Robot-Assisted Nephroureterectomy and Bladder Cuff Excision Without Patient or Robot Repositioning: Description of Modified Port Placement and Technique

Abstract

Introduction: Nephroureterectomy (NUx) with full bladder cuff excision is the gold standard treatment for upper tract urothelial cancer. Minimally invasive techniques, including the use of the da Vinci surgical system, to perform NUx have been described and demonstrate comparable outcomes to the open technique. However, the robotic technique has been limited by the need for intraoperative repositioning of the patient and robot re-docking to approach and manage the distal ureter and bladder cuff. We describe our novel technique of robotic NUx that allows for complete access to the kidney and bladder, allowing for full bladder cuff excision and repair without patient or robot repositioning. Patients and Methods: This modified technique was performed on a consecutive series of patients undergoing robotic NUx for upper tract urothelial cancer from August 2012 to January 2014. Operative parameters and pathologic data were recorded, and the patients were followed for surveillance. Primary measures collected include the operative time, blood loss, length of stay, intraoperative complications, postoperative complications, follow-up cystoscopy, urine cytology, and imaging to detect disease recurrence. After insufflation, the robotic trocars are placed in a standardized manner allowing for a one-time easy switch of instruments to facilitate distal ureteral dissection and a wide bladder cuff excision. The entire procedure is completed without repositioning the patient or re-docking the robot. Results: Between our two centers, a total of 26 patients have effectively undergone NUx using our modified technique. The mean blood loss and operative time was 66 mL and 230 minutes, respectively. There were no intraoperative complications or open conversions, and there were no positive surgical margins on pathologic review of the specimen. The average follow-up time was 7.8 months (range, 2–17 months), and only four cases of cancer recurrence in the bladder were identified. This is a small early series from only two institutions and will need a larger cohort of patients with longer follow-up to validate our initial findings. Conclusions: This novel technique for robotic NUx offers a standardized and easy-to-implement approach for NUx that requires a minimal learning curve for an experienced robotic surgeon while affording a comparable oncologic control without the need for patient repositioning or additional port placement during the procedure. No competing financial interests exist. Runtime of video: 6 mins