Original research

First Canadian experience with robotic single-incision pyeloplasty:

Comparison with multi-incision technique

1,3

Jeffrey Law, MD; Neal Rowe, MD; Jason Archambault, MD; Soﬁa Nastis, MD; Alp Sener, MD;

Patrick P. Luke, MD¹

Western University Schulich School of Medicine and Dentistry; Department of Surgery, Division of Urology, University of Ottawa, Ottawa, ON, Canada; Department of Surgery, London Health Sciences

Centre, Western University, London, ON, Canada

Cite as: Can Urol Assoc J 2016;10(3-4):83-8. http://dx.doi.org/10.5489/cuaj.3440

trauma compared with conventional multi-incision proce-

dures. However, difﬁculties encountered with LESS include

lack of triangulation and counterintuitive movement of tools

secondary to crossing and clashing of instruments. LESS

pyeloplasty is particularly difﬁcult because of the extensive

intracorporeal suturing that is required.

See related article on page 89.

Abstract

By using wristed instrumentation (EndoWrist ) that facil-

Introduction: We compared the outcomes of single-incision, robot-

assisted laparoscopic pyeloplasty vs. multiple-incision pyeloplasty

using the da Vinci robotic system.

Methods: We reviewed all consecutive robotic pyeloplasties by a

single surgeon from January 2011 to August 2015. A total of 30

procedures were performed (16 single:14 multi-port). Two different

single-port devices were compared: the GelPort (Applied Medical,

Rancho Santa Margarita, CA) and the Intuitive single-site access

port (Intuitive Surgical, Sunnyvale, CA).

Results: Patient demographics were similar between the two

groups. Mean operating time was similar among the single and

multi-port groups (225.2 min vs. 198.9 minutes [p=0.33]). There

was no signiﬁcant difference in length of hospital stay in either

group (86.2 hr vs. 93.2 hr [p=0.76]). There was no difference in

success rates or postoperative complications among groups.

Conclusions: Single-port robotic pyeloplasty is non-inferior to

multiple-incision robotic surgery in terms of operative times, hos-

pitalization time, success rates, and complications. Verifying these

results with larger cohorts is required prior to the wide adoption

of this technique. Ongoing objective measurements of cosmesis

and patient satisfaction are being evaluated.

itates suturing in restricted areas, three-dimensional visu-

alization, increased magniﬁcation, and tremour ﬁltration,

the da Vinci robotic surgical platform (Intuitive Surgical,

Sunnyvale, CA, USA) may overcome the challenges of oper-

ating through a single incision. Moreover, a wide variety

of robotic-LESS (R-LESS) ports and instruments have been

developed to facilitate single-incision surgery.

We report the initial Canadian experience with robotic,

single-port pyeloplasty. We used and compare two different

single-site port devices currently available for R-LESS: the

GelPort (Applied Medical, Rancho Santa Margarita, CA) and

the Intuitive Surgical single-site (SS) port (Intuitive Surgical,

Sunnyvale, CA).

Methods

Subjects and methods

Consecutive patients presenting with symptomatic, pri-

mary UPJO were evaluated and suitability for pyeloplasty

was determined based on clinical judgment. Radiographic

diagnosis of UPJO was obtained by diuretic nuclear renog-

raphy and computed tomography (CT) scan in all cases.

Eligible patients underwent multiple-port robotic pyeloplas-

ty between January 2011 and February 2013, after which

R-LESS pyeloplasty was performed until August 2015. Each

surgical patient was entered into a prospectively maintained

institutional review board-approved database.

Introduction

Conventional laparoscopic pyeloplasty for ureteropelvic

junction obstruction (UPJO) is a minimally invasive approach

that generally requires three or four small abdominal wall

incisions. In recent years, laparo-endoendoscopic single-site

surgery (LESS) has been developed via a single transum -

bilical incision, where all instruments are inserted into the

abdominal cavity.

