Robot-assisted Laparoscopic Nephroureterectomy Research Articles

Robotic nephroureterectomy supplanting open and laparoscopic approach for upper tract urothelial carcinoma management: a narrative review.

The use of robotic surgery for managing upper tract urothelial carcinoma (UTUC) has increased significantly over the years. Minimally invasive techniques (MIS) are now used for approximately half of all robot-assisted laparoscopic nephroureterectomy (RAL-NU) performed in the USA. However, there are currently no specific management guidelines that recommend the use of a robotic approach, and the available literature on this topic is limited. For this reason, we reviewed the history and current literature regarding this technique. We searched Web of Science and PubMed for articles between 1934 to 2023 using 20 different search terms and combinations. We restricted our selection to only publications in English language. Comparative retrospective studies between techniques [open nephroureterectomy (ONU), laparoscopic nephroureterectomy (LNU), and RAL-NU] and case series of surgical groups, mostly at short- and mid-term follow-up, were included. Robotic surgery for UTUC is on the rise and is predicted to become the preferred method for nephroureterectomy. A comparison of RAL-NU to LNU and ONU shows several advantages, including less blood loss, pain, and hospital stay, as well as a quicker recovery time. The safety and effectiveness of robotic surgery for lymphadenectomy also supports its use in RAL-NU. As more medical facilities adopt the technique and further studies support its benefits, it is likely that robotic surgery will become the preferred method for NU.

Retroperitoneal robot-assisted laparoscopic nephroureterectomy using the da Vinci Xi and SP systems: Initial experiences in cadaveric models.

To investigate the feasibility and optimal port placements of robot-assisted laparoscopic nephroureterectomy (RANU) via the retroperitoneal approach in the lateral decubitus and supine positions using the da Vinci Xi (DVXi) and da Vinci SP (DVSP) systems. We performed lateral decubitus extraperitoneal RANU on the right side and supine extraperitoneal RANU on the left side using the DVXi and DVSP systems without repositioning in two fresh cadavers. In addition, paracaval and pelvic lymphadenectomies were performed simultaneously during both surgical procedures. The operative time of each procedure was calculated, and the technical details associated with these procedures were evaluated. Lateral decubitus and supine extraperitoneal RANU using the DVXi and DVSP systems were achieved without repositioning. The surgeon console time ranged from 89 to 178 minutes, and no major technical complications were observed. However, carbon dioxide insufflation into the abdominal cavity was observed owing to a peritoneal breach during the creation of the surgical workspace, particularly in the supine position. Compared with the DVXi system, the DVSP system was more suitable for RANU using the retroperitoneal approach, except for renal handling. The DVXi and DVSP systems are feasible for performing lateral decubitus and supine extraperitoneal RANU without patient repositioning. The lateral decubitus position may be better than the supine position, and the DVSP system is more suitable for retroperitoneal RANU than the DVXi system. Nevertheless, further studies should be performed in clinical settings to validate our results.

V09-11 NOVEL USE OF THE DAVINCI SINGLE PORT ROBOT IN NEPHROURETERECTOMY OF A HORSESHOE KIDNEY

You have accessJournal of UrologyCME1 May 2022V09-11 NOVEL USE OF THE DAVINCI SINGLE PORT ROBOT IN NEPHROURETERECTOMY OF A HORSESHOE KIDNEY John Sheng, Chrystal Chang, Michael Stifelman, and Mutahar Ahmed John ShengJohn Sheng More articles by this author , Chrystal ChangChrystal Chang More articles by this author , Michael StifelmanMichael Stifelman More articles by this author , and Mutahar AhmedMutahar Ahmed More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002617.11AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Performing a robotic-assisted laparoscopic nephroureterectomy can be challenging, especially during the distal ureterectomy and bladder cuff portion. We demonstrate how the Da Vinci Single Port Robot facilitates certain portions of the case. We show how the procedure can be performed with one incision compared to a multiport robotic or open technique. METHODS: A 73 year old male was diagnosed with a high grade urothelial cancer of the right renal pelvis on ureteroscopic biopsy. He then underwent neoadjuvant chemotherapy. He also has a horseshoe kidney, making the case more complex than a regular nephroureterectomy. Patient underwent single port robotic assisted laparoscopic right nephroureterectomy with bladder cuff. RESULTS: A single 25mm incision was made supraumbilically for the robotic instruments. No assistant port was used, making this a true single port procedure. The remotely operated suction irrigation system (ROSI) was used not only for suction but dissection as well. The operative time for the case was 187 minutes. Estimated blood loss was 150cc. The patient was discharged within 18 hours of surgery with a foley catheter and no need for post op narcotic use. Even though there is limited space underneath the liver, we were able to work underneath the liver without the use of a liver retractor by using the elbow of our 4th arm to hold it up. We use the “Relocate” function of the SP Robot to perform our distal ureterectomy and bladder cuff portion, preventing the need to re-dock the robot. We performed multiple procedures with one incision: partial nephrectomy, distal ureterectomy with bladder cuff and lymphadenectomy. At our institution, we have performed seven robotic single port nephroureterectomies. Average operating time is 126 minutes, estimated blood loss 92cc and average length of stay is 1.8 days. CONCLUSIONS: The use of the Da Vinci Single Port robot can make increasingly complex cases even more minimally invasive. This can reduce post-operative pain, improve cosmesis and shorten hospital stay. However there is a learning curve in the use of the Da Vinci SP robot. We hope to improve our techniques and surgical approaches further to keep our procedures as minimally invasive as possible. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e808 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information John Sheng More articles by this author Chrystal Chang More articles by this author Michael Stifelman More articles by this author Mutahar Ahmed More articles by this author Expand All Advertisement PDF DownloadLoading ...

