Feasibility and early outcomes of single-port robotic-assisted radical cystectomy with intracorporeal ileal conduit: an initial Spanish case series

Introduction

Radical cystectomy (RC) remains the gold-standard treatment for muscle-invasive bladder cancer (MIBC) and for select cases of high-risk non-muscle-invasive bladder cancer (NMIBC) that are refractory to intravesical therapy (1). Despite significant advances in systemic and bladder-preserving approaches, RC continues to offer the best long-term oncological control in appropriately selected patients. However, the procedure is complex and associated with considerable perioperative morbidity, prolonged recovery, and potential impact on quality of life, which has driven the continuous pursuit of less invasive surgical alternatives.

Over the past two decades, robotic-assisted radical cystectomy (RARC) has progressively gained acceptance as a minimally invasive alternative to the open approach, demonstrating comparable oncological outcomes with reduced estimated blood loss, lower transfusion rates, shorter hospital stay, and earlier convalescence (2). The robotic platform has also facilitated the adoption of intracorporeal urinary diversion (ICUD), which further enhances the minimally invasive concept by avoiding large incisions and reducing bowel manipulation.

Most published RARC series to date have been performed using multiport robotic systems, particularly with the da Vinci^® Xi and Si platforms. These systems, while effective, still require multiple incisions for trocar placement, which may contribute to postoperative pain and parietal trauma. The recent introduction of the purpose-built da Vinci SP^® (Single Port) system represents a new generation of robotic technology specifically designed to enable complex urological procedures through a single access point. This approach aims to facilitate complex robotic procedures through a reduced-access platform while maintaining adequate instrument articulation and visualization. Potential perioperative advantages remain under investigation, particularly in the context of RC requiring ICUD (3,4).

Although the feasibility of single-port RARC (SP-RARC) with ICUD has already been demonstrated in pioneering high-volume centers, worldwide clinical experience remains limited, particularly outside early adopter institutions in the United States. As a result, evidence regarding reproducibility, implementation, and perioperative outcomes during the adoption phase of this technology in other healthcare systems remains scarce. The procedure, particularly when combined with ICUD, presents unique technical challenges such as reduced instrument triangulation, limited workspace, and the need for highly refined surgical coordination. As a result, current evidence is largely restricted to small series reported by select high-volume tertiary centers with extensive experience in robotic pelvic surgery (5-7). Nevertheless, these early experiences have demonstrated the feasibility and safety of SP-RARC with ICUD, with acceptable short-term perioperative outcomes reported in expert hands.

To date, no Spanish series has described the implementation of SP-RARC with intracorporeal diversion. The present study therefore aims to report the initial national experience with this approach, focusing on technical adoption, perioperative outcomes, and early postoperative results during the early implementation phase in a European tertiary referral center. We present this article in accordance with the AME Case Series and SUPER reporting checklists (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0031/rc).

Case presentation

Ethics

The study has been registered in ResearchRegistry.com (research registry ID: researchregistry11777). All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments (8). This study was approved by Research Ethics Committee of HM Hospitales (approval number: 21.10.1901-GHM). Written informed consent was obtained from the patients for the publication of this case series and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Study design and patient selection

We conducted a prospective single-center case series registry including the first four consecutive patients who underwent single-port robotic-assisted radical cystectomy (SP-RARC) with ICUD at our institution, HM Hospitales (Madrid, Spain), a tertiary referral center with a well-established robotic pelvic oncology program, between April and June 2025. All procedures were performed in a dedicated operating theatre following standardized perioperative protocols. Patients were consecutively identified during the recruitment period. Baseline variables included age, sex, body mass index (BMI), smoking status, ASA score, relevant comorbidities (hypertension, diabetes mellitus, dyslipidemia, ischemic heart disease, and chronic pulmonary disease), prior intravesical therapies, and tumor stage. Eligible patients had histologically confirmed MIBC or high-risk NMIBC, with no radiological evidence of nodal or distant metastases. Exclusion criteria included coagulopathy or impaired coagulation parameters, any contraindication to RC or robotic surgery, active urinary tract infection, and a history of extensive abdominal surgery that could preclude safe single-port access.