LESS surgery offers enhanced postoperative cosmetic

appearance and is believed to decrease abdominal wall

-6

A standard data collection spreadsheet was used. The preop-

erative information collected included basic patient character-

istics, such as age and sex. Intraoperative information included

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2016 Canadian Urological Association

lꢀw ꢁt ꢀꢂ.

procedure performed, operative time, estimated blood loss, and

details of the surgical technique. The postoperative information

included complications, hospital length of stay (LOS), objective

resolution of obstruction (MAG-3 lasix renogram), and pain.

working instruments (Fig. 1). Eight millimeter (8 mm) wristed

robotic arms were utilized with the GelPort cases. Two ﬂex-

ible 5 mm non-wristed arms were placed into short curved

trocars in the SS cases. This permitted the functional arms

to cross and triangulate in order to prevent clashing (Fig. 4).

Pyeloplasty surgical technique

Robotic multi-port technique

The da Vinci Si Surgical System was used for all proce -

dures. Ureteric stents were placed immediately prior to the

pyeloplasty procedure. Patients were positioned in lateral

decubitus position. After insertion of the trocars and insufﬂa-

Multi-port pyeloplasty was performed through four intraperi-

toneal port sites. Individual trocars were inserted as previ-

ously described.

tion, the da Vinci robot was docked as previously described

(

Fig. 1). The UPJ was mobilized, dismembered, and the

Statistical analyses

ureter brought anterior to any crossing vessels. The ureter

was then spatulated and re-anastomosed to the renal pelvis

in an Anderson-Hyne technique using 4-0 PDS sutures in

running continuous fashion. Drains were placed through

the umbilical port in R-LESS cases (Fig. 2).

Preoperative, intraoperative, and postoperative out -

comes were compared between each of the two groups.

Complications were classiﬁed according to the Clavien-

Dindo classiﬁcation scheme. Variables were analyzed using

a one-way analysis of variance. A signiﬁcance level of ≤0.05

was chosen for each test. GraphPad Prism v.5.0 (GraphPad

Software, San Diego, U.S.) was used for statistical analyses.

Robotic laparoendoscopic single-site technique

R-LESS pyeloplasty was performed through a single incision

through the umbilicus measuring approximately 1.5–4.0 cm

in length. Either a GelPort or SS port was placed through the

single umbilical incision, and a total of four trocars (camera

trocar, two robot working trocars, and the accessory trocar)

were inserted through the port (Fig. 3), followed by insufﬂa-

tion of the abdominal cavity with carbon dioxide gas. The

daVinci robot was docked with the ﬁrst setup joint locked in

a straight position in order to facilitate proper insertion of the

Results

Demographics

Sixteen (16) patients underwent R-LESS pyeloplasty between

April 2013 and August 2015 (Group 1). Of the R-LESS sur-

geries, nine were performed with the GelPort and seven

Fig. 1. (A) Positioning of the robot over the posterior shoulder of the patient for single-incision

surgery. The patient is positioned at 45 degrees in the right lateral oblique position; (B) The

ﬁrst setup joint is locked in a straight position to facilitate proper insertion of multiple working

instruments in the umbilical port. Rendering © Intuitive Surgical 2015 with permission.

CUAJ • March-April 2016 • Volume 10, Issues 3-4

cꢀꢃꢀdꢄꢀꢃ ꢁxpꢁꢅꢄꢁꢃꢆꢁ wꢄtꢇ ꢅobotꢄꢆ ꢈꢄꢃꢉꢂꢁ-ꢄꢃꢆꢄꢈꢄoꢃ pyꢁꢂopꢂꢀꢈty

Estimated blood loss in the GelPort and

SS port groups was not signiﬁcantly dif-

ferent from the multiple incision group

(

p=0.71). None of the patients in the two

groups required blood transfusion during

the procedures. Length of stay in hospital

for the GelPort (86.2 ± 52.0 hours) and SS

port group (74.3 ± 16.6 hours) was also

not signiﬁcantly different compared with

the multi-port group (93.2 ± 53.0 hours)

(

p=0.76).

