title: Concurrent upper and lower urinary tract robotic surgery: strategies for success.
abstract: OBJECTIVE
  To assess the feasibility of combined upper and lower urinary tract robot-assisted laparoscopic surgery (RALS) during one operative session.
  
  
  METHODS
  We describe strategies for port placement and the use of the new da Vinci S surgical system (Intuitive Surgical, Sunnyvale, CA, USA), equipped with a fourth arm, for concurrent surgeries in a porcine model and in humans within one operative session. We studied various schemes of port placement, patient positioning and robotic arm manoeuvring while doing concurrent ipsilateral upper and lower urinary tract surgery on six pigs. The operative times and estimated blood loss were recorded prospectively. Qualitative data such as robotic arm ergonomics, advantages and disadvantages of various port placement strategies were noted. During the various surgical exercises, particular attention was given to the extent and the limits of instrument arm reach and mobility of the various port-placement schemes. These concepts for port placement and patient positioning were then further evaluated in a cadaver followed by demonstration of feasibility by performing a robot-assisted laparoscopic surgery (RAL) right nephroureterectomy in a patient.
  
  
  RESULTS
  We describe a four-port 'baseball diamond' strategy to allow instrument access to the entire ipsilateral urinary tract in one operating session without repositioning the patient and re-docking the robot. Furthermore, if additional instrument length is required to reach the deep pelvis, we describe a novel 'pivoting triangle' manoeuvre that incorporates the fourth arm and allows dual-port cannulation and lens telescoping.
  
  
  CONCLUSIONS
  Single session, concurrent multiple quadrant RALS is facilitated by using the da Vinci S surgical system with a 'baseball diamond' port-placement strategy.
authors.affiliation: Vattikuti Urology Institute, Henry Ford Health System, Detroit, MI, USA. mbhanda1@hfhs.org
authors.forename: Daniel
authors.initials: D
authors.lastname: Eun
authors.forename: Akshay
authors.initials: A
authors.lastname: Bhandari
authors.forename: Ronald
authors.initials: R
authors.lastname: Boris
authors.forename: Craig
authors.initials: C
authors.lastname: Rogers
authors.forename: Mahendra
authors.initials: M
authors.lastname: Bhandari
authors.forename: Mani
authors.initials: M
authors.lastname: Menon
mesh_terms: D000368:Aged; D000818:Animals; D004867:Equipment Design; D005240:Feasibility Studies; D006801:Humans; D020706:Laparoscopes / Q000592:standards; D010535:Laparoscopy / Q000379:methods*; D008297:Male; D009392:Nephrectomy / Q000295:instrumentation* / Q000379:methods / Q000592:standards; D011446:Prospective Studies; D012371:Robotics / Q000295:instrumentation* / Q000379:methods / Q000592:standards; D013552:Swine; D018666:Ureteroscopy / Q000379:methods* / Q000592:standards; D014570:Urologic Diseases / Q000601:surgery*