Expert-based classification on the technical difficulty of single-port urological robotic procedures

Abstract Single-port (SP) robotic surgery represents the latest paradigm shift in minimally invasive urology. Despite its progressive adoption worldwide, no structured classification of procedural difficulty exists for SP urological procedures. We aimed to develop an expert-based scoring system to grade the technical difficulty of urological procedures performed with the da Vinci SP platform. A questionnaire-based expert-consensus study was conducted during an international meeting on SP robotic surgery (Turin, Italy, February 2026). Consensus here refers to the descriptive convergence of independent, single-round ratings rather than a formal iterative (e.g., Delphi) consensus process. Eligible experts had independent or assisted SP robotic experience. Using a structured questionnaire, they rated each procedure on three dimensions — technical difficulty, operative risk and sustained attention required — on a 7-point Likert scale. A composite difficulty score was obtained by summing the three median values. Experts also estimated the number of cases required to reach proficiency and rated the role of prior multi-port robotic experience. Nine procedures were classified. Composite scores ranged from 8 (pyeloplasty, “slightly difficult”) to 16 (radical cystectomy with intracorporeal diversion, “very difficult”). Estimated proficiency thresholds ranged from 10 to 33 cases. All experts considered prior multi-port robotic experience necessary before SP adoption. Early challenges were dominated by prolonged operative time, limited exposure and reduced ergonomics rather than instrument collision or spatial disorientation. We propose the first structured expert-based difficulty classification for SP robotic urological surgery. The procedural hierarchy mirrors historical laparoscopic and multi-port robotic classifications, supporting the concept that intrinsic complexity transcends the platform. This framework may inform training curricula, case selection during adoption and safe dissemination of SP robotic surgery.