Clinical outcomes were favourable for

both groups (Table 3). In the multi-port

pyeloplasty group, 13 of 14 patients were

asymptomatic after stent removal, and the

most recent MAG-3 lasix renogram scans

showed improved drainage when com-

pared to the preoperative study (postop

six months in all). One of 14 patients

developed recurrent flank pain, which

Fig. 2. (A) Placement of Hemovac drain through the umbilical incision (GelPort platform); (B) Umbilical

incision post-single site platform R-LESS surgery (Intuitive Surgical).

with the SS port. Data for this group were compared with

the 14 most recent consecutive patients who underwent con-

ventional robotic, multi-port pyeloplasty (Group 2). Patient

demographics are listed in Table 1. The groups were similar

with regard to baseline demographics and clinical features.

There were no signiﬁcant differences between male:female

ratio or mean age of patients. All surgeries but one of the

multi-port pyeloplasty cases was unilateral; otherwise, there

was no signiﬁcant difference in the laterality of procedures

between the two groups (Table 1).

required balloon dilatation of the UPJ. In the R-LESS group,

15 of 16 patients had obstructive symptoms resolve post-

operatively. More speciﬁcally, eight of nine patients in the

GelPort group and all of the patients in the SS port group had

resolution of symptoms. The solitary patient in the GelPort

group developed recurrent ﬂank pain and was investigated

with ureteroscopy demonstrating a wide open UPJ.

There were five postoperative complications among

the 14 patients in the robotic, multi-port group, compared

to four complications among 16 patients in the R-LESS

group. For the multi-port group, all of the complications

were Clavien-Dindo Grade 2. The complications included

urinary tract infection (UTI) (two patients), pyelonephritis

(two patients), and cellulitis of the umbilical would (one

patient). In the R-LESS GelPort group, three patients had UTI

requiring antibiotic treatment and one of these patients also

required blood transfusion, but did not necessitate surgical

re-intervention (Clavien-Dindo Grade 2). Of the Intuitive

Surgical port group, one patient had a postoperative UTI

requiring antibiotics. Overall, there was no

Outcomes

Perioperative outcomes are outlined in Table 2. Mean

operative time (including robotic docking) using the GelPort

(

231.6 ± 25.3 min) or the SS port (217.0 ± 58.8 min) was

not signiﬁcantly different compared to robotic, multi-port

pyeloplasty (198.9 ± 57.8 min) (p=0.33). There were no

conversions to standard laparoscopy in any of the groups.

signiﬁcant difference in number of compli-

cations among the GelPort, SS or multi-port

groups (p=0.76).

Discussion

Up to now, case series and reports demon-

strated feasibility of the R-LESS approach

1-6

in performing dismembered pyeloplasty.

The current study is the ﬁrst study com-

paring R-LESS pyeloplasty with robotic,

multiple-incision pyeloplasty. Moreover,

Fig. 3. (A) Placement of inner phalange using GelPort device; (B) Disposable and 8 mm robotic ports

placed through the GelPort device.

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to cross over one another within the trocar so that the

right-entering instrument becomes the left-sided operative

instrument in the abdominal cavity and vice versa (Fig.

). Advantages of this setup are that the arms are further

separated intracorporeally, thus reducing instrument col-

lision and allowing triangulation of the target tissue (Fig.

B). The software of the Si system corrects for the right

to left crossover of the arms, making for more natural

hand-eye coordination. Furthermore, the initial incision

required (~1.5–2.5 cm) is smaller than what is required for

the GelPort. There are two additional trocars with straight

cannulas for a 8.5 mm endoscope and a 5/10 mm assistant

trocar in addition to one insufﬂation valve. At the time of

our study, there were no endo-wristed instruments avail-

able, and monopolar cautery was only available on the

endoscopic L-hook device.

