- Email: [email protected]
Radical Nephroureterectomy Without Patient or Port Repositioning Using the Da Vinci Xi Robotic System: Initial Experience
ARTICLE IN PRESS
Surgical Techniques in Urology Radical Nephroureterectomy Without Patient or Port Repositioning Using the Da Vinci Xi Robotic System: Initial Experience Omer Burak Argun, Panagiotis Mourmouris, Ilter Tufek, Mustafa Bilal Tuna, Selcuk Keskin, Can Obek, and Ali Riza Kural OBJECTIVE MATERIALS AND METHODS
RESULTS
CONCLUSION
To report our initial experience on robot-assisted radical nephroureterectomy, using the da Vinci Xi robotic system without patient or port repositioning. The patients were in a modified flank position. A Bugbee electrode was used to cauterize and mark the ureteral orifice, aiding in the final robotic excision of the distal ureter. For the first step of the procedure, the second robotic arm holds the scope, the fourth robotic arm holds Port #1 (monopolar curved scissors), the first robotic arm holds Port #2 (Fenestrated bipolar forceps), and the third robotic arm holds Port #4 (Prograsp forceps). After completion of nephrectomy, all robotic arms were released and reconfigured. In the new setting, the third robotic arm and second robotic arm were switched between the camera port and the fourth port. The first port remained working with the monopolar curved scissors whereas Prograsp forceps was moved to the second port and fenestrated bipolar forceps was moved to the third port. Two patients underwent 2 successful radical nephroureterectomies with the above-mentioned technique. The console time for the first patient was 150 minutes whereas the estimated blood loss was 200 mL. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization time and catheter removal time were 3 days for both patients and no complications were observed. The use of the da Vinci Xi robotic system enabled us to perform both nephrectomy and distal ureterectomy and/or bladder cuff excision without any repositioning of the patient or trocars. UROLOGY ■■: ■■–■■, 2016. © 2016 Elsevier Inc.
espite the increasing enthusiasm in minimal invasive and endourologic modalities, open radical nephroureterectomy (RNU) still remains the gold standard procedure for the surgical treatment of highgrade upper urinary tract urothelial cell carcinoma.1 The advances in the laparoscopic and robotic urology have set the ground for minimally invasive management of these tumors.2 However, their long-term oncologic safety needs to be proven. Since the initial launch of the da Vinci robotic system, its implementation in urologic surgeries has expanded and now includes robotic-assisted radical nephroureterectomy (RARNU). The limitation of the robotic system in RARNU is the requirement for either
D
patient or port repositioning to reach and safely excise the distal ureter. The introduction of the most recent da Vinci Xi robotic system comes with an ability to alter orientation without changing ports. This specific feature empowers the system to be used for the management of the distal ureter and bladder cuff during RARNU with a simplified surgical approach. We report our initial experience on RARNU with the assistance of the da Vinci Xi robotic system without patient or port repositioning. To the best of our knowledge, our study remains the second report of RARNU with the da Vinci Xi robotic system using this simple modified technique.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Acibadem University, Istanbul, Turkey; the Department of Urology, Aile Hospital, Istanbul, Turkey; and the Department of Urology, Cerrahpasa School of Medicine, Istanbul, Turkey Address correspondence to: Panagiotis Mourmouris, M.D., Department of Urology, Acibadem University, Acibadem Maslak Hospital, Darüs¸s¸afaka Mh., Büyükdere Cad. No: 40 Maslak, 34457 Sarıyer, Turkey. E-mail: [email protected] Submitted: October 30, 2015, accepted (with revisions): February 27, 2016
MATERIALS AND METHODS
© 2016 Elsevier Inc. All rights reserved.
The first patient was a 76-year-old man presenting with hematuria. Magnetic resonance imaging revealed a mass in the right renal pelvis. The patient underwent cystoscopy to rule out concomitant bladder tumor and a flexible ureterorenoscopy to evaluate the tumor size and location at the same setting of the robotic procedure. The second patient was a 71-year-old man with a history http://dx.doi.org/10.1016/j.urology.2016.02.047 0090-4295
1
ARTICLE IN PRESS of left flank pain and hematuria. He underwent a magnetic resonance imaging urography, demonstrating a filling defect in mid ureter. Flexible ureterorenoscopy revealed a suspicious area at this location and biopsies were obtained. The pathology report was consistent with carcinoma in situ of the left ureter. Management options were discussed with the patients and both opted for RNU.
