Da vinci xi

All patients underwent RARC, ePLND, and totally intracorporeal urinary diversion using the da Vinci Xi robotic system (Intuitive Surgical, CA, USA). Studer’s neobladder technique was used as a diversion procedure [11 (link)]. Cystectomy was performed using the method described previously [12 (link)].
In the current study, ePLND was performed, unconventionally, before cystectomy. Following dissection of the ureter and seminal vesicles, we removed nodes between the aortic bifurcation and common iliac vessels proximally, the genitofemoral nerve laterally, the circumflex iliac vein distally, and the internal iliac vessels posteriorly; these tissues were not removed in pieces but removed as a whole. Then, as the pedicle and tissue plans were clearly visible, the bladder branches of the internal iliac artery were controlled and, after dissection of the bladder, the dissected bilateral lymph nodes were sent to pathology as a whole with the bladder. The surgical technique is shown in a supplemental video.

From February 2015 through June 2015, 11 robot-assisted laparoscopic partial nephrectomies were performed with this novel technique. The patient was positioned 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. The outward-facing arm was tucked to the side. The robotic platform used was DaVinci Xi (Intuitive Surgical Inc., Sunnyvale, California, USA) with a 3-arm setup for all surgical cases. Pneumoperitoneum was established with a Veress needle. The port setup used is depicted in Figure 1. An 8-mm port was placed 3 cm lateral to the umbilicus. Two additional 8-mm ports were placed under endoscopic guidance. The first one was placed lateral to the rectus sheath and 8 cm cranial to the camera port. The second one was placed caudal to the camera port on the same line. A 12-mm assistant port was placed on the midline, 5 cm cranial to the umbilicus. A suction device and the grasping forceps were both used through the AirSeal system trocar, either alone or simultaneously in all cases, obviating the need for an additional trocar for the fourth robotic arm. A long suction-and-irrigation device was preferred, to minimize instrument collision with the atraumatic grasping forceps (Figure 2, 3).