Selection for the single-port robotic approach was based not only on oncological indication for RC, but also on technical feasibility criteria established during multidisciplinary evaluation. Factors considered included patient performance status, body habitus, absence of bulky nodal disease or extensive fixation to adjacent organs on preoperative imaging, and the anticipated feasibility of safe single-port pelvic access and intracorporeal reconstruction. Prior pelvic radiotherapy or previous bladder-preserving strategies were not considered absolute contraindications in selected patients when surgery was deemed technically feasible by the experienced robotic team. In these cases, preoperative imaging and multidisciplinary assessment were used to evaluate pelvic fibrosis, anatomical distortion, and the anticipated feasibility of safe dissection and intracorporeal reconstruction.

Patients were followed through scheduled outpatient visits, with review of the electronic medical record. Postoperative outcomes, including 30-day complications and readmissions, were prospectively recorded. The duration of follow-up ranged from 3 to 5 months.

Indications for SP-RARC with intracorporeal ileal conduit included histologically confirmed MIBC or high-risk NMIBC requiring RC after multidisciplinary team discussion. Tumor characteristics, including lesion location and size when available, were obtained from cystoscopy and transurethral resection of bladder tumor (TURBT) reports, as well as from cross-sectional imaging studies.

Patient assessment and measured variables

Baseline characteristics collected included age, sex, comorbidities (hypertension, diabetes, dyslipidemia, ischemic heart disease, and chronic pulmonary disease), BMI, smoking status, American Society of Anesthesiologists (ASA) score, and prior intravesical therapies. Intraoperative parameters assessed were operative time, estimated blood loss, intraoperative complications, and need for conversion.

Postoperative variables included hemoglobin drop, transfusion requirements, pain scores, opioid consumption, time to bowel recovery, and length of hospital stay. Postoperative complications were graded according to the Clavien-Dindo classification (9). Readmissions and emergency department visits within 30 days after surgery were recorded. Pathological evaluation included TNM stage, histological subtype, surgical margin status, and lymph node yield.

Preoperative workup and neoadjuvant treatment

All patients underwent standard staging with computed tomography (CT) of the chest, abdomen, and pelvis and were evaluated by a multidisciplinary tumor board. Two patients received cisplatin-based neoadjuvant chemotherapy, and all had negative nodal and metastatic workups before RC.

Case descriptions

Case 1

A 65-year-old male was initially diagnosed with MIBC in 2021. Following neoadjuvant chemotherapy, repeat transurethral resection of the bladder tumor showed no residual malignancy, and the patient decided to undergo bladder preservation with radiotherapy. After a 4-year disease-free interval, he presented in April 2025 with a recurrence. TURBT revealed high-grade disease with prostatic stromal invasion (cT4), along with an incidental elevation of prostate-specific antigen (PSA) to 10 ng/mL. Subsequent biopsy confirmed a synchronous Gleason 10 prostate adenocarcinoma. The patient underwent single-port robotic cystoprostatectomy with total urethrectomy and intracorporeal Bricker ileal conduit diversion. Given the prior administration of chemotherapy, neoadjuvant chemotherapy was not considered in the multidisciplinary tumor board discussion.

Case 2

A 64-year-old female presented in December 2024 with one month of gross hematuria unresponsive to antibiotics and negative urine cultures. Cystoscopy revealed a 5 cm vesical mass suspicious for malignancy. She underwent TURBT on January 2025, with a histopathological diagnosis of high-grade MIBC (≥ pT3a) with muscularis propria invasion. Staging CT and magnetic resonance imaging (MRI) showed no evidence of nodal or distant metastases. The patient received four cycles of neoadjuvant chemotherapy with cisplatin and gemcitabine. After achieving a complete clinical and radiological response, confirmed by repeat MRI and negative re-TURBT in May 2025, the patient was scheduled for definitive surgical management. Thus, a SP-RARC with intracorporeal Bricker ileal conduit urinary diversion was performed.

