Robot-assisted Radical Nephroureterectomy Research Articles

Initial Experience and Surgical Setup of Robot-Assisted Nephroureterectomy Using the Hugo Robot-Assisted Surgery System.

Robot-assisted radical nephroureterectomy (RANU) has emerged as a valid alternative to open or laparoscopic nephroureterectomy in recent years. However, different types of robotic platforms can limit surgical maneuvers in various ways. This study aimed to describe the surgical procedure and demonstrate RANU's technical feasibility and safety using the Hugo robot-assisted surgery (RAS) system. Using the Hugo RAS system, we reported data from the first five consecutive patients who underwent RANU at Tottori University Hospital. We adjusted the docking angles of the four independent arm carts in each case and performed a complete RANU via a transperitoneal approach. We collected patients' sociodemographic and perioperative data, including complications, and compared them retrospectively with data obtained using the da Vinci surgical system. Arms positions were modified after the first patient to be placed all at the back of the patient. Median overall operative time was 283 min (203-377) and the median time using the robotic system was 187 min (121-277). The median estimated blood loss was 20 mL (5-155). None of the patients required a blood transfusion and none suffered postoperative complications of Clavien-Dindo grade ≥3. These outcomes were similar to those obtained with the da Vinci Xi system. This series represents the first report of RANU executed using the novel Hugo RAS system. Our proposed arm-setup will assist other surgeons and help ensure safe implementation of RANU on the Hugo platform.

Initial Experience and Surgical Setup of Robot-Assisted Nephroureterectomy Using the Hugo Robot-Assisted Surgery System.

Robot-assisted radical nephroureterectomy (RANU) has emerged as a valid alternative to open or laparoscopic nephroureterectomy in recent years. However, different types of robotic platforms can limit surgical maneuvers in various ways. This study aimed to describe the surgical procedure and demonstrate RANU's technical feasibility and safety using the Hugo robot-assisted surgery (RAS) system. Using the Hugo RAS system, we reported data from the first five consecutive patients who underwent RANU at Tottori University Hospital. We adjusted the docking angles of the four independent arm carts in each case and performed a complete RANU via a transperitoneal approach. We collected patients' sociodemographic and perioperative data, including complications, and compared them retrospectively with data obtained using the da Vinci surgical system. Arms positions were modified after the first patient to be placed all at the back of the patient. Median overall operative time was 283 min (203-377) and the median time using the robotic system was 187 min (121-277). The median estimated blood loss was 20 mL (5-155). None of the patients required a blood transfusion and none suffered postoperative complications of Clavien-Dindo grade ≥3. These outcomes were similar to those obtained with the da Vinci Xi system. This series represents the first report of RANU executed using the novel Hugo RAS system. Our proposed arm-setup will assist other surgeons and help ensure safe implementation of RANU on the Hugo platform.

Decisional and prognostic impact of diagnostic ureteroscopy in high-risk upper tract urothelial carcinoma: A multi-institutional collaborative analysis (ROBUUST collaborative group)

BackgroundDiagnostic ureteroscopy (URS) with or without biopsy remains a subject of contention in the management of upper tract urothelial carcinoma (UTUC), with varying recommendations across different guidelines. The study aims to analyse the decision-making and prognostic role of diagnostic ureteroscopy (URS) in high-risk UTUC patients undergoing curative surgery. Materials and methodsIn this retrospective multi-institutional analysis of high-risk UTUC patients from the ROBUUST dataset, a comparison between patients who received or not preoperative URS and biopsy before curative surgery was carried out. Logistic regression analysis evaluated differences between patients receiving URS and its impact on treatment strategy. Survival analysis included 5-year recurrence-free survival (RFS), metastasis-free survival (MFS), cancer-specific survival (CSS) and overall survival (OS). After adjusting for high-risk prognostic group features, Cox proportional hazard model estimated significant predictors of time-to-event outcomes. ResultsOverall, 1,912 patients were included, 1,035 with preoperative URS and biopsy and 877 without. Median follow-up: 24 months. Robot-assisted radical nephroureterectomy was the most common procedure (55.1%), in both subgroups. The 5-year OS (P = 0.04) and CSS (P < 0.001) were significantly higher for patients undergoing URS. The 5-year RFS (P = 0.6), and MFS (P = 0.3) were comparable between the 2 groups. Preoperative URS and biopsy were neither a significant predictor of worse oncological outcomes nor of a specific treatment modality. ConclusionsThe advantage in terms of OS and CSS in patients undergoing preoperative URS could derive from a better selection of candidates for curative treatment. The treatment strategy is likely more influenced by tumor features than by URS findings.

