# Minimally Invasive One-Docking, Two-Target, and Three-Port Robotic-Assisted Nephroureterectomy: Redefining Surgical Approach

## TL;DR

This paper presents a new robotic surgical technique for kidney and ureter removal that uses fewer incisions and is faster and safer.

## Contribution

The study introduces a one-docking, three-port robotic approach for nephroureterectomy, reducing port usage and improving efficiency.

## Key findings

- Median operative time was 133 minutes with minimal blood loss and low complication rates.
- The three-port technique with the Xi platform is safe and effective for multi-quadrant procedures.
- Lymph node dissection did not significantly increase operative time.

## Abstract

This study focuses on robotic radical nephroureterectomy performed for patients with urothelial carcinoma in their kidneys and ureters. The da Vinci Xi platform, which enhances minimally invasive surgical techniques was applied. We aimed to optimize the surgical approach by reducing the number of ports used, and improving visualization during the procedure. The study involved 15 patients operated on by a single surgeon between 2019 and 2024, using a one docking, three-port technique. The median operative time was 133 min, and most surgeries were completed within 150 min. Blood loss was minimal, and complication rate was low. In conclusion, the study highlights that the three-port technique combined with the Xi platform is a safe and effective method for performing robotic radical nephroureterectomy, facilitating quicker procedures and achieving surgical goals.

Objective: Nephroureterectomy (NU) is a challenging multi-quadrant surgical procedure that involves intra–infra- and retroperitoneal dissection. The introduction of the da Vinci Xi platform has further improved the minimally invasive approach. With the Xi robotic system, single docking for multi-quadrant dissection is now feasible and increasingly popular. Herein, we redefined the surgical technique by optimizing minimal port usage, maximizing template visualization, and utilizing the Xi platform’s retargeting system, based on our experience with 15 patients. Methods: This single-center cohort study was based on the experience of a single surgeon with 15 patients who underwent robotic radical nephroureterectomy (RRNU) between 2019 and 2024, performed via the one docking, three-port technique. Patient data were retrospectively collected and analyzed from the medical records. Results: The cohort’s median age was 79 years, with male predominance of 80%. The median operative time was 133 min, with 60% of procedures completed within 150 min; longer times (>150 min) were due to additional intraoperative non-robotic procedures. Median blood loss was 100 mL, with two patients requiring intraoperative blood transfusion. Lymph node dissection (LND) in six patients did not significantly affect the overall operative time. The intraoperative and major postoperative complication rates (Clavien-Dindo grade > III) were 13.3%. Conclusions: The use of three robotic ports combined with the Xi platform’s camera-hop feature is a safe and effective technique for multi-quadrant, minimally invasive procedures, particularly in RRNU. This approach facilitates procedural goals and reduces overall operative time.