Case 3

A 79-year-old male with a history of high-grade NMIBC initially staged as T1 experienced disease progression to T2 after developing Bacillus Calmette-Guérin (BCG) intolerance and persistent lower urinary tract symptoms. He was enrolled in a clinical trial that allowed bladder preservation in the event of a clinical complete response. However, disease evaluation in April 2025 confirmed persistent high-grade T2 disease. Consequently, a SP-RARC with intracorporeal Bricker diversion was performed.

Case 4

A 76-year-old male with a history of high-grade MIBC initially diagnosed in 2023 was treated with a bladder preservation protocol, including neoadjuvant chemoradiotherapy and multiple TURBTs, followed by intravesical BCG. Despite an initial complete response, disease recurrence was confirmed in late 2024 by positron emission tomography (PET)-CT and cystoscopy, showing a locally advanced T4 tumor. During follow-up, the patient developed progressive functional bladder deterioration, with micro-bladder syndrome, persistent lower urinary tract symptoms, refractory hematuria, and the need for long-term catheterization. Quality of life was significantly impaired despite medical management and symptomatic relief strategies. Given the tumor recurrence and poor bladder function, a salvage SP-RARC with intracorporeal Bricker ileal conduit urinary diversion was decided.

Surgical platform and technique

All procedures were performed using the da Vinci SP^® platform (Intuitive Surgical, Sunnyvale, CA, USA), employing a single-port approach. Patients were positioned supine and secured with a 15° Trendelenburg tilt. This setup minimized the need for steep angulation and allowed stable exposure of the pelvis. No leg supports were used, ensuring a streamlined patient positioning protocol (Figure 1A).

Figure 1 Patient positioning and single-port surgical setup for single-port robotic-assisted radical cystectomy. (A) Patient positioned supine with a 15° Trendelenburg tilt, without leg supports, ensuring stable pelvic exposure and ergonomic access. (B) Single-port setup with an infraumbilical midline incision, Alexis^® wound retractor, and da Vinci SP^® cannula docked to the multichannel access device.

Peritoneal access was obtained through a 4 cm infraumbilical midline incision. An Alexis^® wound retractor (Applied Medical) was inserted, over which a dedicated multichannel single-port access device was mounted. The da Vinci SP^® platform cannula was docked directly to this setup, creating a single-entry point for all robotic instruments. This configuration allowed adequate triangulation, full instrument articulation, and optimal endoscopic visualization throughout the procedure, without the need for accessory trocars during the dissection phase (Figure 1B).

All cases were performed by a single high-volume robotic pelvic surgeon (R.B.M.) with extensive prior experience in multiport robotic RC and intracorporeal diversion. The present series reflects the initial institutional adoption phase of the da Vinci SP^® platform after dedicated team training, dry-lab familiarization, and operating room workflow standardization. No technique-specific intraoperative monitoring beyond standard anesthetic monitoring was required. Hemodynamic management and fluid therapy were conducted according to institutional enhanced recovery after surgery (ERAS) protocols (10).

The operative sequence was standardized, beginning with bilateral identification and dissection of the ureters from their course over the iliac vessels to their insertion into the bladder. Once isolated, the ureters were proximally clipped using medium-sized Hem-o-Lok^® clips and then transected. An extended bilateral pelvic lymph node dissection was subsequently performed in all patients, encompassing the external iliac, internal iliac, obturator, and presacral nodal packets. Dissected specimens were placed in endoscopic retrieval bags and extracted at the conclusion of the procedure.