Less invasive and equivalent short-term outcomes with simultaneous en bloc robot-assisted radical cystectomy and laparoscopic nephroureterectomy: Comparison with conventional open radical cystectomy and nephroureterectomy.

To clarify the safety and efficacy of en bloc simultaneous robot-assisted radical cystectomy (RARC) and laparoscopic nephroureterectomy (LNU) for synchronous muscle-invasive bladder carcinoma and upper tract urothelial carcinoma (UTUC) or UTUC of a solitary kidney, we evaluated the perioperative and short-term outcomes of this surgical procedure compared with those of simultaneous open radical cystectomy and nephroureterectomy. We prospectively enrolled consecutive patients receiving en bloc simultaneous RARC and LNU between December 2018 and March 2020 at two institutes. Patients' characteristics, surgical, perioperative, and pathological outcomes and recurrence rate within 6months were compared with a historical control receiving simultaneous open radical cystectomy and nephroureterectomy. Ten patients receiving simultaneous RARC and LNU and 17 receiving simultaneous open radical cystectomy and nephroureterectomy were included in the study. Simultaneous RARC and LNU significantly reduced bleeding volume and blood transfusion (P < .0001, P < .0001, respectively) and significantly prolonged operating time (P=.035). RARC and LNU significantly shortened hospitalization after operation (P=.003) and showed reduced tendency of postoperative complications within 30 days but not significantly (P=.25). Pathological characteristics and recurrence within 6months were not significantly different between the two groups. Our results suggested that en bloc simultaneous RARC and LNU were safer surgical procedures with equivalent short-term oncological outcomes compared to conventional open procedures. It can be a standard minimally invasive surgical method in countries where robot-assisted radical nephroureterectomy is inaccessible.

Single-docking transperitoneal robotic-assisted nephroureterectomy: surgical techniques and outcomes

Objective To introduce and discuss the efficacy of a new technique to perform transperitoneal single-docking robot-assisted laparoscopic nephroureterectomy (RNU). Methods A total of 44 patients diagnosed with urothelial neoplasm of the renal pelvis or were investigated from January 2016 to November 2019. RNU was performed by a single surgeon. Among the 44 patients, 31 were male, and 13 were female. The median age was 63 (IQR: 58-71). The median body mass index (BMI) was 23.08 (IQR: 21.55-24.60) kg/m2. All operations were performed with general anesthesia. The patients were positioned 80 degrees flank with the diseased side up, and the head was tilted 10 degrees downwards. The camera port was placed one finger lateral to the umbilicus. For the right-sided tumors, robotic arm 1 was inserted through the trocar on the right pararectus line, 8 cm above the umbilicus, and robotic arm 2 was inserted through the trocar on the same line, 8 cm below the umbilicus. Assistant trocar 1 was placed where the anterior midline joins the perpendicular bisector of the camera port and robotic 2, and assistant trocar 2 was placed below the xiphoid process. For the left-sided tumors, all trocars were centrosymmetric to that of the right-sided tumors, except that assistant port 2 was placed 3 finger width above the pubic symphysis. The peritoneum was incised along the Toldt line, and the inferior vena cava was isolated (for left sided tumor, the abdominal aorta was isolated instead). The renal artery and vein were clipped with Hem-o-lok and ligated, and the kidney were isolated. The ureter was identified and isolated downwards across the common iliac artery and then clipped distal to the tumor site. The bladder cuff was resected and sutured under the laparoscopy. Results The median operation time was 145 (IQR: 130-175) min, with the median console time of 119 (IQR: 108.5-136.0) min, the anastomosis of bladder cuff of 12 min, and the median estimated blood loss of 50(20-100)ml. After the surgery, 6 Clavien-Dindo grade 2 complications occurred, including 2 chylous leakage, 1 hemostasis, 1 blood transfusion, 1 deep vein thrombus, and 1 acute coronary syndrome. The median length of stay (LOS) was 8 (IQR: 6.5-10.0) d. The median length of follow-up was 12 months. In total, 5 patients were dead, including 3 cancer-specific death. Four recurrence occurred and caused 3 death. The 2-year overall survival and progression-free survival were 68.2% and 77.9%, respectively. Conclusions The technique of RNU with simultaneous bladder cuff excision (BCE). Our technique improved the surgical outcome. The perioperative complication rate was low, and the short-term survival outcomes were satisfactory. Key words: Ureteral neoplasms; Upper tract urothelial carcinoma(UTUC); Nephroureterecto-my; Robotic surgery; Laparoscopic surgery

