(12):1364–1371. doi:10.1089/end.2024.0322

6. Kaouk J, Beksac AT, Abou Zeinab M, et al. "Single-Port Transvesical Robotic Radical Prostatectomy: Initial Clinical Experience and Description of Technique." Urology. 2021;155:130–137. doi:10.1016/j.urology.2021.05.022

7. Abou Zeinab M, Beksac AT, Corse T, et al. "The Multi-Institutional Experience in Single-Port Robotic Transvesical Simple Prostatectomy for Benign Prostatic Hyperplasia Management." J Urol. 2022;208(2):369–378. doi:10.1097/JU.0000000000002692

8. Kaouk JH, Ferguson EL, Beksac AT, et al. "Single-Port Robotic Transvesical Partial Prostatectomy for Localized Prostate Cancer: Initial Series and Description of Technique." Eur Urol. 2022;82(5):551–558. doi:10.1016/j.eururo.2022.07.017

9. Ramos R, Ferguson E, Abou Zeinab M, et al. "Single-Port Transvesical Robot-Assisted Simple Prostatectomy: Surgical Technique and Clinical Outcomes." Eur Urol. 2024;85(5):445–456. doi:10.1016/j.eururo.2023.11.012

10. Ramos R, Soputro N, Pedraza AM, et al. "Single-Port Transvesical Robot-Assisted Radical Prostatectomy." J Endourol. 2025;39(S1):S39–S46. doi:10.1089/end.2024.0291

11. Billah M, Sheckley F, Nguyen J, et al. "Single-Port Modified Partial Nephrectomy: Novel Simultaneous Access to Peritoneal and Retroperitoneal Partial Nephrectomy, Initial Clinical Experience." J Endourol. 2024;38(5):444–449. doi:10.1089/end.2023.0502

12. Cannoletta D, Pellegrino AA, Pettenuzzo G, et al. "Surgical Outcomes of Novel Retroperitoneal Low-Anterior vs Posterior and Transperitoneal Access in Single-Port Partial Nephrectomy." World J Urol. 2024;42(1):387. doi:10.1007/s00345-024-05096-w

13. Cannoletta D, Pettenuzzo G, Pellegrino AA, et al. "Versatility of Single-Port Retroperitoneal Low Anterior Access: Early Outcomes in Multiple Procedures." J Endourol. 2024;38(7):668–674. doi:10.1089/end.2024.0046

14. Bang S, Shin D, Moon HW, et al. "Comparison of Transperitoneal and Retroperitoneal Partial Nephrectomy With Single-Port Robot." J Endourol. 2023;37(5):551–556. doi:10.1089/end.2022.0730

15. Raver M, Ahmed M, Okhawere KE, et al. "Adoption of Single-Port Robotic Partial Nephrectomy Increases Utilization of the Retroperitoneal Approach: A Report From the Single-Port Advanced Research Consortium." J Laparoendosc Adv Surg Tech A. 2025;35(2):131–137. doi:10.1089/lap.2024.0305

16. Gabriel PE, Shariat SF, Rouprêt M, Sfakianos JP, Xylinas E. "Perioperative Outcomes of Multiport or Single-Port, Transperitoneal or Retroperitoneal Robot-Assisted Radical Nephroureterectomy: A Narrative Review." Front Oncol. 2025;15:1655703. doi:10.3389/fonc.2025.1655703

17. Khalil MI, Joseph JV. "Extraperitoneal Single-Port Robot-Assisted Radical Prostatectomy." J Endourol. 2021;35(S2):S100–S105. doi:10.1089/end.2021.0440

18. Ge S, Zeng Z, Li Y, et al. "Comparing the Safety and Efficacy of Single-Port Versus Multi-Port Robotic-Assisted Techniques in Urological Surgeries: A Systematic Review and Meta-Analysis." World J Urol. 2024;42(1):18. doi:10.1007/s00345-023-04711-6