In the females, the posterior vaginal wall was exposed by suspending the uterus to the anterior abdominal wall with a transabdominal silk suture, thereby improving access to the vesicovaginal plane. Dissection proceeded along the posterior fornix, which was incised proximally using energy devices, and was continued to the urethra, which was fully isolated, clipped, and divided. The surgical specimen, including the bladder, anterior vaginal wall, and lymphadenectomy packets, was extracted via a posterior colpotomy.

When required, the posterior vaginal wall was reconstructed with a running 3-0 barbed suture (V-Loc™, Medtronic). In selected cases, the vaginal route was also used to introduce the laparoscopic stapler during the urinary diversion phase, prior to colporrhaphy and vaginal reconstruction, thus obviating the need for an additional trocar.

In males, cystoprostatectomy was performed following a standard posterior-to-anterior approach. The rectoprostatic space was developed by careful dissection of the posterior plane, aided, when necessary, by suspension of the seminal vesicles and Denonvilliers’ fascia with a transabdominal suture to optimize exposure. The distal urethra was fully mobilised, clipped proximally, and transected at the prostatic apex. In cases requiring complete urethrectomy, the distal urethra was clipped, and a perineal approach was undertaken following the robotic portion to ensure complete resection of the remaining urethral segment.

ICUD (Bricker technique)

Following bladder removal, an intracorporeal Bricker ileal conduit was constructed in all cases. A 20-cm segment of terminal ileum, starting approximately 20 cm proximal to the ileocecal valve, was isolated, and bowel continuity was restored with a side-to-side, functional end-to-end anastomosis using a laparoscopic linear stapler (Endo-GIA^®).

Although the extirpative phase of the procedure was completed through a single-port robotic approach, construction of the intracorporeal ileal conduit occasionally required the selective use of a 12 mm assistant trocar during the urinary diversion phase. This adjunctive access was used primarily to facilitate safe bowel handling and stapling during intracorporeal reconstruction, particularly in anatomically complex situations. The need for an accessory trocar reflects the current technical limitations of single-port robotic cystectomy with urinary diversion and has also been reported in other early SP-RARC series (5). In male patients, it was positioned in the right lower quadrant at the future stoma site, facilitating bowel division, conduit construction, and stoma exteriorization. In female patients, the same trocar was used in most cases, while in others, the stapler was introduced transvaginally through the posterior colpotomy prior to vaginal closure, allowing a fully intracorporeal reconstruction.

Each ureter was implanted separately into the conduit using interrupted 4-0 Monocryl^® sutures without an anti-reflux mechanism. Ureteral stents were placed and exteriorized through the stoma. All urinary diversions were completed intracorporeally without conversion or intraoperative complications. The key steps of the procedure are illustrated in Video 1.

To ensure quality and procedural consistency, patient selection was discussed in a multidisciplinary tumor board; all cases followed a predefined stepwise operative sequence [ureteral dissection, extended bilateral pelvic lymph node dissection (PLND), cystectomy, and intracorporeal Bricker diversion], and a standardized instrument set and operating room workflow were used. Key perioperative variables and complications were recorded in a dedicated registry.

Safety measures included careful ureteral handling with minimal devascularization and tension-free implantation, meticulous hemostasis during pelvic lymph node dissection, and routine specimen bagging. The addition of an auxiliary port or conversion to a multiport or open approach was considered in the presence of significant intraoperative difficulties, however, all procedures were completed using a single- port technique without conversions to multiport or open surgery.

Statistical analysis

All data were prospectively collected and analyzed using a descriptive approach. Continuous variables are presented descriptively as mean values and ranges, while categorical variables are reported as absolute numbers and percentages. Owing to the small cohort size, no inferential statistical tests were performed. Data management and analysis were carried out using IBM SPSS Statistics (IBM Corp. Released 2013. IBM SPSS Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp.).