V7-10 ROBOT-ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY OF A RIGHT PELVIC KIDNEY IN A PEDIATRIC PATIENT

You have accessJournal of UrologyPediatrics1 Apr 2016V7-10 ROBOT-ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY OF A RIGHT PELVIC KIDNEY IN A PEDIATRIC PATIENT Michael V. Hollis, Patricia S. Cho, Evalynn Vasquez, David A. Diamond, and Richard N. Yu Michael V. HollisMichael V. Hollis More articles by this author , Patricia S. ChoPatricia S. Cho More articles by this author , Evalynn VasquezEvalynn Vasquez More articles by this author , David A. DiamondDavid A. Diamond More articles by this author , and Richard N. YuRichard N. Yu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2016.02.567AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Pelvic kidney occurs due to failure of the kidney to ascend normally from the pelvis during development. The condition is typically asymptomatic, but many patients are prone to ureteropelvic junction (UPJ) obstruction due to malposition or malrotation. Complications of pelvic kidney include infections, stones, and renal failure. Enhanced visualization and greater dexterity are needed to locate and to control anomalous blood vessels. Added difficulty is encountered in patients with adhesive disease from previous abdominal surgery such as those with a VP shunt. The robotic approach allows for better access to and for delicacy with deep pelvic structures. We aim to demonstrate the application and safety of a robotic approach to the pelvic kidney nephroureterectomy in the pediatric population. METHODS A 4 year old (16 kg) male with a history of hydrocephalus with VP shunt reported recurrent abdominal pain and emesis, and a right lower quadrant mass was noted on physical exam. Ultrasound demonstrated a right pelvic kidney with moderate hydronephrosis of the upper and lower pole moieties. MAG-3 nuclear medicine scan findings were difficult to interpret due to poor renal function. A DMSA scan revealed a split differential function of 8% on the right side, indicating severely impaired renal function. The patient underwent a robot-assisted laparoscopic nephroureterectomy of a right pelvic kidney. RESULTS The right pelvic kidney was removed without perioperative complications. Pathology revealed hydroureteronephrosis, marked glomerulosclerosis, and tubular hypertrophy/atrophy with chronic interstitial nephritis. Ultrasound at 6 weeks post-op demonstrated normal compensatory hypertrophy of the left kidney and an unremarkable right lower quadrant absent of fluid collections. CONCLUSIONS Nephroureterectomy of a pelvic kidney is challenging due to anomalous renal vessels. The robotic approach allows for excellent visualization and for dissection of deep pelvic structures. Robotic nephroureterectomy of a pelvic kidney is feasible and successful in the pediatric population, and the presence of a VP shunt does not preclude this procedure. © 2016FiguresReferencesRelatedDetails Volume 195Issue 4SApril 2016Page: e725 Advertisement Copyright & Permissions© 2016MetricsAuthor Information Michael V. Hollis More articles by this author Patricia S. Cho More articles by this author Evalynn Vasquez More articles by this author David A. Diamond More articles by this author Richard N. Yu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Use of Intraoperative Indocyanine Green to Facilitate Robot-Assisted Laparoscopic Upper Pole Partial Nephroureterectomy

Abstract Introduction: During partial nephrectomy, identifying and occluding the appropriate segmental vessels that supply the diseased parenchyma before resection are critical to minimizing blood loss. While it is sometimes possible to identify vascular changes visually, the presence of complicated renal vascular anatomy may complicate appropriate identification of polar vessels. We now report the use of near-infrared fluorescence (NIRF) with intravenous indocyanine green (ICG) to confirm appropriate vascular occlusion before parenchymal resection during a robot-assisted laparoscopic partial nephroureterectomy. Materials and Methods: A left robot-assisted laparoscopic upper pole partial nephroureterectomy was performed for an obstructed, minimally functional left upper pole moiety in the setting of persistent left flank pain using the da Vinci Si System. The patient was positioned, prepped, draped, and trocars placed in the typical manner. The colon was reflected medially. A complex renal hilum was ident...