Surgical Technique Endourological Manipulations. After the induction of general endotracheal anesthesia and patient positioning in the lithotomy position, cystoscopy is performed. A Bugbee electrode is used to cauterize the orifice and the intramural ureter on the tumor bearing side to aid as a marker in the final robotic excision of the distal ureter. A Foley catheter is then inserted and patients are repositioned for robotic surgery. Patient Positioning. The patient is in a modified flank position with the diseased side up and then flexed using the table break at the level of anterior superior iliac crest. Upper arm is tucked to the patient’s side. Care is taken to pad all pressure points in efforts to avoid neuropraxia. Port Placement. Port placement is the key to success for a single docking procedure. Pneumoperitoneum is established using a Veress needle. An initial 8-mm port is placed 3 cm lateral to the umbilicus. Three 8-mm additional ports are then placed under endoscopic guidance. The second 8-mm port is placed lateral to the rectus sheath and 8 cm cranial to the camera port. The third 8-mm port is placed caudal to the camera port on the same line and the fourth 8-mm port is placed approximately 15 cm lateral to the camera port and 2 cm caudal to the lower pole of the kidney. A 12-mm assistant port is placed on the midline, 5 cm cranial to the umbilicus. For tumors on the right side, an additional 5-mm port needs to be placed close to the xiphoid for liver retraction. Our preference is to use a valveless insufflator trocar system as an assistance port, but this is not a requirement. The da Vinci
Xi robot is docked perpendicular to the bed over the backside of the patient.
Procedure For the nephrectomy and lymphadenectomy steps of the procedure, the fourth robotic arm holds Port #1 and is used as the right arm (monopolar curved scissors). The first robotic arm holds Port #2 and is used as the left arm (fenestrated bipolar forceps). Camera port is held by the third robotic arm for this particular part of the procedure, whereas the 2nd robotic arm holds Port #4, which is used to assist with retraction of the kidney (Prograsp forceps) (Fig. 1). Our dissection plate is hilar and paracaval lymph nodes in patients with a tumor in the right renal pelvis and hilar and para-aortic in the patients with a tumor in the left middle ureter. Upon completion of nephrectomy and lymphadenectomy, attention is then directed to the distal ureterectomy portion of the procedure. All robotic arms are released and reconfigured for the distal ureteral dissection. The robotic crane is positioned to the lower pelvis. The third and second robotic arms are switched between the camera port and the fourth port. The second port continues to hold the fenestrated bipolar forceps, whereas Prograsp forceps is moved to the first port, and hot scissors to the third port. This reconfiguration of instruments facilitates the management of both the distal ureter excision and the bladder cuff reconstruction. During bladder cuff suturing, a large needle driver is placed into the right hand (Port #4) (Fig. 2). A 30-degree lens is used during the entire case.
RESULTS The procedures were accomplished without the requirement of patient and/or port repositioning. The console time for the first patient was 150 minutes and the estimated blood loss was 200 mL. The hospitalization time was 3 days and the catheter was removed on postoperative day 3. There were no intraoperative or postoperative complications. The
Figure 1. Port and robotic arm configuration of the first part of the procedure (nephrectomy). The figure presents configuration for the right side. The left side would be a mirror image configuration excluding the uppermost port used for liver retraction. (Color version available online.)
2
UROLOGY ■■ (■■), 2016
ARTICLE IN PRESS
Figure 2. Port and robotic arm configuration of the second part of the procedure (ureterectomy/bladder cuff excision). The figure presents configuration for the right side. (Color version available online.)
pathology report revealed a 2.7 cm low-grade, noninvasive urothelial cancer in the renal pelvis (pTa). Surgical margins were negative. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization and catheter removal days were both 3 and no complications were observed. The pathology report was consistent with carcinoma in situ along a 10 cm portion of the ureter. Lymphadenectomy specimens, which contained 6 lymph nodes for each patient, were free of metastasis in both patients.