Safety and oncological outcome of early intraoperative intravesicle mitomycin C vs. deferred instillation in patients receiving robot-assisted radical nephroureterectomy.

Radical nephroureterectomy with concurrent bladder cuff excision (RNUBCE) is the gold standard surgical approach for high-risk primary upper tract urothelial carcinoma (UTUC). Given the notably high incidence of bladder tumor recurrence following this procedure, this study aimed to evaluate the effect and safety of intraoperative mitomycin-C (MMC) instillation vs. deferred instillation on overall oncological outcomes following robot-assisted RNUBCE. This is a retrospective chart review study. Patients with non-invasive (N0, not T3/T4) UTUC who underwent robotic RNUBCE combined an intraoperative MMC instillation or a deferred MMC instillation after surgery at a medical center in Taiwan between November 2013 and June 2020 were eligible for inclusion. Patients with prior bladder UC, carcinomas of other origins, received neoadjuvant chemotherapy, and had undergone kidney transplantation were excluded. All surgeries were executed by a single surgical team under the guidance of the same surgeon. The primary outcomes was the risk of bladder tumor recurrence between patients received intraoperative (IO) vs. deferred MMC instillation postoperatively (PO) during one-year follow-up. The secondary outcome was postoperative adverse events assessed by the Clavien-Dindo classification. Univariate and multivariable Cox regression analyses were performed to determine the associations between study variables and the outcomes. A total of 54 patients were included in the analysis. 12 (22.2%) patients experienced a bladder tumor recurrence during follow-up (IO: 7.7%, PO: 35.7%, p < 0.021). After adjustment in the multivariable, intraoperative MMC instillation was significantly associated with lower risk of bladder recurrence [adjusted hazard ratio (aHR) = 0.15, 95% CI: 0.03-0.81, p = 0.028]. No MMC-related Clavien-Dindo Grade III-IV adverse events were found in either group. IIntraoperative MMC instillation is safe and associated with a lower bladder tumor recurrence risk in patients undergoing robotic RNUBCE for UTUC than deferred instillation. Future large, prospective studies are still warranted to confirm the findings.

Robot-Assisted Radical Nephroureterectomy Using the KangDuo Surgical Robot-01 System: A Prospective, Single-Center, Single-Arm Clinical Study.

To investigate the feasibility, safety, and efficacy of the KangDuo Surgical Robot-01 (KD-SR-01) system for robot-assisted radical nephroureterectomy (UTUC). This prospective, single-center, single-arm clinical study of patients with UTUC was conducted from August 2022 to July 2023 using the KD-SR-01 system. The perioperative and follow-up data were prospectively recorded. The National Aeronautics and Space Administration Task Load Index was calculated to present ergonomics. The technique was described in detail. A total of 13 patients underwent RARNU. None of the cases conversed to laparoscopic surgery or open surgery. The median docking time and console time were 524 (range, 139-963) seconds and 102.2 (range, 55.3-249.3) minutes, respectively. The median estimated blood loss was 40 (range, 10-100) ml. None of the patients required intraoperative blood transfusion. The median postoperative hospital stay was 4 (range, 2-7) days. Intraoperative or postoperative complications (Clavien-Dindo grade I) occurred in 9 patients. The surgeon Task Load Index global score achieved 1.05±1.86. Three patients received the single-docking technique, demonstrating similar perioperative results compared to patients with re-docking. The KD-SR-01 system was feasible, safe, and effective for robot-assisted radical nephroureterectomy.

Robot-assisted radical nephroureterectomy for upper urinary tract tumor: initial experience with the use of novel surgical robot system, hinotori.