Oncologic Outcomes Following Robot-Assisted Laparoscopic Nephroureterectomy with Bladder Cuff Excision for Upper Tract Urothelial Carcinoma

Robot-assisted laparoscopic nephroureterectomy with bladder cuff excision is a minimally invasive alternative to open surgery for managing upper tract urothelial carcinoma. We report oncologic outcomes following robot-assisted laparoscopic nephroureterectomy with bladder cuff excision. The records of the initial 65 patients who underwent robot-assisted laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma between 2008 and 2014 were reviewed from our institutional review board approved, prospectively maintained database. All patients underwent surgery with the single docking technique. Baseline demographic features, pathological variables and perioperative data were analyzed. Kaplan-Meier methodology was used for survival analysis. Cox proportional hazards regression was applied to determine the prognostic effect of different variables on survival. Mean patient age was 69.1 years. Final pathological evaluation revealed pT2 stage or lower in 65% of patients, pT3 in 28.3% and pT4 in 6.7%. High grade pathological findings were present in 85% of patients, including 13.3% with concomitant carcinoma in situ and 30% with lymphovascular invasion. Median followup was 25.1 months (range 6 to 68.9). At 2 and 5 years overall survival was 86.9% and 62.6%, cancer specific survival was 92.9% and 69.5%, and recurrence-free survival was 65.3% and 57.1%, respectively. A total of 23 patients experienced disease recurrence. Bladder recurrence developed in 15 patients, 12 had isolated bladder recurrence and 8 had metastatic disease. On univariate analysis age greater than 70 years, preoperative hydronephrosis, nodal disease and concomitant carcinoma in situ were significantly associated with decreased recurrence-free survival (p=0.002, 0.04, 0.006 and 0.001, respectively). However, none was statistically significant on multivariate analysis. On univariate analysis impaired preoperative renal function (creatinine greater than 2 mg/dl) and lymphovascular invasion were associated with reduced cancer specific survival (p=0.03 and 0.01, respectively). However, only lymphovascular invasion was associated with decreased cancer specific survival on multivariate analysis (p=0.048). Our reported data on oncologic outcomes following robot-assisted laparoscopic nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma demonstrate satisfactory oncologic control at intermediate term followup. Long-term outcomes are required to assess true efficacy.

Operative technique and early experience for robotic-assisted laparoscopic nephroureterectomy (RALNU) using da Vinci Xi.

PurposeRobotic-assisted laparoscopic nephroureterectomy (RALNU) has been previously utilized for management of upper tract urothelial carcinoma. The da Vinci Xi surgical system was released in April of 2014. We describe our operative technique and early experience for RALNU using the da Vinci Xi system highlighting unique features of this surgical platform.Materials and methodsA total of 10 patients with a diagnosis of upper tract urothelial carcinoma underwent RALNU using the da Vinci Xi system between April and November of 2014. A novel, oblique “in line” robotic trocar configuration was utilized to access the upper abdomen (nephrectomy portion) and pelvis (bladder cuff excision) without undocking. The port hopping feature of da Vinci Xi was utilized to facilitate optimal, multi-quadrant visualization during RALNU.ResultsRobotic-assisted laparoscopic nephroureterectomy was successfully completed without open conversion in all 10 patients. Mean operative time was 184 min (range 140–300 min), mean estimated blood loss was 121 cc (range 60–300 cc), and mean hospital stay was 2.4 days. Final pathology demonstrated high grade urothelial carcinoma in all patients. Surgical margins were negative in all patients. No intra-operative complications were encountered. One patient developed a pulmonary embolus after being discharged. No patients required a blood transfusion. Mean patient follow-up was 130 days (range 15–210 days).ConclusionThe use of da Vinci Xi with a novel, oblique “in line” port configuration and camera port hopping technique allows for an efficient and reproducible method for RALNU without the need for repositioning the patient or the robot during surgery.Electronic supplementary materialThe online version of this article (doi:10.1186/s40064-015-1076-6) contains supplementary material, which is available to authorized users.

