title: Operative technique and early experience for robotic-assisted laparoscopic nephroureterectomy (RALNU) using da Vinci Xi.
abstract: OBJECTIVE
  Robotic-assisted laparoscopic nephroureterectomy (RALNU) has been previously utilized for management of upper tract urothelial carcinoma. The da Vinci Xi surgical system was released in April of 2014. We describe our operative technique and early experience for RALNU using the da Vinci Xi system highlighting unique features of this surgical platform.
  
  
  METHODS
  A total of 10 patients with a diagnosis of upper tract urothelial carcinoma underwent RALNU using the da Vinci Xi system between April and November of 2014. A novel, oblique "in line" robotic trocar configuration was utilized to access the upper abdomen (nephrectomy portion) and pelvis (bladder cuff excision) without undocking. The port hopping feature of da Vinci Xi was utilized to facilitate optimal, multi-quadrant visualization during RALNU.
  
  
  RESULTS
  Robotic-assisted laparoscopic nephroureterectomy was successfully completed without open conversion in all 10 patients. Mean operative time was 184 min (range 140-300 min), mean estimated blood loss was 121 cc (range 60-300 cc), and mean hospital stay was 2.4 days. Final pathology demonstrated high grade urothelial carcinoma in all patients. Surgical margins were negative in all patients. No intra-operative complications were encountered. One patient developed a pulmonary embolus after being discharged. No patients required a blood transfusion. Mean patient follow-up was 130 days (range 15-210 days).
  
  
  CONCLUSIONS
  The use of da Vinci Xi with a novel, oblique "in line" port configuration and camera port hopping technique allows for an efficient and reproducible method for RALNU without the need for repositioning the patient or the robot during surgery.
authors.affiliation: Department of Urology, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB 1560, Miami, FL 33136 USA.
authors.forename: Fadi
authors.initials: F
authors.lastname: Darwiche
authors.affiliation: Department of Urology, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB 1560, Miami, FL 33136 USA.
authors.forename: Sanjaya
authors.initials: S
authors.lastname: Swain
authors.affiliation: Department of Urology, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB 1560, Miami, FL 33136 USA.
authors.forename: George
authors.initials: G
authors.lastname: Kallingal
authors.affiliation: Department of Urology, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB 1560, Miami, FL 33136 USA.
authors.forename: Sanoj
authors.initials: S
authors.lastname: Punnen
authors.affiliation: Department of Urology, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB 1560, Miami, FL 33136 USA.
authors.forename: Murugesan
authors.initials: M
authors.lastname: Manoharan
authors.affiliation: Department of Urology, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB 1560, Miami, FL 33136 USA.
authors.forename: Dipen J
authors.initials: DJ
authors.lastname: Parekh
authors.affiliation: Department of Urology, University of Miami Miller School of Medicine, 1120 NW 14th Street, CRB 1560, Miami, FL 33136 USA.
authors.forename: Mark L
authors.initials: ML
authors.lastname: Gonzalgo
keywords: Laparoscopy; Nephroureterectomy; Outcomes; Robotic surgery; Urothelial cancer