V03-07 TECHNICAL CAVEATS IN ROBOT-ASSISTED RADICAL NEPHROURETERECTOMY WITH RETROPERITONEAL LYMPHADENECTOMY FOR POST CHEMOTHERAPY UPPER TRACT UROTHELIAL CARCINOMA

Abstract

INTRODUCTION AND OBJECTIVE: Upper tract urothelial carcinoma (UTUC) forms 5% of all urothelial cancers.Urothelial carcinoma has been known for tumors developing lymphatic metastases at a relatively high incidence of 20–30%. Post chemotherapy UTUC with residual lymph nodes represents a distinct surgical challenge because of severe desmoplastic reactions. Radical nephroureterectomy with retroperitoneal lymphadenectomy provides a technically feasible and safe option in such patients. A robotic approach is being increasingly used to perform this complex oncologic procedure in view of its distinct advantages. We hereby present a video of robot assisted radical nephroureterectomy with retroperitoneal lymph node dissection for post chemotherapy UTUC and discuss a few points of technique related to it. METHODS: A 64 year female was incidentally found to have left renal pelvis urothelial carcinoma. CECT KUB revealed a poorly defined mildly enhancing lesion distending the left renal pelvis and left upper ureter. Multiple retrocaval lymph nodes was present. Left ureteroscopy showed upper ureteric and pelvis wall thickening with 2-3 cm sized protruding mass in the left renal pelvis. Biopsy was taken which came out as high grade urothelial carcinoma. Chemotherapy (Gemcitabine + Cisplatin) x 3 cycles was given after which FDG avidity and number of lymph nodes decreased. Transperitoneal robot assisted radical nephroureterectomy with retroperitoneal lymphadenectomy was then performed. Patient was first placed in standard left lateral position. Pneumoperitoneum created using Veress needle. Standard right kidney 7 ports made, 4 of 8 mm, 1 of 5 mm and 2 of 12 mm. Da Vinci Xi docked. Right colon reflected along the white line of Toldt, duodenum kocherized. Right gonadal vein identified, traced up, clipped and divided. IVC dissected, pre caval, para caval and inter aortic caval lymph node dissection done till proximal right common iliac vein (crossing of ureter). Right renal vein dissected gently and lymph node tissue behind renal vein removed. Large lymphatic vessels clipped before cutting.Hemostatsis confirmed. Robot undocked, ports removed and closed, keeping 2, 12 mm assitant port in situ. Patients position changed to right lateral decubitus. Standard left kidney 4 robotic ports inserted. Left ureter and gonadal vein identified and lifted. Pre and para aortic lymph node dissection done till left proximal common iliac artery (crossing of ureter) with the combination of sharp and blunt dissection. Renal vein identified and Hilar dissection done. Gonadal vein along with adjacent lymph nodes traced proximaly upto the renal vein where they were ligated and divided. Lumbar veins draining to renal vein clipped and divided. Stapling of renal hilum with endo GIA stapler was done. Ureteric clipping was done before mobilization of kidney. Kidney mobilized from all its attachements. Ureter mobilized as inferiorly as possible. Camera and right robotic arm instruments switched. Left lower ureter dissected. Left ueretrovesical junction identified. Bladder dissected distally and Stay V - loc 3.0 suture taken. Lower end of left ureter removed along with cuff of bladder wall. Bladder closed in one layer with V loc. Haemostasis ensured & drain placed. Robot undocked & Specimen retrieved through a pfannensteil incision. Abdomen closed in layers and ports removed under vision. Port site closed. RESULTS: Total console time was 425 minutes and blood loss was 50ml. Per urethral catheter and drain were removed on POD 5 and 1 respectively. Patient was discharged in stable condition on POD 2. Histopathology revealed urothelial carcinoma-pT3N0M0. CONCLUSIONS: In post chemotherapy UTUC, severe desmoplastic reaction as well as larger-volume residual disease requires more extensive retroperitoneal dissection. This increase the technical demands of the surgery and make it one of the most difficult and dangerous operations. Robot assisted RNU with RPLND remains a technical feasible and safe option in such patients. Source of Funding: None