The hinotori surgical robot system is a promising robotic platform that has been recently introduced into routine clinical practice. The aim of this study was to report our initial experience of robot-assisted radical nephroureterectomy (RANU) using hinotori. This study included a total of eight patients with upper urinary tract tumor (UUTT) who underwent RANU using hinotori via the transperitoneal approach. In this series, nephrectomy was initially performed at the kidney direction stage followed by distal ureterectomy and bladder cuff excision at the bladder direction stage without repositioning of patient or port. Lymphadenectomy was performed at either stage. Median age, body mass index, and tumor diameter were 76 years, 21.7 kg/m2, and 13 mm, respectively. Of eight patients, three were diagnosed with renal pelvic tumors and five with lower ureteral tumors. They underwent lymphadenectomy targeting the renal hilum plus para-aorta and the pelvis, respectively. All procedures in this series were completed without conversion to open surgery. Median operative time, time using the robotic system, estimated blood loss, and length of hospital stay were 230 minutes, 138 minutes, 23 mL, and 8 days, respectively. No major perioperative complication occurred. Pathological examinations of the tumors revealed seven urothelial carcinomas and one papilloma, the median number of resected lymph nodes was 13, and one patient was positive for both cancer margin and lymph node metastases. Despite being a small case series, this is the first study characterizing RANU using the hinotori surgical robot system. RANU was efficaciously and safely performed, resulting in the achievement of favorable perioperative findings.

Minimally Invasive Radical Nephroureterectomy: 5-Year Update of Techniques and Outcomes.

The gold standard treatment for non-metastatic upper tract urothelial cancer (UTUC) is represented by radical nephroureterectomy (RNU). The choice of surgical technique in performing UTUC surgery continues to depend on several factors, including the location and extent of the tumor, the patient's overall health, and very importantly, the surgeon's skill, experience, and preference. Although open and laparoscopic approaches are well-established treatments, evidence regarding robot-assisted radical nephroureterectomy (RANU) is growing. Aim of our study was to perform a critical review on the evidence of the last 5 years regarding surgical techniques and outcomes of minimally invasive RNU, mostly focusing on RANU. Reported oncological and function outcomes suggest that minimally invasive RNU is safe and effective, showing similar survival rates compared to the open approach.

Perioperative, renal function and oncological outcomes of robot-assisted radical nephroureterectomy for patients with upper tract urothelial carcinoma.

To report perioperative, renal function and oncological outcomes of robot-assisted radical nephroureterectomy (RNU) for patients with upper tract urothelial carcinoma (UTUC). This was a retrospective single-arm monocentric study including all consecutive UTUC patients treated with robot-assisted RNU at our institution between 2014 and 2022. Descriptive statistics with median and interquartile range (IQR) for continuous variables and numbers with frequencies for categorical variables were used to report perioperative and renal function outcomes while Kaplan-Meier curves were computed to present extravesical and intravesical recurrence-free survival(RFS) as well as cancer-specific (CSS) and overall survival (OS) with the corresponding 95% confidence intervals(CIs). Overall, 70 patients with a median age of 69.6 [63.3-74.9] years were included in our study. With regards to perioperative outcomes, the median operative time was 157 [130-182] min with a median blood loss of 200 [100-300] cc. Intraoperative complications occurred in 4 (5.7%) patients but no conversion to open or laparoscopic surgery was required. Postoperative complications occurred in 9 (12.9%) patients, including 5 (7.1%) with grade ≥ 3 complications according to the Clavien-Dindo classification. The median length of stay was 4 [3-6] days. With regards to renal function outcomes, the median postoperative loss in estimated glomerular filtration rate at discharge was 16 [10.25-26] mL/min/1.73 m2. With regards to oncological outcomes, the 3-year extravesical and intravesical RFS, CSS and OS rates were 73.6 [62.8-86.2]%, 68.1 [54.6-85]%, 82.5 [72-94.4]% and 75.3 [63.4-89.5]%, respectively. We report favorable perioperative and oncological outcomes with expected decrease in renal function after robot-assisted RNU for patients with UTUC.

MP68-13 THE PREVALENCE OF PORT-SITE INCISIONAL HERNIA AFTER UROLOGIC ROBOT-ASSISTED LAPAROSCOPIC SURGERY: A SINGLE-CENTER RETROSPECTIVE STUDY

