Operative technique and early experience for robotic-assisted laparoscopic nephroureterectomy (RALNU) using da Vinci Xi

A retrospective analysis of our institutional review board approved robotic surgery
database was performed to identify subjects who underwent RALNU. A total of ten consecutive
patients with a diagnosis of upper tract urothelial carcinoma underwent RALNU using
the da Vinci Xi surgical system at the University of Miami Hospital between April
and November of 2014.

Preoperative variables included patient demographics [age, sex, body mass index (BMI)],
side of tumor, and biopsy pathology or cytopathology results (if available). Outcome
measures included specimen pathology, operative time, estimated blood loss (EBL),
complications, length of hospitalization, and length of catheterization.

General considerations

The da Vinci Xi surgical platform utilizes a four overhead arm architecture (see Figure 1). The robotic arms are thinner compared to prior models of da Vinci with joints that
can be manipulated to provide additional patient clearance from the robotic arms.
All da Vinci Xi robotic instruments have longer shafts and the endoscope has a camera
built into the distal tip. The robotic camera easily fits into an 8 mm trocar which
allows its insertion into any of the four robotic arms. After the trocars have been
placed, the robot is positioned with the target sign from the boom aligned over the
designated camera port. The camera is docked first, after which targeting of the organ
being removed is performed to allow automatic adjustment of the remaining arms before
coupling with trocars. A “patient clearance” button can be used to rotate joints and
help keep arms away from the patient. In general, we found that maneuvering of the
robot and docking was easier using the Xi system compared to prior models. The da
Vinci Xi system follows a standardized approach for positioning the robot over the
camera port and targeting of the camera before docking of the remaining robotic ports.

Figure 1. da Vinci Xi surgical system.

Positioning and port placement

After insertion of a Foley catheter, the patient is placed in modified lateral flank
position with the break of the operating table at the level of the anterior superior
iliac crest. The bed may be flexed if desired to permit greater exposure of the abdomen.
The anterior abdominal wall is brought toward the edge of the table to allow a greater
degree of freedom for the robotic arms without interference from the table. The lower
arm of the patient is supported by an arm board and the upper arm is supported by
an additional armrest. Both arms may be slightly angled in a cephalad position if
more room is needed by the surgical team. The patient is secured to the table with
adhesive tape and gel support. The inferior leg is flexed with padding under the knee
and ankle. Pillows are placed between the legs to pad the superior leg, which is straight.
The area is prepped and draped in the standard fashion.

For initial insufflation, a Veress needle technique may be used. We utilize four,
8 mm robotic ports positioned in an oblique straight line starting with a robotic
port located two finger breadths below the costal margin just lateral to the rectus
abdominis muscle with a minimum distance of 6–8 cm between the ports. The second cephalad
port is designated to be the camera port for the initial part (nephrectomy portion)
of the procedure. The patient cart is placed on the side of the patient’s back at
a right angle with the bed and the robot is brought toward the patient with the target
sign of the boom aligned over the camera port. A 30° down lens is used and inserted
into the camera port (second cephalad port). The target center is localized to a point
between the kidney and ureter. Automatic repositioning of the remaining robotic arms
using the targeting feature is performed before connecting to the trocars. All robotic
ports are placed in a straight, oblique line (see Figures 2, 3). A 12 mm assistant port is placed closer to the midline and between the two most
cephalad robotic ports. A 5 mm port may be placed below the xiphoid for liver retraction
for right-sided RALNU. Instruments utilized for RALNU are: monopolar curved scissors
(right hand), fenestrated bipolar (left hand), and ProGrasp forceps. Suturing is performed
with two large needle drivers.

Figure 2. Right sided port placement. Bullet 8 mm robotic port, A assistant port, x 5 mm port.

Figure 3. Left sided port placement. Bullet 8 mm robotic port, A assistant port.

Kidney dissection

Dissection is started by incising the white line of Toldt lateral to the colon and
mobilizing the colon medially. Medial retraction by the assistant facilitates clearing
of the anterior Gerota’s fascia. On the left side, the lienocolic and phrenicocolic
ligaments are incised to allow the left colic flexure to fall medially along with
the pancreas. On the right side, a Kocher maneuver is performed to mobilize the duodenum
and expose the inferior vena cava. Care should be taken to leave the kidney attached
laterally to avoid unnecessary mobilization into the operative field. After complete
mobilization of the colon, the lower pole of the kidney is identified. Upward traction
on Gerota’s fascia and the lower pole tissues will allow identification of the gonadal
vein, ureter, and psoas muscle. The ureter is swept laterally and followed proximally
to the lower pole of the kidney until identification of the renal hilum. The ureter
is dissected from surrounding structures, and a clip is placed on the ureter below
the level of the tumor. The renal artery and vein are identified and divided using
a vascular stapling device. The plane between the adrenal gland and kidney may be
developed and the remaining lateral attachments are divided in order to free the kidney
and leave the ureter intact.

Distal ureterectomy and bladder cuff excision

A unique feature of the da Vinci Xi system is camera port hopping. The camera may
be switched to the second caudal trocar at this point in the operation to facilitate
visualization of pelvic anatomy for distal ureterectomy and bladder cuff excision.
The distal ureter is carefully dissected as it courses over the iliac vessels in order
to prevent injury. Ureteral dissection is carried inferiorly to the level of the bladder
hiatus and the superior vesicle pedicles can be preserved. The bladder is filled with
sterile water and the detrusor muscle is dissected until identification of the bladder
mucosa. Bladder cuff excision is performed by incising the mucosa of the bladder in
a circumferential manner. An absorbable suture is preplaced at the edge of the cystotomy
before completely excising the ureter and bladder cuff in order to maintain traction
and control. The bladder defect is then closed in two layers with absorbable, running
suture. The integrity of the repair is tested by filling the bladder with sterile
water via the Foley catheter. If a leak is identified, additional sutures may be placed
until no further extravasation is observed. The nephroureterectomy specimen is placed
into a laparoscopic specimen retrieval bag. The renal bed and pelvis are reexamined
to ensure hemostasis as the insufflation pressure is lowered to 5 mmHg. A drain is
placed and the robot is undocked and all trocars are removed. The specimen may be
extracted by making a midline or Gibson incision incorporating the most caudal port.