DISCUSSION Several techniques have been described for the management of the distal ureter and the bladder cuff during RNU, Various extravesical and transvesical approaches have been utilized, with none proving to be safer or more efficient than the others. Data reports similar oncologic outcomes with laparoscopic extravesical or transvesical approaches compared to open series.3,4 The extravesical stapling of the distal ureter and bladder cuff was found to be associated with a higher incidence of positive surgical margins.5 We find endoscopic marking by cauterization of the orifice and intramural ureter at the beginning of the procedure helpful for facilitating the identification of the distal limits of dissection during robotic bladder cuff excision. This ensures not only adequate resection of the intramural ureter on the diseased side, but also minimizes the risk of injury to the contralateral orifice. The major drawback of the laparoscopic approach remains the requirement for advanced technical skills for surgical maneuvers. The use of the da Vinci robotic system and the advantage of the 7 degrees of freedom with the surgical instruments make the distal ureterectomy part of the procedure easier for the surgeon and aid in achieving satisfactory UROLOGY ■■ (■■), 2016
results.6-8 Nevertheless, distal ureterectomy, bladder cuff excision, and suture closing of the bladder remain challenging steps during a RARNU. The difficulty arises from the anatomical configuration of these structures, restricting the surgeon with very limited working space. Patient positioning and placement of the ports are critical steps. The standard approach for RARNU, following the steps of robotic nephrectomy, requires the patient in a lateral flank position.6-8 The same position was utilized for the cases in this report as well. Placement of the ports, on the other hand, has shown great variance to date. The first pure RARNU needed patient repositioning and the change of orientation of the robot for obtaining access to the distal ureter and bladder cuff.8 The increase in surgical time and its related burden for the patient forced many surgeons to develop novel techniques in efforts to overcome this hurdle. Initial experience with single docking technique came from Eun et al.7 They used a 6-port “baseball diamond” configuration in the center, making “pivoting” of the camera and the robotic instruments between these ports feasible to reach the deeper parts of the ureter. This modality allowed changing the scope and the robot arm position without any repositioning of the patient or trocars. Park et al9 published their “hybrid” port technique utilizing 4 ports for left sided tumors and 5 ports for right-sided tumors. They reported 50 minutes shorter operative time without complications. More recently, many surgeons published their work, proving the feasibility of performing RARNU without any repositioning with the use of the da Vinci S or Si systems. Lee et al performed RARNU with a homemade single port device in 12 patients. Their mean operative time and estimated blood loss were 227 minutes and 248 mL, respectively. They did not report any conversions to open surgery.10 Hemal and coworkers reported their experience of RARNU 3
ARTICLE IN PRESS with a mean console time of 111 minutes, mean estimated blood loss of 103 mL, and mean hospital stay of 2.73 days. They concluded that RARNU without repositioning was feasible.11 In pursuit of the same goal, Zargar et al followed 31 patients and published their experience of RARNU without any repositioning of the patient or undocking of the robot. They concluded that their technique was a feasible alternative to the existing ones and could be reproduced easily.12 The new robotic da Vinci Xi system carries features that gave urologic surgeons a powerful tool for optimizing RARNU. The da Vinci Xi combines the functionality of a boom-mounted system with the flexibility of a mobile platform, ensuring optimal configuration for the procedure simply by pointing the scope to the target anatomy. With the previous models of the da Vinci robotic system, the repositioning of the patient or ports was the standard procedure despite the above-mentioned techniques, which were not easily adapted to everyday practice. Recently, a group from the University of Miami published the first series on the performance of RARNU with the new Xi system, allowing them to complete the procedure without patient repositioning in 10 patients. Their technique consisted of port placement in a straight oblique line that enabled them to change the camera position in reaching the deeper pelvis and completing the procedure without any repositioning. They concluded that the use of the da Vinci Xi gives a big advantage due to the easy maneuverability between the upper and lower urinary tract in performing RARNU.13 Patel and colleagues assessed the impact of using the Xi system compared to the Si system for RARNU. Their series is relatively large, consisting of 70 patients, of whom 55 required RNU that was performed with the use of either the Si or Xi system. They found that the use of the Xi system was superior in preventing collisions, in patients with challenging body habitus, and at instances with difficult access to the lower ureter.14 Herein, we report our similar experience on RARNU without patient or port repositioning with the Xi system, adding to the scarce data available to date. Our port setup more closely resembles the classical port placement typically used for upper tract surgeries. This may be an advantage allowing for wider adaptability to the everyday clinical practice, with more reproducible results. It also allows for maximum ergonomics and optimum optical field for both upper and lower tracts. Our operative time and estimated blood loss were in concordance with those in the literature and there were no complications observed.