Laparoscopic Ureterolysis In Patients With Retroperitoneal Fibrosis And Obstructive Uropathy: Taipei City Hospital Experience

Materials and Methods: Between July 2014 and March 2015, 6 female patients received refined pluck technique by ureteral occlusion and transurethral cystorrhaphy in nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma (UTUC). At beginning, the ureter orifice was occluded with intravesical silk suture transurethrally aided by extracorporeal knot tying. Transurethral excision of bladder cuff was performed by circumcision of the ureteric orifice and intramural ureter with a Collins knife. The bladder cuff is freed deeply to extravesical space allowing subsequent“plucking” of the entire ureter from above. The bladder defect is repaired with absorbable sutures transurethrally. The tumor was pyelocaliceal in 4 cases, ureteral in 2 cases. The follow-up was performed by cystoscopy, urine cytology and computed tomography (CT) scan. We present our preliminary data. Results: 4 transperitoneal robot-assisted laparoscopic nephroureterectomy with bladder cuff excision and 2 hand-assisted retroperitoneoscopic nephroureterectomy with bladder cuff excisionwere performed. All patients are female. Histology showed high grade in everyone. There were 2 patients with pT1 staging, 2 patients with pT2 staging and 2 patients with pT3 staging. There was no lymph node metastasis found in the specimen and all surgical margin were clear. No major perioperative complications occurred. Conclusion: This refined pluck technique by ureteral occlusion and transurethral cystorrhaphy in nephroureterectomy with bladder cuff excision for upper tract urothelial carcinoma (UTUC) is a safe and effective alternative according to our preliminary experience. Long term follow-up and larger patient number are needed.

Distal ureterectomy techniques in Laparoscopic Nephroureterectomy (LNU) and Robotic-assisted Laparoscopic Nephroureterectomy (RALNU) - A Review of the Literature.

Laparoscopic Nephroureterectomy and Robotic-Assisted Laparoscopic Nephroureterectomy are reported as alternative procedures to the open approach in the management of Upper Tract Transitional Cell Carcinoma (UTTCC). Although, they are considered to be equivalently effective to Open Nephroureterectomy (ONU), controversy still exists regarding the best method for managing the distal ureter and bladder cuff during the laparoscopic and robotic-assisted laparoscopic approach. This review describes the surgical steps, the advantages and disadvantages of several techniques used for ureter and bladder cuff resection including open excision, transurethral resection of ureteral orifice (‘Pluck’ Technique), ureteric intussusception and total laparoscopy or robotic-assisted laparoscopy. Although, the existing data does not confirm the superiority of one technique over another, total laparoscopic and robotic-assisted laparoscopic nephroureterectomy with complete laparoscopic dissection and suture reconstruction of ureter and bladder cuff seem to be better tolerated than open nephroureterectomy providing equal efficacy and without deteriorating the oncological outcome. Transurethral resection of the ureteric orifice and the bladder cuff after occlusion of the ureter with a balloon catheter seems to be an attractive alternative option for low stage, low grade tumors of the renal pelvis and the proximal ureter, in case we would like to avoid a low abdominal incision. Η Λαπαροσκοπική Νeφροουρητηρeκτομή και η Ρομποτικά Υποβοηθούμeνη Λαπαροσκοπική Νeφροουρητηρeκτομή αναφέρονται ως eναλλακτικές eπιλογές της Ανοικτής Νeφροουρητηρeκτομής στη διαχeίριση ασθeνών μe Καρκίνο Αποχeτeυτικής μοίρας του Ουροποιητικού Συστήματος. Παρόλο που όμως θeωρούνται ισοδύναμeς eπeμβάσeις μe την Ανοικτή Νeφροουρητηρeκτομή, παραμένeι αμφιλeγόμeνο ποιος τρόπος eίναι ο καλύτeρος όσον αφορά την αντιμeτώπιση του άπω τμήματος του ουρητήρα και την eκτομή της eνδοκυστικής μοίρας αυτού. Η παρούσα ανασκόπηση πeριγράφeι τα χeιρουργικά βήματα και τα πλeονeκτήματακαι Μeιονeκτήματα των διάφορωντeχνικών πουχρησιμοποιούνται για την eκτομή του τeλικού τμήματος του ουρητήρα, όπως eίναι η ανοικτή ουρητηρeκτομή, η διουρηθρική eκτομή του ουρητηρικού στομίου (‘pluck’ τeχνική), η τeχνική eγκολeασμού του ουρητήρα και η ολική Λαπαροσκοπική ή ολική Ρομποτικά-Υποβοηθούμeνη Λαπαροσκοπική eκτομή του ουρητήρα. Αν και οι υπάρχουσeς μeλέτeς δeν eπιβeβαιώνουν την ανωτeρότητα κάποιας τeχνικής συγκριτικά μe κάποια άλλη, η ολική Λαπαροσκοπική και η ολική Ρομποτικά-Υποβοηθούμeνη Λαπαροσκοπική Νeφροουρητηρeκτομή μe καθολική eκτομή της eνδοκυστικής μοίρας του ουρητήρα και του κυστικού τοιχώματος που τον πeριβάλλeι φαίνeται να eίναι καλύτeρα Ανeκτές σe σχέση μe την ανοικτήν eφροουρητηρeκτομή, παρέχοντας ισοδύναμη αποτeλeσματικότητα, χωρίς να eπηρeάζουν το Ογκολογικό αποτέλeσμα. Eναλλακτικά, σe πeρίπτωση που θέλουμe να αποφύγουμe τη Χαμηλή κοιλιακή τομή, η διουρηθρική eκτομή του ουρητηρικού στομίου, μeτά από τοποθέτηση ουρητηρικού καθeτήρα μe μπαλόνι απόφραξης, φαίνeται να αποτeλeί μια καλή eπιλογή για νόσους χαμηλού σταδίου της νeφρικής πυέλου και του eγγύς μουρητήρα.