All procedures were successfully completed using a single-port robotic approach without conversion to open surgery. Intracorporeal Bricker ileal conduit urinary diversion was achieved in all four patients. No intraoperative complications or need for blood transfusion were reported. To reduce infectious complications, perioperative antibiotic prophylaxis with intravenous cefazolin (2 g administered at anesthetic induction) was employed, together with structured education on stoma and urostomy care. Suspected urinary tract infections were managed according to urine culture results and clinical severity, with escalation to intravenous therapy and hospital readmission in the presence of systemic signs. The prospectively collected patient characteristics and postoperative outcomes are detailed in Table 1.

The docking time ranged from 15 to 21 min (mean 17.5 min) and operative time from 192 to 310 min (mean 249.5 min), with a consistent workflow across cases. Mean estimated blood loss was 500 mL (range, 300–900 mL), and no patient required postoperative transfusion.

Postoperative recovery and hospital stay

Enhanced recovery protocols were applied uniformly. All patients resumed oral intake on postoperative day 1 with chewing gum and a soft diet. Early ambulation was achieved within the first 24 hours. The length of hospital stay was 5 days for patient 1, 7 days for patient 2, 5 days for patient 3, and 6 days for patient 4. Mean hospital stay was 5.75 days. Surgical drains were removed by postoperative day 3.

Complications and follow-up

All enrolled patients underwent the planned surgical intervention. Procedural adherence was defined as successful completion of SP-RARC with intracorporeal ileal conduit urinary diversion without conversion or procedure abandonment. Tolerability was assessed based on intraoperative events, postoperative recovery parameters, and postoperative complications graded according to the Clavien-Dindo classification. No patients were lost to follow-up; all completed the planned postoperative surveillance and were included in the final analysis.

Two patients experienced minor complications within 30 days. Patient 2 developed a urinary tract infection managed with oral antibiotics (Clavien-Dindo II). Patient 4 experienced a paroxysmal episode of atrial fibrillation that resolved spontaneously (Clavien-Dindo I), followed by a febrile urinary tract infection requiring hospital readmission and intravenous antibiotics (Clavien-Dindo II). No major complications (≥ Clavien-Dindo III), anastomotic leaks, or reoperations were observed. Follow-up ranged from 3 to 5 months, with no readmissions or urinary diversion-related complications in the remaining cases. All surgical margins were negative on final pathological assessment of the surgical specimens. Final pathology showed pT4aN0, pT1N0 after neoadjuvant chemotherapy, pT3aN0 and pT4aN1, with negative surgical margins in all cases.

Discussion

The advent of the da Vinci SP^® platform has expanded the technical possibilities of minimally invasive robotic surgery, particularly for complex procedures such as RC with ICUD. Despite the historical technical challenges that have hindered the widespread adoption of laparoscopic single-site surgery, the specific design of this novel platform was developed to address some of the technical limitations associated with reduced-access robotic surgery, including lack of triangulation, instrument collisions, and suboptimal ergonomics (11).

Initial results from various institutional series have demonstrated that single-port RARC can be performed safely and effectively, with low rates of conversion or need for additional access, even in patients with complex anatomy (7). Notably, Kaouk et al. reported a series of cases with negative surgical margins, acceptable operative times, and no major intraoperative complications (12). Similarly, Zhang et al. emphasized that, with appropriate technique and an adequate learning curve, ICUD can be successfully incorporated into this approach, achieving early postoperative complication rates comparable to those observed with other robotic platforms (4). Complications were limited to minor events (Clavien I–II), with one readmission for urinary tract infection and no major complications or reoperations. This contrasts with the 25–35% rate of ≥ Clavien III complications typically observed after open or multiport RARC (13,14) and aligns with recent SP series, which have reported major complication rates under 15%. Our findings add to the growing evidence that the SP approach can be safe in carefully selected patients when performed in high-volume centers.

Beyond technical feasibility, the potential perioperative advantages of the single-port platform in RC remain to be clearly established. Although prior studies in other urological procedures such as radical prostatectomy have suggested possible reductions in postoperative pain, opioid use, and hospital stay, these findings may not be directly transferable to RC, which involves a substantially more complex extirpative and reconstructive procedure. In the present series, ERAS protocols were uniformly applied, and therefore any specific contribution of port reduction alone to postoperative recovery cannot be determined. Our findings should therefore be interpreted primarily as an initial feasibility experience rather than evidence of clinical superiority over conventional multiport robotic approaches (10,15).