4
CONCLUSION The use of the da Vinci Xi robotic system for performing RARNU is a feasible and safe alternative that facilitates surgery and decreases operative time. The port setup presented gives maximum maneuverability and good visual field in both the upper and lower urinary tract surgery without requirement of extra patient or port repositioning.
References 1. Margulis V, Shariat SF, Matin SF, et al. Outcomes of radical nephroureterectomy: a series from the Upper Tract Urothelial Carcinoma Collaboration. Cancer. 2009;115:1224-1233. 2. Simone G, Papalia R, Guaglianone S, et al. Laparoscopic versus open nephroureterectomy: perioperative and oncologic outcomes from a randomised prospective study. Eur Urol. 2009;56:520-526. 3. Hattori R, Yoshino Y, Komatsu T, et al. Pure laparoscopic complete excision of distal ureter with a bladder cuff for upper tract urothelial carcinoma. World J Urol. 2009;27:253-258. 4. Shoma AM. Purse-string technique for laparoscopic excision of a bladder mucosal cuff in patients with transitional cell carcinoma of the upper urinary tract: initial report with intermediate follow-up. BJU Int. 2009;104:1505-1509. 5. Matin SF, Gill IS. Recurrence and survival following laparoscopic radical nephroureterectomy with various forms of bladder cuff control. J Urol. 2005;173:395-400. 6. Nanigian DK, Smith W, Ellison LM. Robot-assisted laparoscopic nephroureterectomy. J Endourol. 2006;20:463-465. 7. Eun D, Bhandari A, Boris R, et al. Concurrent upper and lower urinary tract robotic surgery: strategies for success. BJU Int. 2007;100:11211125. 8. Eandi JA, Nelson RA, Wilson T, et al. Oncologic outcomes for complete robot-assisted laparoscopic management of upper-tract transitional cell carcinoma. J Endourol. 2010;24:969-975. 9. Park SY, Jeong W, Ham WS, et al. Initial experience of robotic nephroureterectomy: a hybrid-port technique. BJU Int. 2009;104:17181721. 10. Lee Z, Cadillo-Chavez R, Lee D, et al. The technique of single stage pure robotic nephroureterectomy. J Endourol. 2013;27:189-195. 11. Hemal AK, Stansel I, Babbar P, et al. Robotic-assisted nephroureterectomy and bladder cuff excision without intraoperative repositioning. Urology. 2011;78:357-364. 12. Zargar H, Krishnan J, Autorino R, et al. Robotic nephroureterectomy: a simplified approach requiring no patient repositioning or robot redocking. Eur Urol. 2014;66:769-777. doi:10.1016/ j.eururo.2014.02.060; [Epub 2014 Mar 12]. 13. Darwiche F, Swain S, Kallingal G, et al. Operative technique and early experience for robotic-assisted laparoscopic nephroureterectomy (RALNU) using da Vinci Xi. Springerplus. 2015;4:298. doi:10.1186/ s40064-015-1076-6; eCollection 2015. 14. Patel MN, Aboumohamed A, Hemal A. Does transition from the da Vinci Si® to Xi robotic platform impact single-docking technique for robot-assisted laparoscopic nephroureterectomy. BJU Int. 2015;116:990-994.
