Abstract
IntroductionWhile various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity. We developed a novel port placement and technique allowing to perform robot-assisted NU by a unique retroperitoneal approach.MethodsBetween February and June 2021 patients with history of UTUC were treated by robot-assisted NU completely restricted to retroperitoneal space using a singular trocar placement and a two-step docking without relocation of the surgical robot. Patient characteristics, perioperative outcomes and short-term follow-up were prospectively analyzed.ResultsThe analysis included five patients [median age: 73 years; BMI: 27.2 kg/m2; Charlson comorbidity index 5]. All five patients had UTUC with a mean tumor size of 3.02 cm (range 0.9–6.0). UTUC was localized to distal ureter in two and to kidney in three cases. No positive surgical margins were noted for all patients with UTUC [1 low-grade and 4 high-grade]. Retroperitoneal lymphadenectomy in three patients did not reveal positive nodes. No intraoperative adverse events exceeding EAUiaiC classification ≥ 2 were observed, while median EBL was 150 ml (IQR 100–250). No patient experienced postoperative complications exceeding Clavien–Dindo classification ≥ 3a. Median hospital stay was 5.4d without any 30-d readmission.ConclusionWe demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is easily reproducible, while surgical outcomes are similar to other established techniques.
Highlights
While various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity
Based on the experience from robot-assisted partial nephrectomy a strictly retroperitoneal approach might in turn be beneficial for the control of hilar structures and reduction of intraoperative blood loss, operative time and hospital stay by decreasing postoperative discomfort especially triggered by pain and intestinal atony [9,10,11]
American Society of Anesthesiologists score (ASA): American Society of Anesthesiologists; BMI: body mass index; EAUiaiC: Intraoperative Adverse Incident Classification by European Association of Urology; CCI: Charlson Comorbidity Index; estimated blood loss (EBL): Estimated Blood Loss; UTUC: upper urinary tract cancer; LN: lymph node IQR: interquartile range and the console time defined as a period during which console surgeon is operating at console was 124.4 min
Summary
While various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity. Conclusion We demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is reproducible, while surgical outcomes are similar to other established techniques. In the majority of cases management of the bladder cuff after robot-assisted retroperitoneal nephrectomy was only possible through intraoperative switch to either conventional laparoscopic surgery or even open surgery [4, 12, 13]
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