You have accessJournal of UrologyCME1 Apr 2023MP68-13 THE PREVALENCE OF PORT-SITE INCISIONAL HERNIA AFTER UROLOGIC ROBOT-ASSISTED LAPAROSCOPIC SURGERY: A SINGLE-CENTER RETROSPECTIVE STUDY Lek Hong Tan, Guan Heng Chen, Chao Hsiang Chang, Chi Rei Yang, Chi Ping Huang, and Hsi Chin Wu Lek Hong TanLek Hong Tan More articles by this author , Guan Heng ChenGuan Heng Chen More articles by this author , Chao Hsiang ChangChao Hsiang Chang More articles by this author , Chi Rei YangChi Rei Yang More articles by this author , Chi Ping HuangChi Ping Huang More articles by this author , and Hsi Chin WuHsi Chin Wu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003331.13AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Port-site incisional hernia is a rare but potentially dangerous complication following laparoscopic surgery. However, only sporadic studies reported this complication after robotic surgery. Therefore, this study investigates the prevalence of port-site incisional hernia after urologic robot-assisted laparoscopic surgery. METHODS: This is a retrospective, single-center, observational study. Medical records were reviewed for 1295 patients who underwent urologic robot-assisted laparoscopic surgery from September 2013 to September 2021. The prevalence of port-site incisional hernia of robot-assisted radical prostatectomy (RARP), robot-assisted partial nephrectomy (RAPN), robot-assisted radical cystectomy (RARC), and robot-assisted radical nephroureterectomy with bladder cuff excision (RANUBCE) was computed. In addition, the association between uremic status and the post-operative port-site incisional hernia was shown with an odd ratio (OR) against a reference group. RESULTS: Among 527 patients who underwent RARP, 9 patients suffered from port-site incisional hernia (1.71%; 95% CI: 0.90%, 3.22%), 1 out of 154 patients in RAPN (0.65%; 95% CI: 0.11%, 3.59%), 4 out of 46 patients in RARC (8.70%; 95% CI: 3.44%, 20.33%), and 4 out of 136 patients in RANUBCE (2.94%; 95% CI: 1.15%, 7.32%). For all 4 patients who suffered from port-site incisional hernia after undergoing RARC, their neobladders were constructed extracorporeally, of which 2 performed ileal conduit, Studer pouch in 1 patient, and another one underwent J-pouch construction. The average time to occurrence of port-site incisional hernia was 366 days and the longest time to occurrence was 1129 days. Most of the incisional hernia occurred at the camera port site (70.59%; 95% CI: 46.87%, 86.72%), and uremic status is associated with a higher tendency to suffer from port-site incisional hernia (OR= 3.68, p<0.05). CONCLUSIONS: RARC has a higher prevalence rate of port-site incisional hernia, among other types of urologic robot-assisted surgery. Incisional hernia tends to occur in RARC with extracorporeal neobladder construction. In addition, the port-site incisional hernia is associated with the larger port size and the uremic status of the patients. Source of Funding: No © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e958 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Lek Hong Tan More articles by this author Guan Heng Chen More articles by this author Chao Hsiang Chang More articles by this author Chi Rei Yang More articles by this author Chi Ping Huang More articles by this author Hsi Chin Wu More articles by this author Expand All Advertisement PDF downloadLoading ...

Robot-assisted radical nephroureterectomy for upper tract urothelial carcinoma: Peri and postoperative outcomes

IntroductionThe treatment of urothelial tumours of the upper urinary tract at high risk of specific mortality is based on radical nephroureterectomy (RNU). Robotic-assisted laparoscopic radical nephroureterectomy (RARNU) is still under investigation to definitively establish the safety of this procedure in the management of urothelial tumours of the upper urinary tract. The primary objective is to evaluate the intra- and postoperative safety of RARNU and, subsequently, to evaluate the medium-term oncological results. MethodsOur study is a retrospective, mono-centric study with a collection of RARNUs conducted between 1st January 2015 and 1st October 2021. The RARNUs were performed with the assistance of the Da Vinci Si® robot, then from 2017 the Da Vinci Xi® robot. Whenever possible, the entire procedure was carried out without re-docking. ResultsBetween 1st January 2015 and 1st October 2021, 29 RARNUs were carried out at our centre. Complete surgery without re-docking was possible in 80% of cases with the Da Vinci Xi® robot. One patient required conversion to open surgery due to difficult dissection. 50% of tumours were classified as T3 or T4. The 30-day complication rate was 31%. The median length of hospitalisation was 5 days. The disease-free survival at the mean survival time (27.5 months) was of 75.2%. One patient had a recurrence in the nephrectomy compartment and no patient had a peritoneal or trocar orifice recurrence. ConclusionPerforming RARNU for the management of tumours of the upper urinary tract appears to meet the criteria of surgical safety and those of oncological safety.

Comparison of Perioperative Outcomes and Complications of Laparoscopic and Robotic Nephroureterectomy Approaches in Patients with Upper-Tract Urothelial Carcinoma.