UROLOGY ■■ (■■), 2016
Surgical Techniques in Urology Radical Nephroureterectomy Without Patient or Port Repositioning Using the Da Vinci Xi Robotic System: Initial Experience Omer Burak Argun, Panagiotis Mourmouris, Ilter Tufek, Mustafa Bilal Tuna, Selcuk Keskin, Can Obek, and Ali Riza Kural OBJECTIVE MATERIALS AND METHODS
RESULTS
CONCLUSION
To report our initial experience on robot-assisted radical nephroureterectomy, using the da Vinci Xi robotic system without patient or port repositioning. The patients were in a modified flank position. A Bugbee electrode was used to cauterize and mark the ureteral orifice, aiding in the final robotic excision of the distal ureter. For the first step of the procedure, the second robotic arm holds the scope, the fourth robotic arm holds Port #1 (monopolar curved scissors), the first robotic arm holds Port #2 (Fenestrated bipolar forceps), and the third robotic arm holds Port #4 (Prograsp forceps). After completion of nephrectomy, all robotic arms were released and reconfigured. In the new setting, the third robotic arm and second robotic arm were switched between the camera port and the fourth port. The first port remained working with the monopolar curved scissors whereas Prograsp forceps was moved to the second port and fenestrated bipolar forceps was moved to the third port. Two patients underwent 2 successful radical nephroureterectomies with the above-mentioned technique. The console time for the first patient was 150 minutes whereas the estimated blood loss was 200 mL. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization time and catheter removal time were 3 days for both patients and no complications were observed. The use of the da Vinci Xi robotic system enabled us to perform both nephrectomy and distal ureterectomy and/or bladder cuff excision without any repositioning of the patient or trocars. UROLOGY ■■: ■■–■■, 2016. © 2016 Elsevier Inc.
espite the increasing enthusiasm in minimal invasive and endourologic modalities, open radical nephroureterectomy (RNU) still remains the gold standard procedure for the surgical treatment of highgrade upper urinary tract urothelial cell carcinoma.1 The advances in the laparoscopic and robotic urology have set the ground for minimally invasive management of these tumors.2 However, their long-term oncologic safety needs to be proven. Since the initial launch of the da Vinci robotic system, its implementation in urologic surgeries has expanded and now includes robotic-assisted radical nephroureterectomy (RARNU). The limitation of the robotic system in RARNU is the requirement for either
D
patient or port repositioning to reach and safely excise the distal ureter. The introduction of the most recent da Vinci Xi robotic system comes with an ability to alter orientation without changing ports. This specific feature empowers the system to be used for the management of the distal ureter and bladder cuff during RARNU with a simplified surgical approach. We report our initial experience on RARNU with the assistance of the da Vinci Xi robotic system without patient or port repositioning. To the best of our knowledge, our study remains the second report of RARNU with the da Vinci Xi robotic system using this simple modified technique.
Financial Disclosure: The authors declare that they have no relevant financial interests. From the Department of Urology, Acibadem University, Istanbul, Turkey; the Department of Urology, Aile Hospital, Istanbul, Turkey; and the Department of Urology, Cerrahpasa School of Medicine, Istanbul, Turkey Address correspondence to: Panagiotis Mourmouris, M.D., Department of Urology, Acibadem University, Acibadem Maslak Hospital, Darüs¸s¸afaka Mh., Büyükdere Cad. No: 40 Maslak, 34457 Sarıyer, Turkey. E-mail: [email protected] Submitted: October 30, 2015, accepted (with revisions): February 27, 2016
MATERIALS AND METHODS
© 2016 Elsevier Inc. All rights reserved.
The first patient was a 76-year-old man presenting with hematuria. Magnetic resonance imaging revealed a mass in the right renal pelvis. The patient underwent cystoscopy to rule out concomitant bladder tumor and a flexible ureterorenoscopy to evaluate the tumor size and location at the same setting of the robotic procedure. The second patient was a 71-year-old man with a history http://dx.doi.org/10.1016/j.urology.2016.02.047 0090-4295
1
ARTICLE IN PRESS of left flank pain and hematuria. He underwent a magnetic resonance imaging urography, demonstrating a filling defect in mid ureter. Flexible ureterorenoscopy revealed a suspicious area at this location and biopsies were obtained. The pathology report was consistent with carcinoma in situ of the left ureter. Management options were discussed with the patients and both opted for RNU.
