title: Does transition from the da Vinci Si to Xi robotic platform impact single-docking technique for robot-assisted laparoscopic nephroureterectomy?
abstract: OBJECTIVE
  To describe our robot-assisted nephroureterectomy (RNU) technique for benign indications and RNU with en bloc excision of bladder cuff (BCE) and lymphadenectomy (LND) for malignant indications using the da Vinci Si and da Vinci Xi robotic platform, with its pros and cons. The port placement described for Si can be used for standard and S robotic systems. This is the first report in the literature on the use of the da Vinci Xi robotic platform for RNU.
  
  
  METHODS
  After a substantial experience of RNU using different da Vinci robots from the standard to the Si platform in a single-docking fashion for benign and malignant conditions, we started using the newly released da Vinci Xi robot since 2014. The most important differences are in port placement and effective use of the features of da Vinci Xi robot while performing simultaneous upper and lower tract surgery. Patient positioning, port placement, step-by-step technique of single docking RNU-LND-BCE using the da Vinci Si and da Vinci Xi robot are shown in an accompanying video with the goal that centres using either robotic system benefit from the hints and tips. The first segment of video describes RNU-LND-BCE using the da Vinci Si followed by the da Vinci Xi to highlight differences. There was no need for patient repositioning or robot re-docking with the new da Vinci Xi robotic platform.
  
  
  RESULTS
  We have experience of using different robotic systems for single docking RNU in 70 cases for benign (15) and malignant (55) conditions. The da Vinci Xi robotic platform helps operating room personnel in its easy movement, allows easier patient side-docking with the help of its boom feature, in addition to easy and swift movements of the robotic arms. The patient clearance feature can be used to avoid collision with the robotic arms or the patient's body. In patients with challenging body habitus and in situations where bladder cuff management is difficult, modifications can be made through reassigning the camera to a different port with utilisation of the retargeting feature of the da Vinci Xi when working on the bladder cuff or in the pelvis. The vision of the camera used for da Vinci Xi was initially felt to be inferior to that of the da Vinci Si; however, with a subsequent software upgrade this was much improved. The base of the da Vinci Xi is bigger, which does not slide and occasionally requires a change in table placement/operating room setup, and requires side-docking especially when dealing with very tall and obese patients for pelvic surgery.
  
  
  CONCLUSIONS
  RNU alone or with LND-BCE is a challenging surgical procedure that addresses the upper and lower urinary tract simultaneously. Single docking and single robotic port placement for RNU-LND-BCE has evolved with the development of different generations of the robotic system. These procedures can be performed safely and effectively using the da Vinci S, Si or Xi robotic platform. The new da Vinci Xi robotic platform is more user-friendly, has easy installation, and is intuitive for surgeons using its features.
authors.affiliation: Department of Urology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA.
authors.forename: Manish N
authors.initials: MN
authors.lastname: Patel
authors.affiliation: Department of Urology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA.
authors.forename: Ahmed
authors.initials: A
authors.lastname: Aboumohamed
authors.affiliation: Department of Urology, Wake Forest University Baptist Medical Center, Winston-Salem, NC, USA.
authors.forename: Ashok
authors.initials: A
authors.lastname: Hemal
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000295:instrumentation* / Q000379:methods*; D008197:Lymph Node Excision; D008297:Male; D008875:Middle Aged; D009392:Nephrectomy / Q000295:instrumentation* / Q000379:methods*; D056888:Patient Positioning; D065287:Robotic Surgical Procedures / Q000295:instrumentation* / Q000379:methods*; D014551:Urinary Tract / Q000601:surgery; D013520:Urologic Surgical Procedures
keywords: lymph node dissection; nephroureterctomy; robotic; technique; upper tract; urothelial cell carcinoma