Robot-Assisted Excision of Ureteral Tumor and Reconstruction in Patients with Unifocal Urothelial Cancers

Abstract

Introduction and Objective: There are different surgical options for management of upper tract urothelial tumors, ranging from nephroureterectomy to segmental ureteral excision and reconstruction. Ureteral sparing techniques are particularly useful for unifocal, low-grade cancers in select patients. We have performed robot-assisted segmental excision of ureteral tumor with reconstruction in seven patients. Methods: An Institutional Review Board (IRB)-approved retrospective review of our robotic surgery database was performed to identify all consecutive patients who underwent robot-assisted segmental ureterectomy between 2009 and 2010 for biopsy-confirmed, low-grade urothelial carcinoma. We have performed robot-assisted excision of ureteral tumor and reconstruction in seven patients (two for mid ureter; five for lower ureter). In three of the five lower ureteral tumors, we have performed ipsilateral pelvic lymphadenectomy. In this video, we describe our technique for excision of a midureteral transitional cell carcinoma followed by an end-to-end ureteral anastomosis. In addition, our technique of ureteral stenting is demonstrated for midureteral lesions. The steps of the procedure demonstrated in our video include (1) port placement, (2) reflection of colon and exposure of the retroperitoneum, (3) ureteral mobilization, (4) application of Hem-o-lock clips proximally and distally, (5) excision of ureteral tumor, (6) intracorporeal Double-J stent placement, and (7) ureteral–ureteral anastomosis. Results: Final pathology revealed low-grade carcinoma in five patients, whereas two patients demonstrated high-grade urothelial malignancy without any carcinoma in situ (CIS) or positive surgical margins. Mean estimated blood loss was 75 mL, and mean length of hospital stay was 1.5 days. Stents were removed at 4 weeks postoperatively. At follow-up, ranging from 3 to 20 months, cystoscopy and upper tract imaging were normal in all but two patients. One patient developed ipsilateral iliac lymphadenopathy. Lymph node biopsy revealed transitional cell carcinoma and this patient underwent chemotherapy. The second patient developed disease recurrence in the bladder, which was managed with endoscopic resection, and to date has not recurred again. Both these patients who recurred had distal ureteral tumors. Conclusions: In selected cases, segmental ureterectomy and primary ureteroureteral anastomosis are feasible for ureteral carcinomas. Long-term and regular follow-up are necessary, as in any patient with urothelial malignancy. The authors have nothing to disclose. Runtime of video: 7 mins 21 secs