Regarding operative times, we found no signiﬁcant dif-

ference in mean operative time among the GelPort, SS, or

multi-port pyeloplasty. Patients were not selected for SS or

GelPort access and as a result, patient demographics did

not differ. Our mean operative time for R-LESS pyeloplasty

was 225.2 ± 42.2 min and is consistent with most pub -

Fig. 4. Diagram showing the orientation of the single-site device (Intuitive).

Note that the curved working ports house the ﬂexible instruments. The working

ports cross one another mid-fascia at the fulcrum, requiring the software of the

da Vinci Si robot to reorient the working arms of the robot with the controls at

the console. Rendering © Intuitive Surgical 2015 with permission.

,2,4,5

lished reports.

However, the authors note that without

the endo-wristed instruments, R-LESS pyeloplasty was sig-

niﬁcantly more challenging with the SS system. The curved

cannulas also needed to be pulled further out of the SS

port to facilitate completion of the pyeloplasty procedures

in some smaller patients, which also reduced the ability to

triangulate the working instruments.

most investigations to date have been performed with the

GelPort device.¹^,²^,⁴^,⁵The novel SS robotic surgery platform

was evaluated critically for R-LESS pyeloplasty for the ﬁrst

time in North America at our centre. To our knowledge,

this is the ﬁrst series comparing the SS system to the GelPort

system.

The GelPort contains a gelatin platform for trocar place-

ment. The advantages compared to other platforms include

a limitless number of potential trocar conﬁgurations and

the ability to accommodate different abdominal wall thick-

nesses. A large working proﬁle reduces external clashing and

instruments can be spaced apart to obtain better triangula-

tion. Importantly, the robotic instruments using endo-wristed

tools are also compatible with the GelPort (Fig. 5A).

The SS access port is a ﬁve-lumen port that contains

two curved cannulas that allow for the robotic instruments

In terms of safety, no intraoperative complications were

reported for either R-LESS or the robotic, multiple-incision

groups. The postoperative complication rate was low, with

all complications being Grade 2 according to the Clavien-

Dindo classiﬁcation. We observed no signiﬁcant difference

in postoperative complication rates among each of the sin-

gle-port approaches and multi-port pyeloplasty. In general,

postoperative complications reported by other groups have

been low-grade, although urine leak requiring a nephros-

,2,5

tomy tube has been described in a some cases.

As for length of hospital stay, we found no signiﬁcant dif-

Table 1. Patient characteristics

Type of robotic pyeloplasty

Group 2

Group 1

Single-port)

SS³

(

Total

p value

(

Multi-port)²

GelPort

Combined

Number of patients

Male:Female

0.93

0.94

3:6

4:3

7:9

7:7

14:16

5.8

43.6

(17.6)

39.3

(16.3)

34.1

(19.8)

36.2

(18.2)

Mean age of patient, years (SD)

Laterality, left:right

0.53

0.97

(15.3)

3:6

Four of the single-port procedures required an extra port (“single +1 procedure”); One of the multiple-port procedures was a bilateral pyeloplasty; Single-site platform (Intuitive Surgical). SD:

3:4

6:10

7:8

13:18

standard deviation; SS: single-site.

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Table 2. Perioperative outcomes

Type of robotic pyeloplasty

Group 2

Group 1

Single-port)

(

Total

p value

(Multi-port)

GelPort

Combined

Number of patients

0.93

0.33

(

31.6

25.3)

41.7

217.0

(58.8)

225.2

(42.2)

198.9

(57.8)

213.5

(51.8)

Mean OR time, minutes (SD)

(

92.9

(60.8)

115.3

(101.2)

115

(74)

119.1

(102.9)

Mean estimated blood loss, mL (SD)

Conversion to laparoscopy

Mean LOS, hours (SD)

0.71

1.0

156.2)

(

6.2

52.0)

74.3

(16.6)

86.67

(46.1)

93.2

(53.0)

87.8

(46.5)

0.76

LOS: length of stay; OR: operating time; SD: standard deviation; SS: single-site.

ferences among the GelPort or SS port compared with multi-

port surgery, although there seemed to be a trend towards

a shorter stay for those who had undergone R-LESS pyelo-

plasty. The length of postoperative stay from this operation

likely relates with postoperative protocols rather than resolu-

tion of ileus or limitations of incisional pain, as evidenced

in the literature, which demonstrates hospital stay being

through the 10 mm assistant port in a hybrid approach.