Surgical Technique Endourological Manipulations. After the induction of general endotracheal anesthesia and patient positioning in the lithotomy position, cystoscopy is performed. A Bugbee electrode is used to cauterize the orifice and the intramural ureter on the tumor bearing side to aid as a marker in the final robotic excision of the distal ureter. A Foley catheter is then inserted and patients are repositioned for robotic surgery. Patient Positioning. The patient is in a modified flank position with the diseased side up and then flexed using the table break at the level of anterior superior iliac crest. Upper arm is tucked to the patient’s side. Care is taken to pad all pressure points in efforts to avoid neuropraxia. Port Placement. Port placement is the key to success for a single docking procedure. Pneumoperitoneum is established using a Veress needle. An initial 8-mm port is placed 3 cm lateral to the umbilicus. Three 8-mm additional ports are then placed under endoscopic guidance. The second 8-mm port is placed lateral to the rectus sheath and 8 cm cranial to the camera port. The third 8-mm port is placed caudal to the camera port on the same line and the fourth 8-mm port is placed approximately 15 cm lateral to the camera port and 2 cm caudal to the lower pole of the kidney. A 12-mm assistant port is placed on the midline, 5 cm cranial to the umbilicus. For tumors on the right side, an additional 5-mm port needs to be placed close to the xiphoid for liver retraction. Our preference is to use a valveless insufflator trocar system as an assistance port, but this is not a requirement. The da Vinci
Xi robot is docked perpendicular to the bed over the backside of the patient.
Procedure For the nephrectomy and lymphadenectomy steps of the procedure, the fourth robotic arm holds Port #1 and is used as the right arm (monopolar curved scissors). The first robotic arm holds Port #2 and is used as the left arm (fenestrated bipolar forceps). Camera port is held by the third robotic arm for this particular part of the procedure, whereas the 2nd robotic arm holds Port #4, which is used to assist with retraction of the kidney (Prograsp forceps) (Fig. 1). Our dissection plate is hilar and paracaval lymph nodes in patients with a tumor in the right renal pelvis and hilar and para-aortic in the patients with a tumor in the left middle ureter. Upon completion of nephrectomy and lymphadenectomy, attention is then directed to the distal ureterectomy portion of the procedure. All robotic arms are released and reconfigured for the distal ureteral dissection. The robotic crane is positioned to the lower pelvis. The third and second robotic arms are switched between the camera port and the fourth port. The second port continues to hold the fenestrated bipolar forceps, whereas Prograsp forceps is moved to the first port, and hot scissors to the third port. This reconfiguration of instruments facilitates the management of both the distal ureter excision and the bladder cuff reconstruction. During bladder cuff suturing, a large needle driver is placed into the right hand (Port #4) (Fig. 2). A 30-degree lens is used during the entire case.
RESULTS The procedures were accomplished without the requirement of patient and/or port repositioning. The console time for the first patient was 150 minutes and the estimated blood loss was 200 mL. The hospitalization time was 3 days and the catheter was removed on postoperative day 3. There were no intraoperative or postoperative complications. The
Figure 1. Port and robotic arm configuration of the first part of the procedure (nephrectomy). The figure presents configuration for the right side. The left side would be a mirror image configuration excluding the uppermost port used for liver retraction. (Color version available online.)
2
UROLOGY ■■ (■■), 2016
ARTICLE IN PRESS
Figure 2. Port and robotic arm configuration of the second part of the procedure (ureterectomy/bladder cuff excision). The figure presents configuration for the right side. (Color version available online.)
pathology report revealed a 2.7 cm low-grade, noninvasive urothelial cancer in the renal pelvis (pTa). Surgical margins were negative. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization and catheter removal days were both 3 and no complications were observed. The pathology report was consistent with carcinoma in situ along a 10 cm portion of the ureter. Lymphadenectomy specimens, which contained 6 lymph nodes for each patient, were free of metastasis in both patients.
