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Originally published May 19, 2025
Last updated May 19, 2025
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Single-port robotic surgery is the newest iteration of robotic surgery that is now being widely adopted in the field of urology. Whereas multiport surgery requires four or more surgical ports to be inserted through keyhole-sized incisions, single-port surgery utilizes a single 3- to 4-centimeter incision to facilitate the entry of all the articulating surgical instruments to perform delicate and precise surgeries such as prostatectomies and partial nephrectomies. Pain and recovery times for patients are often shorter, allowing for high rates of same-day discharge. For surgeons, however, much is required to successfully perform the single-port procedure, as the learning curve of the single-port robot tends to require a lot of attention to detail, dedication and commitment to a new technology.
“You can’t think big; you have to think small, as single-port surgeries require a combination of small steps since we are more precise and regionalized to the target organ,” says Sij Hemal, MD, a urologist with USC Urology, part of Keck Medicine of USC. “There is a steep learning curve associated with single-port robotic surgery. In a way, that’s a blessing in disguise because the prostate and surrounding organs are very delicate, and precision/accuracy is a must. My goal as the surgeon is to preserve the architecture around the prostate as best as I can.”
The biggest benefit of single-port surgery is regionalization, Hemal says. The robot allows for very fine dissection, enabling surgeons to better preserve critical structures around the prostate gland during surgery, which ultimately helps maintain continence and erectile function postoperatively. Since surgeons are able to perform the surgery through the extraperitoneal, retroperitoneal or transvesical spaces, without violating the abdominal cavity, patients have less pain and recover much faster. In fact, regionalizing surgery helps allow these procedures to be performed on patients with so-called “hostile abdomens” (i.e., patients who have had multiple previous abdominal surgeries).
“With single-port robotic surgery, we’re able to use less traction during surgery on these delicate organs,” Hemal explains. “As a result, patients do better in terms of recovering their continence and sexual function, as there is less mechanical trauma to the critical nerves, ligaments and pelvic floor surrounding the prostate.”
The learning curve for single-port robotic surgery is surgeon-specific, Hemal says. For one surgeon, it could take 50 cases; for another, 100. Mastering the procedure takes effort and patience.
“I’m very lucky that I was at the right place at the right time when this technology was approved by the FDA for application in urology in 2018. One of the biggest things as a surgeon that you must let go of is the current dogma of using conventional laparoscopy or multiport robotic surgery,” advises Hemal, who specializes in surgical techniques, including robotic radical prostatectomy, robotic partial/radical nephrectomy, robotic simple prostatectomies for enlarged prostates, robotic nephroureterectomy and robotic adrenalectomy for urologic malignancies. “You need a different mindset when doing single-port surgery. You need to think in a much more regionalized and targeted way. It’s like telling someone to drive stick shift after they have been driving an automatic transmission all along. But once you learn the stick shift and you start seeing better outcomes in your patients without compromising on the oncologic outcomes, that inspires you to keep pushing the envelope.”
Some surgeons find single-port robotic surgery frustrating because it requires a lot of very small, fine movements. “But if you persist, it gets easier to perform, just like riding a bike. And once you see the benefits in your patients, it will be worth it,” Hemal says.
“I had my fair share of rough cases initially up front, but then when I saw the patients post-op, they were doing remarkably well, and they recovered so quickly. Who doesn’t want their patients to go home the same day on just acetaminophen and ibuprofen? Who doesn’t want their patients to be able to pick up their grandkids or go out and play golf two weeks after surgery?”
One benefit of single-port robotic surgery is that post-surgery many patients don’t require oxycodone or narcotic pain medications, Hemal says. “They get back on their feet right away. They can eat regular diets and have low rates of bowel complications and, in general, go through less stress to their bodies,” he says. “Overall, because you’re not really violating the abdominal cavity and staying completely outside of the abdomen, you’re staying in these spaces that we could not get to with the multiport robot.”
These benefits are why more surgeons are looking to learn how to perform single-port techniques.
Another benefit of the single-port technique is for patients who are not good candidates for multiport surgery, Hemal says. This includes patients who have had multiple previous abdominal surgeries and for whom undergoing a multiport surgery would be very challenging because of bowel adhesions or risk of vascular injury, he says. Another good qualifying patient for single-port surgery would be someone who cannot tolerate the Trendelenburg (head down) operating position due to obesity or pulmonary issues.
“It’s a really good option for medically complex patients or people with certain comorbidities, because with a single-port surgery, the patient can be completely flat or supine during surgery. I get many referrals for patients with hostile abdomens, such as those with previous colostomies or significant bowel surgeries, since their abdomens do not facilitate the performance of the conventional transperitoneal multiport robotic surgery due to the higher risk of bowel or vascular complications,” Hemal says.
Still, there are surgical cases for which a multiport procedure remains the best option. The bottom line is that it’s helpful for a surgical center to offer multiple options for more personalized treatment approaches.
“Multiport surgery is going to be here forever and has a place for some very complex surgeries. However, single-port technology is a great option for an overwhelming majority of my patients, and I am currently performing approximately 70%-80% of all my robotic surgeries with the single-port route,” Hemal says. “It has been a game changer for my prostate cancer patients, since I do a bulk of these with the single-port approach, and these patients do remarkably well postoperatively. Importantly, we have not compromised on the oncologic margins or efficacy and have been able to maintain the standard of care using this technology.”
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