An additional point of relevance in our series is that two of the patients had undergone prior pelvic radiotherapy. These cases are usually considered more challenging due to the presence of fibrosis, distorted tissue planes, and increased risk of intraoperative and postoperative complications (16). The fact that both procedures were completed successfully, with favorable perioperative outcomes, suggests that the approach may be technically achievable in selected complex surgical scenarios.

Pathological assessment revealed stages ranging from pT1N0 to pT4aN1, with negative surgical margins in all cases. This mirrors other SP-RARC series, which consistently report margin-negative resections above 95% (17). Although negative surgical margins were achieved in all cases, the very limited follow-up of the present series precludes any meaningful assessment of oncological outcomes, recurrence patterns, or long-term cancer control.

Nevertheless, it is crucial to underscore that the successful implementation of this technology relies heavily on multidisciplinary patient selection and the expertise of the surgical team. In the present series, selection criteria were primarily based on technical feasibility for the single-port approach rather than disease stage alone, and included preoperative assessment of anatomical suitability, absence of bulky unresectable disease, and the anticipated ability to safely complete intracorporeal reconstruction. Intraoperative coordination, familiarity with the single-port configuration, and the support of a well-trained nursing team are all critical factors that must be considered when launching an SP robotic surgery program. From an implementation standpoint, the da Vinci SP^® platform entails substantial capital and disposable costs, which may limit widespread adoption. However, potential improvements in postoperative recovery pathways could partially offset costs in selected settings, although formal cost-effectiveness analyses are still required.

Despite the limited number of cases, the outcomes from our initial experience are encouraging and provide preliminary evidence supporting the technical reproducibility of SP-RARC during early institutional adoption. However, several important limitations must be acknowledged. First, this was a single-center experience involving an extremely limited cohort size, which substantially restricts interpretation of perioperative safety and limits the generalizability of our findings. Second, the absence of a contemporaneous multiport robotic cystectomy cohort prevents any meaningful comparison of perioperative outcomes, recovery pathways, or potential advantages between platforms. Therefore, the present study should be interpreted as a descriptive implementation experience rather than a comparative effectiveness analysis. Furthermore, because all procedures were performed using a transperitoneal approach within a standardized ERAS pathway, the present study cannot determine whether reduction in the number of ports alone translates into clinically meaningful improvements in postoperative recovery compared with conventional multiport robotic cystectomy. In addition, all procedures were performed at a high-volume expert robotic center, which may limit reproducibility in other clinical settings. The cohort was also heterogeneous, including salvage procedures and patients with prior pelvic radiotherapy, which may further limit interpretation of perioperative outcomes. Finally, the short follow-up period precludes meaningful assessment of long-term oncological control, recurrence patterns, functional outcomes, or urinary diversion-related complications. Therefore, the present findings should be considered preliminary and hypothesis-generating only.

Conclusions

Single-port robot-assisted RC with intracorporeal ileal conduit reconstruction was technically achievable in this initial Spanish experience when performed by an experienced robotic team. Our preliminary findings demonstrate the feasibility of institutional adoption and provide early perioperative data regarding this approach. However, given the very limited sample size, absence of a comparative cohort, and short follow-up, no definitive conclusions regarding superiority, long-term safety, or oncological outcomes can be established. Further multicenter studies with larger cohorts and extended follow-up are required.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the AME Case Series and SUPER reporting checklists. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0031/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0031/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0031/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the Declaration of Helsinki and its subsequent amendments. This study was approved by Research Ethics Committee of HM Hospitales (No. 21.10.1901-GHM). Written informed consent was obtained from the patients for the publication of this case series and accompanying images and video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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