DISCUSSION Several techniques have been described for the management of the distal ureter and the bladder cuff during RNU, Various extravesical and transvesical approaches have been utilized, with none proving to be safer or more efficient than the others. Data reports similar oncologic outcomes with laparoscopic extravesical or transvesical approaches compared to open series.3,4 The extravesical stapling of the distal ureter and bladder cuff was found to be associated with a higher incidence of positive surgical margins.5 We find endoscopic marking by cauterization of the orifice and intramural ureter at the beginning of the procedure helpful for facilitating the identification of the distal limits of dissection during robotic bladder cuff excision. This ensures not only adequate resection of the intramural ureter on the diseased side, but also minimizes the risk of injury to the contralateral orifice. The major drawback of the laparoscopic approach remains the requirement for advanced technical skills for surgical maneuvers. The use of the da Vinci robotic system and the advantage of the 7 degrees of freedom with the surgical instruments make the distal ureterectomy part of the procedure easier for the surgeon and aid in achieving satisfactory UROLOGY ■■ (■■), 2016
results.6-8 Nevertheless, distal ureterectomy, bladder cuff excision, and suture closing of the bladder remain challenging steps during a RARNU. The difficulty arises from the anatomical configuration of these structures, restricting the surgeon with very limited working space. Patient positioning and placement of the ports are critical steps. The standard approach for RARNU, following the steps of robotic nephrectomy, requires the patient in a lateral flank position.6-8 The same position was utilized for the cases in this report as well. Placement of the ports, on the other hand, has shown great variance to date. The first pure RARNU needed patient repositioning and the change of orientation of the robot for obtaining access to the distal ureter and bladder cuff.8 The increase in surgical time and its related burden for the patient forced many surgeons to develop novel techniques in efforts to overcome this hurdle. Initial experience with single docking technique came from Eun et al.7 They used a 6-port “baseball diamond” configuration in the center, making “pivoting” of the camera and the robotic instruments between these ports feasible to reach the deeper parts of the ureter. This modality allowed changing the scope and the robot arm position without any repositioning of the patient or trocars. Park et al9 published their “hybrid” port technique utilizing 4 ports for left sided tumors and 5 ports for right-sided tumors. They reported 50 minutes shorter operative time without complications. More recently, many surgeons published their work, proving the feasibility of performing RARNU without any repositioning with the use of the da Vinci S or Si systems. Lee et al performed RARNU with a homemade single port device in 12 patients. Their mean operative time and estimated blood loss were 227 minutes and 248 mL, respectively. They did not report any conversions to open surgery.10 Hemal and coworkers reported their experience of RARNU 3
ARTICLE IN PRESS with a mean console time of 111 minutes, mean estimated blood loss of 103 mL, and mean hospital stay of 2.73 days. They concluded that RARNU without repositioning was feasible.11 In pursuit of the same goal, Zargar et al followed 31 patients and published their experience of RARNU without any repositioning of the patient or undocking of the robot. They concluded that their technique was a feasible alternative to the existing ones and could be reproduced easily.12 The new robotic da Vinci Xi system carries features that gave urologic surgeons a powerful tool for optimizing RARNU. The da Vinci Xi combines the functionality of a boom-mounted system with the flexibility of a mobile platform, ensuring optimal configuration for the procedure simply by pointing the scope to the target anatomy. With the previous models of the da Vinci robotic system, the repositioning of the patient or ports was the standard procedure despite the above-mentioned techniques, which were not easily adapted to everyday practice. Recently, a group from the University of Miami published the first series on the performance of RARNU with the new Xi system, allowing them to complete the procedure without patient repositioning in 10 patients. Their technique consisted of port placement in a straight oblique line that enabled them to change the camera position in reaching the deeper pelvis and completing the procedure without any repositioning. They concluded that the use of the da Vinci Xi gives a big advantage due to the easy maneuverability between the upper and lower urinary tract in performing RARNU.13 Patel and colleagues assessed the impact of using the Xi system compared to the Si system for RARNU. Their series is relatively large, consisting of 70 patients, of whom 55 required RNU that was performed with the use of either the Si or Xi system. They found that the use of the Xi system was superior in preventing collisions, in patients with challenging body habitus, and at instances with difficult access to the lower ureter.14 Herein, we report our similar experience on RARNU without patient or port repositioning with the Xi system, adding to the scarce data available to date. Our port setup more closely resembles the classical port placement typically used for upper tract surgeries. This may be an advantage allowing for wider adaptability to the everyday clinical practice, with more reproducible results. It also allows for maximum ergonomics and optimum optical field for both upper and lower tracts. Our operative time and estimated blood loss were in concordance with those in the literature and there were no complications observed.
4
CONCLUSION The use of the da Vinci Xi robotic system for performing RARNU is a feasible and safe alternative that facilitates surgery and decreases operative time. The port setup presented gives maximum maneuverability and good visual field in both the upper and lower urinary tract surgery without requirement of extra patient or port repositioning.
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