The Transvesical Approach to Radical Prostatectomy: A Paradigm Shift in Minimally Invasive Surgery

Since the advent of robotic surgery, our field has been in a constant state of evolution. I completed my residency in 2003, just as the first robotic platforms were being introduced. As a rotating resident at Hackensack University Medical Center, one of the earliest adopters, I was fortunate to witness this transformation firsthand. We began, as many did, with prostatectomies. The robot offered a level of precision in suturing and dissection that was a world away from the challenges of open surgery. I still recall one of my mentors in residency, after a particularly grueling open prostatectomy, remarking, "The prostate is not meant to be taken out." Although laparoscopy was an improvement, it was physically taxing. The robot, however, was a game changer, making one of the most complex open surgeries more manageable and precise. Today, nearly all prostatectomies in the United States are performed robotically.

Our expertise grew, and we soon expanded to partial nephrectomies and complex reconstructions. In 2006, I performed my first robotic cystectomy, initially with extracorporeal bowel work but quickly transitioning to a fully intracorporeal approach. Open surgery is now a rarity in my practice, reserved for only the most extensive cases. I’ve found that the key is a deep understanding of anatomy. The robot is a tool, and like any tool, its effectiveness is dictated by the skill of the user. With over 6000 robotic cases of various types under my belt, I can attest to the technology’s ability to facilitate minimally invasive procedures as well as its capability to preserve the surgeon’s own physical well-being.

The Dawn of the Single-Port Era

The quest for ever-less invasive surgery led to the development of the da Vinci SP (single-port) system, which received FDA approval in 2018.¹ Early attempts at single-site surgery were met with challenges; the instruments were flimsy and prone to collision. But the true single-port platform was a different beast. Hackensack was once again at the forefront, acquiring our da Vinci SP robot in December 2018.

Initially, I replicated my multiport techniques with the new system, performing transperitoneal prostatectomies with an assistant port. However, the true potential of the da Vinci SP robot was unlocked with the concept of "air docking" and the use of the GelPoint trocar. This innovation enabled us to work effectively in the extraperitoneal space, representing a significant leap forward for procedures such as prostate and kidney surgery. This led to the development of the da Vinci SP robot access port, or the "globe," which integrated an assistant port and an accessory port, simplifying the procedure. The use of a flexible suction device and a continuous insufflator is, in my opinion, essential for efficient single-port surgery, allowing for stable pressure and a clear surgical field.

This evolution in technology has allowed me to transition from an intraperitoneal to extraperitoneal approach for most of my prostate and kidney surgeries. The results have been remarkable: less pain, quicker recovery, and often same-day discharge for my patients.

A New Trajectory: The Transvesical Approach

The single-port platform has not just refined existing techniques; it has enabled entirely new ones. The transvesical approach to radical prostatectomy is a prime example. By making a small incision in the bladder, we can directly access the prostate, avoiding the peritoneal cavity altogether. This pneumovesical technique offers several advantages.

This method has been shown to lead to a faster recovery of urinary control and a shorter hospital stay. Based on my experience with over 120 cases, I have found this to be an efficient procedure with excellent outcomes. We are able to achieve maximal removal of the adenoma, which is crucial for relieving urinary retention, regardless of the bladder’s tone. The direct access also allows for a meticulous, water-tight closure.

The SPAM Incision: A Novel Approach to Retroperitoneal Surgery

For retroperitoneal procedures such as partial nephrectomy, I developed a new incision technique I call the SPAM (SP Ahmed modification) incision.² Dissatisfied with the cosmetic results and potential for hernias with midline and traditional subcostal incisions, I sought a better way. The SPAM incision, placed more laterally, near the anterior superior iliac spine, allows for a more direct, retroperitoneal approach. By carefully dissecting through the fascial layers, we can reach the retroperitoneal space without entering the peritoneum.

This approach provides a clearer path to the kidney, especially in patients with a high body mass index or dense perinephric fat. The kidney is naturally held up by its anterior peritoneal attachments, and with the help of the robot’s fourth arm, I can achieve excellent exposure of the hilum. This has simplified my approach to the retroperitoneum, leading to better patient outcomes, including a reduction in pain, improved cosmesis, and a lower risk of hernia.

A Global Mission: Teaching the Future of Robotic Surgery

As one of the highest-volume single-port surgeons in the world, I believe it is my responsibility to share this knowledge. At Hackensack University Medical Center, Michael D. Stifelman, MD, professor and chair of urology, Hackensack Meridian School of Medicine, and the northern chair for urology for Hackensack Meridian Health, and I place a high value on educating the next generation of surgeons.

We have established a fellowship program dedicated to training the next generation of robotic surgeons. Our fellows receive extensive hands-on training, performing a high volume of diverse cases. We also host an annual national single-port symposium to educate residents and fellows from across the country.

My commitment to education extends globally. I have had the privilege of traveling to many European countries, as well as South Korea and Bangladesh, to demonstrate these techniques and help establish robotic surgery programs. It is incredibly rewarding to see the adoption of these minimally invasive approaches worldwide, knowing that more patients will benefit from these advancements.

Advice for Aspiring Single-Port Surgeons

For those beginning their journey with the single-port platform, my advice is simple: master the anatomy. A thorough understanding of the anatomical relationships is the foundation of any successful surgical approach.

Be prepared for a learning curve. My first few single-port cases left me feeling like I was operating with 1 hand tied behind my back. But with commitment, you will learn the nuances of the system—how to manipulate the instruments, adjust the camera, and avoid collisions. Start with simpler cases and gradually progress to more complex procedures. Don’t be afraid to step out of your comfort zone and try new approaches. The single-port robot is not just a new tool; it’s an invitation to rethink how we perform surgery. Embrace the opportunity to offer your patients a less invasive, more refined surgical experience. They will undoubtedly appreciate it.

References

1. Intuitive Surgical announces innovative single port platform — the da Vinci SP Surgical System. News release. Intuitive Surgical. May 31, 2018. Accessed November 5, 2025. https://investor.intuitivesurgical.com/news-releases/news-release-details/intuitive-surgical-announces-innovative-single-port-platform-da
2. Ahmed M, Billah S. Single-port surgery: creating new opportunities in robotic surgery. AUA News. May 4, 2023. Accessed November 5, 2025. https://auanews.net/issues/articles/2023/may-2023/single-port-surgery-creating-new-opportunities-in-robotic-surgery