This study reports the ﬁrst and only Canadian experi -

ence with R-LESS pyeloplasty to date and the only North

American experience with the SS system for pyeloplasty.

The limitations of this study include the small number of

patients and that cosmetic results were not evaluated due to

lack of validated assessment tools. Larger series and prospec-

tive studies are necessary to properly deﬁne the role of the

R-LESS technique. Despite reasonable operative times and

functional results with two different R-LESS access ports, we

believe this approach remains more technically challeng-

ing than conventional robotic, multiple-incision pyeloplasty.

Ongoing reﬁnement of this technique is critical prior to pro-

motion and widespread adoption. Re-evaluation of robotic

platforms speciﬁcally designed for single-incision surgery

will be necessary going forward.

anywhere between one to greater than ﬁve days. In terms

of functional results, over 93% of patients experienced a

resolution of symptoms as well as an improved T on lasix

renogram post-R-LESS procedures, consistent with success

rates of open, laparoscopic, robotic and LESS pyeloplasty.⁶

There were a number of disadvantages with both of the

single-site access ports used. With the GelPort, robotic cases

were associated with instrument crossing and difﬁculty in

placement of the accessory instruments used for suction or

retraction. The GelPort also requires a larger initial incision

(

~3–4 cm) for positioning of the inner ring. By comparison,

Conclusion

the major drawback of the SS system is that the tools cur-

rently do not have endo-wrist articulation, which hinders

one of the important advantages of the surgical robot. Unlike

the GelPort, there is less ﬂexibility in the number, size, and

conﬁguration of instruments that can be placed. Moreover,

there is less ﬂexibility for adapting to different abdominal

thicknesses and the port is prone to air leaks as well. In

order to facilitate suturing, one of the curved ports was often

removed and replaced by a standard endo-wrist instrument

This study has demonstrated that our early experience with

both R-LESS and robotic, multiple-incision pyeloplasty are

comparable in terms of surgical safety, as well as periopera-

tive and postoperative outcomes.

Competing interests: Dr. Sener has received grants/honoraria from CONMED, Eli Lily, and FirstKIND;

and is the co-founder of Clearwater Clinical Limited. The remaining authors declare no competing

ꢀ

nancial or personal interests.

Table 3. Postoperative outcomes

Type of robotic pyeloplasty

Group 1

Single-port)

Group 2

Multi-port)

(

Total

p value

(

GelPort

Combined

Number of patients

0.93

0.63

Patients with persistent obstruction post-pyeloplasty

on renogram

1/9

0/7

1/16

1/14

2/30

Number of patients requiring reintervention

1/9

0/7

1/16

1/14

2/30

0.63

0.76

Number of complications

SS: single-site.

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Fig. 5A. Laparoscopic image demonstrating view of target tissues using the

GelPort system. The instruments are standard articulating tools, providing

good dexterity. In order to separate the instruments, the umbilical incision

needs to be 3‒4 cm long instead of 1.5‒2.5 cm required for the single-site

platform.

Acknowledgments: We would like to thank Judy Li Wanpo from Minogue Medical for her expertise

and for providing images from Intuitive Surgical.

This paper has been peer-reviewed.

Fig. 5B. Image of the single-site (Intuitive) ports and instruments. The

instruments cross at the level the fascia. The curved ports and ﬂexible

instruments provide separation between instruments and the camera.

However, dexterity is limited by the lack of wristed instruments for the current

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