What are the differences between DaVinci (da Vinci robotic surgical system) single-port and multi-port systems for prostate surgery in male patients?

Da Vinci Single-Port vs Multi-Port for Prostate Surgery

Based on current evidence, both da Vinci single-port (SP) and multi-port (MP) robotic systems are safe and effective for prostate surgery with equivalent oncologic and functional outcomes, though SP may offer marginal advantages in cosmesis and hospital stay without compromising surgical quality. 1

Oncologic Outcomes

No difference exists in cancer control between SP and MP platforms. The evidence demonstrates:

• Surgical margin rates are equivalent between SP and MP radical prostatectomy, with no definitive difference in positive margin status 1
• Biochemical recurrence rates show no difference between the two platforms 1
• In the largest comparative analysis, SP radical prostatectomy achieved an 18% positive margin rate (80% of which had T3 disease), comparable to historical MP outcomes 2
• Pathologic outcomes are similar, with both platforms achieving appropriate cancer staging and lymph node retrieval when indicated 3, 2

Perioperative Outcomes

Operative Time

• No clear difference in operative time between SP and MP approaches 1
• Mean SP operative time ranges from 161-234 minutes across studies 3, 2
• Learning curve is rapid: experienced robotic surgeons achieve operative times <200 minutes by their third SP case 3
• MP operative time averages 216.6 minutes, compared to 232.4 minutes for SP (not statistically significant, p=0.39) 4

Blood Loss and Transfusion

• Blood loss is equivalent between platforms, averaging 148-227 mL for SP vs 195.7 mL for MP 1, 3, 2, 4
• No difference in transfusion requirements has been demonstrated 1

Complications

• Overall complication rates are similar between SP and MP platforms 1
• SP shows a trend toward slightly higher complications (42.86% vs 21.28%, p=0.09) in simple prostatectomy, though not statistically significant 4
• Clavien Grade IIIa complications occur at low rates with both platforms (approximately 7-8%) 3, 2
• No conversions to open surgery or additional ports were required in initial SP series 5, 3

Functional Outcomes

Urinary Continence

• Continence recovery is equivalent between SP and MP platforms 1
• Early continence rates with SP are promising: 82% of patients were continent at catheter removal in Retzius-sparing SP series 2
• Both platforms benefit from nerve-sparing and Retzius-sparing techniques when oncologically appropriate 3, 2
• Meta-analyses show robotic approaches (both SP and MP) demonstrate statistically significant advantages in 12-month urinary continence compared to open or laparoscopic approaches 6

Sexual Function

• Erectile function recovery shows no difference between SP and MP platforms 1
• Potency outcomes depend primarily on nerve-sparing technique, patient age, and preoperative function rather than port configuration 1, 2
• Mean Sexual Health Inventory for Men scores at 3 months were 18 in nerve-sparing SP cases 2

Patient Experience Advantages

Hospital Stay

• SP may reduce length of stay compared to MP, though differences are modest 1
• Mean hospital stay for SP is 1-2 days, with some patients discharged within 23 hours 3, 2
• MP hospital stay averages 2 days vs 2.5 days for SP (p=0.45) 4

Pain and Cosmesis

• SP may improve postoperative pain: 61% of SP patients required no opioids postoperatively 2
• Cosmetic outcomes theoretically favor SP due to single incision, though this has not been robustly demonstrated across all studies 1
• Patient satisfaction with incisions may be higher with SP, though data are limited 1

Catheter Duration

• Catheter duration is equivalent between platforms, averaging 7 days 3

Technical Considerations

Port Configuration

• SP uses a single 25mm robotic cannula plus one 12mm assistant port for suction, suture passage, and clip placement 5, 3
• MP uses multiple ports (typically 4-5 ports total) distributed across the abdomen 4
• Magnetic retraction devices can facilitate SP surgery by improving tissue exposure and ergonomics 5

Surgical Approach Compatibility

• Both traditional retropubic and Retzius-sparing approaches are feasible with SP platform 3, 2
• Retzius-sparing SP radical prostatectomy is safe and achieves excellent early continence rates 2
• Lymphadenectomy can be performed with SP platform when indicated (86% of cases in one series) 2

Clinical Decision Algorithm

Choose SP platform when:

• Surgeon has adequate SP training and experience 6
• Patient prioritizes cosmesis and potentially reduced pain 1
• Center has SP platform available and surgeon is past learning curve 3

Choose MP platform when:

• Surgeon lacks SP experience or is early in learning curve 6
• Complex anatomy or prior radiation may benefit from additional port flexibility 2
• SP platform is unavailable 4

Either platform is appropriate when:

• Standard radical prostatectomy is planned 1
• Simple prostatectomy for benign prostatic hyperplasia is indicated 4
• Patient has no strong preference for cosmesis 1

Common Pitfalls and Caveats

• Selection bias exists in published studies: most SP data come from high-volume surgeons at centers of excellence, limiting generalizability 1
• Surgeon experience remains the critical determinant of outcomes regardless of platform choice 6, 1
• Learning curve considerations: even experienced robotic surgeons require initial cases to optimize SP technique 3
• Prior radiation increases complexity: 11% of SP patients had prior prostate radiation, demonstrating feasibility but requiring careful patient selection 2
• Assistant port placement matters: optimal positioning of the 12mm assistant port is still being refined for true single-site surgery 5
• Longer follow-up needed: most SP data have mean follow-up of only 6 months, insufficient for definitive long-term oncologic conclusions 2