Patients must have documented sterile urine preoperatively, as there is considerable chance of spillage of urine into the abdomen or retroperitoneum intraoperatively. Perioperative antibiotics should be selected based on recent culture data, or, if cultures are negative, empiric broad-spectrum coverage should be provided against typical skin and urinary flora. Simple bowel preparation of clear liquids, the day prior to surgery, and an enema or suppository the evening prior to surgery help reduce colonic distension and facilitate dissection.

Informed consent should address the potential complications of both laparoscopic renal surgery and traditional stone surgery. Risks of bleeding, infection, damage to kidney or abdominal viscera, loss of kidney, and conversion to open technique should be discussed. Further risks including failure to eradicate all stone fragments and stone recurrence should also be considered.

Sequential compression devices are applied to the lower extremities and activated prior to induction of general anesthesia. An orogastric tube and an indwelling 16 French urethral catheter are inserted. For a transperitoneal approach, the patient is then placed in a modified (45°–60°) lateral decubitus position with minimal flexion of the operating table and kidney rest elevation. Slight reverse Trendelenburg is recommended with the daVinci S and Si model robots as the fourth arm and port may come close to iliac crest or collide with the patient’s hip. We believe this minimizes arm collision when working in the pelvis. In contrast, with the da Vinci Xi model robot, this is not necessary.

For a retroperitoneal approach, the patient is placed in a full flank position. Care is taken to ensure adequate padding of all pressure points. An axillary roll is placed, and the patient is secured to the table with seatbelts, Velcro straps, and/or tape. Next, the urethral catheter is clamped to allow gradual distension of the urinary bladder. This facilitates antegrade placement of a double pigtail ureteral stent later in the operation, as a fuller bladder allows greater space for the distal end of the stent to coil. Additionally, the reflux of urine via the stent (seen as drops of urine emanating from the holes in the stent) provides reassurance regarding correct placement of the lower end of the stent in the bladder rather than in the distal ureter [8].

We have performed REP via both transperitoneal and retroperitoneal approaches, but we now universally prefer a transperitoneal approach unless a compelling reason favors a retroperitoneal approach (i.e., prior extensive intraperitoneal surgery). The retroperitoneal approach, while theoretically superior in terms of reduced risk of peritoneal contamination with urine or stone fragments, remains an extreme technical challenge for REP , as the creation of the retroperitoneal space and appropriate placement of trocars to provide wide excursion is cumbersome. We have also found it difficult to employ a retroperitoneoscopic robotic approach in obese and short-statured patients. However, the design of the new Xi robot is more conducive to the retroperitoneal approach.

If using a 0°or 30° down stereoscopic lens, a 12 mm camera trocar is placed through the lateral edge of the rectus muscle at the level of the umbilicus, while the two 8 mm robotic trocars are placed in such a manner to form a skewed wide isosceles triangle [14]. The cranial 8 mm robotic trocar is placed an inch away from the midline ipsilaterally between the xiphoid process and the umbilicus (almost at the level of the renal hilum), and the second more caudal 8 mm robotic trocar is placed in the ipsilateral iliac fossa along the anterior axillary line at least 7–8 cm away from the camera trocar, thus minimizing instrument collisions. A 12 mm assistant trocar in the midline allows for suction, retraction, and passage of suture materials and instruments such as the specimen retrieval bag and flexible nephroscope (Fig. 12.1). Another optional 5 mm assistant trocar in the midline allows for liver retraction during right-sided procedures. In general, we utilize a three-armed robotic technique; however, a four-armed robotic trocar can be added above the pubic symphysis in a paramedian location in line with the cranial robotic trocar for the purpose of retraction and dissection. This should only be utilized if felt to be necessary as it adds to the overall cost of the procedure.

Alternatively, when using a 30° up stereoscopic lens, the 12 mm camera trocar is placed at the level of umbilicus and lateral between the anterior axillary and mid-clavicular lines. The two 8 mm robotic trocars are placed alongside the rectus muscle, at a plane lower than the camera trocar and triangulated toward the renal pelvis [8, 14].

Pneumoperitoneum of 14 mmHg is achieved using a Veress needle in standard fashion. Trocars are placed linearly along the lateral border of rectus muscle. Port placement consists of an 8 mm camera port placed lateral and superior to the umbilicus and lateral to the rectus muscle. After placing this port, peritoneoscopy is performed, and the rest of the robotic ports are placed as dictated by the patient’s intra-abdominal anatomy after inflation. The second robotic port is placed about 6 cm cranial to the camera port and lateral to the rectus muscle. The third 8 mm port is placed about 6 cm caudal to the camera port and lateral to the rectus muscle. For cost-saving purposes, stone surgery can be performed using three robotic ports inclusive of the camera port. A 12 cm AirSeal (SurgiQuest Inc, Milford, CT) assistant port is placed in the midline approximately 2–3 cm cranial to the umbilicus. For additional cost-reducing measures, AirSeal does not have to be used, and an alternative 12 mm port can be placed. The robot is docked perpendicular to the patient from the back on the ipsilateral side.

The illustrations of port placement for da Vinci Xi (Fig. 12.2) and da Vinci Si (Fig. 12.3) platform can be modified according to patient factors such as body mass index, previous surgeries, and disease factors such as large kidney and location of renal pelvis.

The robotic instruments required for the procedure include: Maryland bipolar or plasma kinetic forceps on the left-hand side and “hot” curved monopolar scissors on the right side which can be interchangeable with a needle driver. While using the da Vinci Xi, we use fenestrated or Maryland bipolar forceps as plasma kinetic forceps are currently not available with this platform. The instrument configuration may change according to dominant hand of the surgeon. Limiting the number of robotic instruments to three improves cost-effectiveness. Alternatively, two needle drivers for ease of suturing; a hook for blunt dissection of the Gil-Vernet’s plane , and a ProGrasp™ forceps may be used.

The procedure is initiated using a Maryland bipolar forceps on the left side and a curved scissor on the right. Upon inspecting the abdominal cavity, if adhesions exist, these should be lysed sharply with minimal electrocautery in order to avoid inadvertent bowel injury. The electrocautery settings are 30 W for monopolar scissors and 25 W for bipolar forceps. In contrast, for the Xi robot, monopolar cut is set to 2–3 dry cut, monopolar coagulation is set to 2–3 forced coag, and bipolar cautery is set to 2–3 soft coag. The insufflation pressure used throughout the procedure is maintained at 15 mmHg. On the left side, a limited mobilization of the colon overlying the kidney and renal pelvis is performed by incising along the white line of Toldt. In a thin individual, sparse mesocolic fat may allow a trans-mesocolic approach wherein a window is created in the mesocolon overlying the renal pelvis. The renal pelvis may be identified as a bulge due to the presence of a stone within it with or without hydronephrosis. On the right side, an additional 5 mm liver retractor placed below the xiphoid may be required to elevate the right lobe of the liver and provide better visualization of the renal hilum and renal pelvis. The lateral peritoneal attachments of the hepatic flexure are incised to mobilize the ascending colon and duodenum providing access to the renal hilum. Contrary to the open technique, entire mobilization of the kidney (especially the lateral attachments) is avoided to prevent it from falling medially and hampering vision.