V7-14 ROBOT-ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY IN A 9-YEAR-OLD GIRL WITH OBSTRUCTED HEMIVAGINA IPISILATERAL RENAL ANOMALY

You have accessJournal of UrologyPediatrics1 Apr 2015V7-14 ROBOT-ASSISTED LAPAROSCOPIC NEPHROURETERECTOMY IN A 9-YEAR-OLD GIRL WITH OBSTRUCTED HEMIVAGINA IPISILATERAL RENAL ANOMALY Amanda Saltzman and Christopher Roth Amanda SaltzmanAmanda Saltzman More articles by this author and Christopher RothChristopher Roth More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1945AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Obstructed hemivagina ipsilateral renal anomaly (OHVIRA) is a rare Mullerian duct abnormality with renal manifestations (renal agenesis, hypoplasia, ectopic ureter, multicystic dysplastic kidney). Classically, this presents after menarche with abdominal pain, but because of its rarity, diagnosis is often delayed. There have been less than 20 reported cases of prepubertal OHVIRA, with most involving neonates. In the infant female, diagnosis can sometimes be made with unilateral renal agenesis on prenatal ultrasound and vaginal bulge after birth. Rarely do girls present between the newborn and pubertal period. There are no definitive guidelines for treatment of prepubertal girls with OHVIRA. METHODS We present a case of OHVIRA diagnosis and management in a 9-year-old girl, which came to light via continuous incontinence that developed after incorrect diagnosis and treatment for imperforate hymen. RESULTS A 9-year-old female presented to an outside emergency room with abdominal pain. Abdominal ultrasound showed hydrocolpos and an absent left kidney. The working diagnosis was imperforate hymen with blockage of menses and she underwent “hymenotomy”. Since this procedure, she has had continuous vaginal leakage. Genitourinary exam showed Tanner 1 genitalia, pooling of fluid within the vagina, a circumferentially intact hymenal ring and a deeper area of tissue within the vagina that had previously been incised. There were no abdominal masses and the urethra was normal. Cross sectional imaging revealed uterus didelphys, a normal right kidney and a small left pelvic kidney that took up and excreted contrast into a hydronephrotic left ureter. We took the patient to the operating room with a presumptive diagnosis of OHVIRA with a left atrophic kidney with a presumed ectopic ureter into the left hemivagina that had been incised. We explored the pelvis robotically and identified the dilated left ureter within the pelvis with insertion into the left vagina. Proximally, there was an atrophic pelvic kidney with a series on anomalous vessels. We performed a left nephroureterectomy. The distal ureter was amputated at its entry point into the vagina. The patient recovered uneventfully and went home on post-operative day 1. She was immediately dry after the procedure. CONCLUSIONS OHVIRA is a rare diagnosis that requires a high index of suspicion. When presented with a prepubertal patient with renal abnormalities and a pelvic mass careful work up is important prior to surgical intervention to ensure accurate diagnosis and treatment in the same setting. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e663 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information Amanda Saltzman More articles by this author Christopher Roth More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Robot-assisted nephroureterectomy for upper tract urothelial carcinoma: the Taiwan Robot Urological Surgery Team (TRUST) experience.

