Simplifying Retroperitoneal Robotic Single-port Surgery: Novel Supine Anterior Retroperitoneal Access

Background: Multiport robotic surgery in the retroperitoneum is limited by the bulky robotic frame and clashing of instruments. Moreover, patients are placed in the lateral decubitus position, which has been linked to complications. Objective: To assess the feasibility and safety of a supine anterior retroperitoneal access (SARA) technique with the da Vinci Single-Port (SP) robotic platform. Design, setting, and participants: Between October 2022 and January 2023, 18 patients underwent surgery using the SARA technique for renal cancer, urothelial cancer, or uret-eral stenosis. Perioperative variables were prospectively collected and outcomes were assessed. Surgical procedure: With the patient in a supine position, a 3-cm incision is made at the McBurney point and the abdominal muscles are dissected. Finger dissection is used to develop the retroperitoneal space for the da Vinci SP access port. After docking, the first step is to dissect retroperitoneal tissue to reveal the psoas muscle. This allows identifi-cation of the ureter, the inferior renal pole, and the hilum. Measurements: A descriptive statistical analysis was performed. Data collected included demographics, operative time, warm ischemia time (WIT), surgical margin status, com-plications, length of hospital stay, 30-d Clavien-Dindo complications, and postoperative narcotic use. Results and limitations: Twelve patients underwent partial nephrectomy (PN) and two each underwent pyeloplasty, radical nephroureterectomy, and radical nephrectomy. In the PN group, mean age was 57 yr (interquartile range [IQR] 30-73), median body mass index was 32 kg/m2 (IQR 17-58), and 25% had stage & GE;3 chronic kidney disease. The med-ian Charlson comorbidity index was 3 (IQR 0-7) and 75% of PN patients had an American Society of Anesthesiologists score & GE;3. The median RENAL score was 5 (IQR 4-7). The median WIT was 25 min (IQR 16-48) and the median tumor size was 35 mm (IQR 16-50). The median estimated blood loss was 105 ml (IQR 20-400) and the median operative time was 160 min (IQR 110-200). Positive surgical margins were found in one patient. In the overall cohort, one patient was readmitted and managed conserva-tively; 83% of the PN group were discharged on the same day as their surgery, with

Automated summary

The feasibility and safety of the supine anterior retroperitoneal access (SARA) technique with the da Vinci Single-Port (SP) robotic platform were assessed in patients undergoing surgery for renal cancer, urothelial cancer, or ureteral stenosis. The surgical procedure involves a 3-cm incision at the McBurney point and the development of the retroperitoneal space for robotic access. The outcomes of the surgery were favorable.