The patient is initially placed in the supine position for induction of anesthesia. An orogastric or nasogastric tube and an 18 Fr urethral catheter are placed at the beginning of the case to decompress the stomach and bladder, respectively, to facilitate safe access to the peritoneal cavity for insufflation. The abdomen is then shaved from the xiphoid process to the pubic symphysis. The patient is then positioned in a modified lateral decubitus position at a 45° angle between the patient’s back and the surface of the operating room table. This position is maintained with a large gel roll positioned behind the back of the patient for support. Because the patient is not in a full flank position, an axillary roll is generally not required to prevent brachial nerve injury. The bed is flexed to approximately 30° with the break of the bed positioned at the superior margin of the iliac crest to elevate and expand the ipsilateral flank. The dependant leg is flexed to a 90° angle at the knee and is supported at the knee and ankle with gel or foam padding to protect the peroneal nerve and avoid vascular compression. Pillows are placed between the legs to support the nondependant leg which is aligned in a neutral extended position. Sequential compression devices are applied to the lower extremities and activated.

The dependant arm is padded and placed on top of an arm board that is angled slightly cephalad to provide sufficient working space for the robotic arms as well as surgical assistant. The two arms may be separated and padded in a variety of ways in order to maintain a comfortable and neutral position without direct contact with the robotic arms during the operation. We routinely place three to four pillows between the dependant and nondependant arms and then secure the patient to the operative table using 2″ cloth tape at the level of the upper torso and thighs and ankles. Figure 10.2 illustrates proper patient positioning.

Although we utilize a two-docking approach to RARNU, a single trocar configuration allows completion of both the nephrectomy and ureterectomy portions with minimal modifications as shown in Fig. 10.3a, b. Trocar placement begins with a 12 mm paraumbilical trocar for the endoscope. One 8 mm robotic trocar is then placed lateral to the rectus muscle near the anterior axillary line just below the level of the umbilicus. A second 8 mm robotic trocar is placed two to three fingerbreadths below the costal margin lateral to the rectus muscle. These trocars accommodate the left and right robotic arms for the nephrectomy portion of the operation, respectively. For the surgical assistant, a 15 mm metal robotic cannula from the 8/15 mm convertible Hybrid Cannula Trocar (Intuitive Surgical, Inc., Sunnyvale, CA) is placed in the midline midway between the umbilicus and pubic tubercle. This 15 mm trocar has a plastic reducer placed to allow for retraction, suction, and irrigation by the assistant (Fig. 10.4a). While trocar placement is dependent on body habitus, it is important that all trocars are spaced at least 8 cm apart to avoid external collision. In obese patients with a large abdominal pannus, this trocar configuration may require a slight lateral shift toward the ipsilateral kidney to allow for optimal visualization and to reach the target organ. For right-sided cases, an additional 5 mm laparoscopic trocar can be placed to provide liver retraction at the subcostal margin near the xiphoid process to accommodate a 5 mm grasper for retraction. This should be placed cephalad and more medial with respect to the subcostal 8 mm trocar in efforts to avoid external instrument clashing between the two trocars. For left-sided cases, release of the splenorenal ligament typically leads to adequate visualization of the upper pole of the kidney without the need for an additional trocar for retraction of the spleen.

After the nephrectomy portion of the case, the robot is repositioned as previously described (Fig. 10.1b) and the ureterectomy/bladder cuff excision is performed after making two trocar adjustments. First, the 8 mm cannula of the 8/15 mm Hybrid Cannula Trocar is inserted into the 15 mm assistant trocar for the left robotic arm creating a “hybrid” trocar (Fig. 10.4a, b). Second, the 8 mm subcostal trocar which previously housed the right robotic arm is sealed with the 5 mm trocar valve and becomes the new assistant trocar (Fig. 10.3b). It is important to create the “hybrid” port using the Hybrid Cannula Trocar to prevent capacitive coupling which will be discussed in greater detail later (see “Steps to Avoid Complications”).