BackgroundTo report Taiwan’s experience in robot-assisted laparoscopic nephroureterectomy (RANU) for upper tract urothelial carcinoma (UTUC).MethodsTwenty patients with a diagnosis of renal pelvic or ureteral urothelial carcinoma underwent RANU at three medical centers. We performed RANU by re-docking the robot after the nephrectomy with or without repositioning for excision of the distal ureter and bladder cuff.ResultsFrom November 2010 to July 2013, a total of 20 patients with a mean age of 70.1 +/- 9.9 years (range 43 to 92 years) and mean body mass index (BMI) of 22.9 +/-3.8 kg/m2 underwent RANU for renal pelvic or ureteral urothelial carcinoma. Mean operative time was 251.6 +/- 126.7 minutes (range 110 to 540 minutes), estimated blood loss was 50.0 +/- 42.9 mL (range 10 to 200 mL), and mean length of hospital stay was 6.7 +/- 2.4 days (range 4 to 12 days). Pathology data revealed 19 high and one low-grade urothelial carcinoma and staged Ta for three, T1 for five, T2 for five and T3 for seven. With a mean follow-up of 14.7 months (range 2 to 34 months), three intravesical recurrences developed in the bladder, and four of them also developed metastatic disease.ConclusionsThe TRUST early experience showed that RANU is a safe and feasible minimally invasive procedure for UTUC.

Comparison of Pediatric Robotic-assisted Laparoscopic Nephroureterectomy and Laparoendoscopic Single-site Nephroureterectomy

To compare outcomes between pediatric robotic-assisted laparoscopic nephroureterectomy (RALNU) and laparoendoscopic single-site nephroureterectomy (LESSNU). A retrospective cohort study was performed of all patients who underwent RALNU and LESSNU at a single pediatric institution from April 2009 to April 2013. Patient demographics, perioperative details, and outcomes were reviewed. Thirty-two patients (20 men, 12 women) were identified. Twenty-four patients underwent RALNU and 8 patients underwent LESSNU. There was no significant blood loss, intraoperative complication, or conversion to open or standard laparoscopy for either procedure. Median age was 55.1 months (range 4.5-171.8 months) for RALNU and 51.6 months (range 16.3-144.9 months) for LESSNU (P = .695). Median weight was 19.1 kg (range 7-55 kg) for RALNU and 16.9 kg (range 11-41 kg) for LESSNU (P = .727). Median operative time was 227 minutes (range 112-362 minutes) for RALNU and 174 minutes (range 74-288 minutes) for LESSNU (P = .028). Median length of hospital stay was 2 days (range 1-4 days) for RALNU and 1 day (range 0-6 days) for LESSNU (P = .134). Median in-patient postoperative narcotic use of morphine-equivalent was 0.03 mg/kg/day (range 0-0.2) for RALNU and <0.01 mg/kg/day (range 0-0.2) for LESSNU (P = .134). Median in-patient postoperative Ketorolac use was <0.01 mg/kg/day (range 0-0.8) for RALNU and <0.01 mg/kg/day (range 0-0.5) for LESSNU (P = .784). Median follow-up was 22 months (range 0.8-48.4 months) for RALNU and 18.8 months (range 0.3-29.4 months) for LESSNU (P = .361). We observed 2 complications (8.3%) in RALNU and 1 in LESSNU (P = 1). LESSNU has a significantly shorter operative time with comparable in-patient postoperative narcotics use as compared to RALNU.

Editorial Comment

Advances in minimally invasive surgical techniques have been evolving at a fast pace. Since the introduction of laparoscopic surgery, numerous minimally invasive alternatives have been described, such as single site laparoscopy, robotic-assisted laparoscopic surgery, and natural orifice endoscopic procedures. Unfortunately, breakthrough surgical procedures are not regularly submitted to the scientific rigor of other therapeutic innovations and are often influenced by the powerful impact of the medical device industry. Therefore, academic surgeons should take on the role of applying sound scientific methodology to newer surgical techniques in order to ensure that patients receive the safest and most cost-effective treatment modality. From this perspective, the authors should be congratulated for their report comparing 2 minimally invasive techniques for laparoscopic nephroureterectomy in the treatment of benign conditions in children against conventional laparoscopic nephrectomy (CLN). Comparison of Pediatric Robotic-assisted Laparoscopic Nephroureterectomy and Laparoendoscopic Single-site NephroureterectomyUrologyVol. 83Issue 2PreviewTo compare outcomes between pediatric robotic-assisted laparoscopic nephroureterectomy (RALNU) and laparoendoscopic single-site nephroureterectomy (LESSNU). Full-Text PDF

"The Lister Technique": a new technique for the management of the distal ureter during radical robotic nephroureterectomy.

We describe "The Lister Technique"-a new 3 step procedure developed in our department for robotic assisted laparoscopic nephroureterectomy (RANU). Our new technique facilitates the complete excision of the whole ureter including ureteric orifice and reduces this risk of tumour spillage from the distal ureter without the need for bivalving the bladder. Our initial data indicates that the technique is associated with reduction in bladder recurrence post-operatively in comparison to current published series. Longer follow up and larger patient numbers are required to validate these results further.

