NARUS 2018: Ports, Setup, Positioning, Stents, Percs, Principles

Las Vegas, NV (UroToday.com) Dr. Alvin Goh from Memorial Sloan Kettering Cancer Center (MSKCC) presented tips and tricks for patient position and port placement for ureteral robotic surgery. Dr. Goh started his presentation by comparing the Si and Xi robotic systems, noting that the Si system is a 4-arm system, has an analog 10 mm camera, is cart-based, has joints requiring arm spacing, a smaller target workspace, and uses 5 mm and 8mm instruments. Comparatively, the Xi system is a 4-arm system, a digital camera (8mm), is boom-based, tighter spacing of arms requiring smaller joints, multi-quadrant workspace, 8 mm instruments, increased flexibility with port placement, and decreased collisions and increased patient clearance with a base that can be placed anywhere. 

In Dr. Goh’s opinion, there are several cases where the Xi system is advantageous for reconstructive surgery. These include long stricture segments, multiple strictures, bilateral cases, and complex reconstruction (ie. bowel interposition). Specific to patient factors, this may include high BMI (>50), a small torso, and prior abdominal surgery. Additional Xi features include: (i) a camera toggle for the 30 degree up/down, better range of motion to reach from upper to lower abdomen, versatility of ports to move camera around, more options for the robotic stapler, and near-infrared fluorescent (NIRF) imaging built into the camera system. Dr. Goh notes that NIRF is used to verify vascularity of the reconstructed segment, and off-label usage includes antegrade/retrograde via a nephrostomy or ureteral catheter to aid in ureteral identification. 

Dr. Goh states that patient positioning is pathology driven. For upper/mid tract surgery (proximal strictures, UPJ-obstruction), he uses a modified lateral position with a break of 30-40 degrees, without an axillary roll and arms together and padded with pillows. For distal strictures, reimplants or psoas hitches, he uses a supine or lithotomy position (ie. the prostatectomy position), which allows access to the bladder and distal 3rd of the ureter. For long or multifocal strictures, Dr. Goh uses a modified thoracoabdominal positioning with the upper torso lateral and the hips flat. This allows access “top to bottom” and permits simultaneous endoscopic access. Similarly, for port access, depending on the pathology he will place ports to triangulate the work area (lower, mid, upper). Dr. Goh prefers the veress needle for access, with a no-lift technique, aspiration, drop test with normal saline, and subsequent insufflation. However, when patients have had prior abdominal surgery he typically uses an open Hasson technique, using S-retractors to identify the fascia (which is also useful for obese patients).

Dr. Goh’s preference for pre-op tube management is to remove stents and convert to a percutaneous nephrostomy tube early (<2 weeks) if possible. His reasoning for this is to reduce inflammation and tissue edema, allows a stricture to mature, and permits better assessment of the diseased segment. Post-operatively he internalizes the stent and usually leaves these in place for 4-6 weeks. He then obtains a renal ultrasound at 1 month and functional study at 3 months.

In conclusion, Dr. Goh notes that robotic instrumentation facilitates a minimally invasive approach to ureteral reconstruction for benign and malignant conditions. Furthermore, the Xi platform can be useful for more complex cases, and imaging adjuncts such as NIRF or intraoperative ultrasound can aid in reconstruction planning and execution. 


Presented By: Alvin Goh, Memorial Sloan Kettering Cancer Center, New York, NY

Written By: Zachary Klaassen, MD, Urologic Oncology Fellow, University of Toronto, Princess Margaret Cancer Centre, @zklaassen_md ,at the 2018 North American Robotic Urology Symposium, February 16-17, 2018 - Las Vegas, NV