Robot-assisted nephroureterectomy for upper tract urothelial carcinoma: Initial experience

ObjectiveTo report our early experience with robot-assisted laparoscopic nephroureterectomy (RANU) for upper tract urothelial carcinoma (UTUC). Materials and methodsFour consecutive patients with a diagnosis of renal pelvic or ureteral urothelial carcinoma underwent RANU. We performed RANU by redocking the robot after the nephrectomy without repositioning the patient for excision of the distal ureter and bladder cuff. ResultsThree women and one man with a mean age of 72.3 years and mean body mass index (BMI) of 24.25 kg/m2 underwent RANU for right-sided renal pelvic or ureteral urothelial carcinoma. The mean operative time was 495 minutes (range 390–540 minutes), estimated blood loss was 52.5 mL (range 10–100 mL), and mean hospital stay was 5.5 days. Pathology data revealed all specimens were high grade carcinoma with one specimen each staged Ta, T1, T2, and T3. After a mean follow-up of 14.25 months (range 12–18 months), no intravesical recurrence developed in the bladder, and no patients developed distant metastasis. ConclusionOur early experience showed that RANU is a safe and feasible minimally invasive procedure for UTUC.

Intermediate-Term Outcomes of Robot-Assisted Laparoscopic Nephroureterectomy in Upper Urinary Tract Urothelial Carcinoma

BackgroundThe purpose of this study was to evaluate the intermediate-term oncological outcomes after (RAL-NU) for UUT-UC. Patients and MethodsBetween May 2007 and December 2010, 32 patients with UUT-UC underwent RAL-NU. Data were obtained from a prospectively maintained database. ResultsMedian patient age was 66.5 years. Final pathological stage was pathologic stage Ta (pTa) in 12.5% (n = 4) of patients, pT1 in 28.1% (n = 9), pT2 in 18.8% (n = 6), pT3 in 40.6% (n = 13), and pT4 in 0%. High-grade lesions were present in 81.2% (n = 26) of patients and multifocal disease was present in 25.0% (n = 8). Positive surgical margins occurred in 1 patient. Median follow-up was 45.5 months (range, 24-65). At 2 and 5 years, overall survival was 81.3% and 60.9%; cancer-specific survival was 87.3% and 75.8%, and nonurothelial recurrence-free survival was 71.5% and 68.1%, respectively. On univariate analysis, female sex, positive surgical margins, and pathological tumor stage pT2 and higher are associated with reduced recurrence-free survival (P = .035 and .011, respectively). On multivariate analysis, only female sex and pathological stage pT2 or higher were significant factors (P = .020 and .049, respectively). No factors were found to affect cancer-specific survival. ConclusionTo our knowledge, this represents the largest and longest follow-up after RAL-NU to date. Intermediate-term oncological outcomes seem comparable with those of open and laparoscopic nephroureterectomy. We recommend further larger studies with longer follow-up periods to further define the role of RAL-NU in the treatment of UUT-UC.

Robotic-assisted laparoscopic day-case nephroureterectomy

Objective: The objective of this article is to describe our initial experience of performing day-case robotic-assisted laparoscopic nephroureterectomy. Subjects/patients and methods: Based on our previous experience of performing day-case laparoscopic nephrectomies, a standardised surgical and anaesthetic procedure, and patient selection criteria were applied to two patients undergoing nephroureterectomy. Results: Both patients underwent successful robotic-assisted laparoscopic nephroureterectomy for upper tract transitional cell carcinoma and were discharged home on the day of surgery. Neither experienced a post-operative complication or required hospital admission. Conclusion: Day-case nephroureterectomy is a viable option in appropriately selected patients. We present the first report of nephroureterectomies performed as day-case surgery.

Current Status of Robot Assisted Laparoscopic Radical Nephroureterectomy for Management of Upper Tract Urothelial Carcinoma

Upper tract urothelial carcinomas (UUT-UC) are usually aggressive tumours and require radical treatments. The standard of care for localised UUT-UC is radical nephroureterectomy (RNU). Robot-assisted laparoscopic surgeries are currently employed in various urological procedures, including RNU. We conducted a literature search on medical databases (PubMed/ MEDLINE) using free text keywords nephroureterectomy, distal ureter, bladder cuff, urothelial carcinoma and/or robotic. In this review, we aim to provide an up-to-date status on robot-assisted laparoscopic nephroureterectomy (RAL-NU) for the management of UUT-UC. The various surgical techniques and approaches for RAL-NU and retroperitoneal lymph node dissection (RPLND) will be discussed and their perioperative and early oncological outcomes reported. The feasibility and safety of RAL-NU has been demonstrated in a number of studies but intermediate and long term clinical and oncological outcomes are still lacking.