For medical institutions without robotic equipment, it remains uncertain whether laparoscopic radical nephroureterectomy (LNU) can achieve results similar to those of robotic surgery for the treatment of upper tract urothelial carcinoma (UTUC). This meta-analysis aimed to compare the efficacy and safety of robot-assisted radical nephroureterectomy (RANU) with that of LNU using a large sample size of patients. A systematic meta-analysis was performed using data (available to May 2022) acquired from multiple scientific databases. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and Assessing the Methodological Quality of Systematic Reviews (AMSTAR) guidelines, according to the protocols registered with PROSPERO (CRD42021264046), were followed to perform this cumulative analysis. Nine high-quality studies were included in this analysis, considering factors such as operative time (OT), estimated blood loss (EBL), length of hospital stay (LOS), positive surgical margins (PSM), and complications. Statistical indicators revealed no significant differences between the RANU and LNU groups in terms of OT (weighted mean difference [WMD] 29.41, 95% confidence interval [CI] -1.10 to 59.92; p=0.22), EBL (WMD -55.30, 95% CI -171.14 to 60.54; p=0.13), LOS (WMD -0.39, 95% CI -1.03 to 0.25; p=0.12), PSM (odds ratio [OR] 1.22, 95% CI 0.44-3.36; p=0.17], or complications (OR 0.91, 95% CI 0.49-1.69; p=0.13). The meta-analysis showed that the perioperative and safety indicators of both RANU and LNU were similar and both showed favorable outcomes in UTUC treatment. However, some uncertainties remain in the implementation and selection of lymph nodes for dissection.

Robotic nephroureterectomy in the management of upper tract urothelial cancer: inching toward standard of care?

Upper-tract urothelial carcinoma is a relatively rare malignancy. Current guidelines strongly recommend radical nephroureterectomy with bladder cuff excision and template-based lymph node dissection for all high-risk upper-tract urothelial carcinomas. Although the open approach is still considered the standard of care, evolution of minimally invasive approaches especially the robotic-assisted approach, has been found to be oncologically equivalent. Since its initial description in 2006, the surgical technique as well as the robotic surgical system has gone through a major evolution. With well-established advantages of the minimally invasive approach, robotic radical nephroureterectomy also has the ability to address both upper and lower urinary tract simultaneously without the need of patient repositioning, standardized single docking technique, ease of performing crucial steps like excision of ureterovesical junction and bladder cuff with watertight cystotomy closure, allowing perioperative instillation of intra-vesical chemotherapy. Robot-assisted radical nephro-ureterectomy and template-based lymph node dissection is gradually emerging as the current standard of care to achieve the best possible oncologic and functional outcomes. In this review article we are focusing on the evolution of this approach in the management of upper-tract urothelial carcinoma along with a review of oncologic outcomes.

VE38 - Robot-assisted radical nephroureterectomy with extravesical excision of the intramural segment of the ureter

VE38 - Robot-assisted radical nephroureterectomy with extravesical excision of the intramural segment of the ureter

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.

SC138 - Radical nephroureterectomy pentafecta: a proposal for standardisation of oncologic outcomes reporting following open, laparoscopic or robot-assisted radical nephroureterectomy

SC138 - Radical nephroureterectomy pentafecta: a proposal for standardisation of oncologic outcomes reporting following open, laparoscopic or robot-assisted radical nephroureterectomy

Robot-Assisted Radical Nephroureterectomy.

First proposed by Kimball and Ferris in 1933 for the treatment of papillary tumors in the upper urinary tract, radical nephroureterectomy (RNU) with bladder cuff excision remains the gold standard for management of high-risk upper tract urothelial carcinoma involving the proximal ureter and/or pelvicaliceal system. Over three decades since the first description of laparoscopic RNU, minimally invasive approaches to RNU have continued to evolve and become increasingly utilized. More recently, robot-assisted RNU (RARNU) has increasingly become a viable approach. Specifically, RARNU affords a reduction in perioperative morbidity and improved convalescence as a minimally invasive approach, all while adhering to traditional open surgical principles and providing surgeons with improved technical ergonomics and streamlined operating room logistics, particularly with the advent of the da Vinci Xi platform. In this study, we describe our approach to transperitoneal RARNU, including indications, operating room setup, step-by-step surgical technique, and perioperative care.

P0793 - Radical nephroureterectomy pentafecta: A proposal for standardisation of oncologic outcomes reporting following open, laparoscopic or robot-assisted radical nephroureterectomy

P0793 - Radical nephroureterectomy pentafecta: A proposal for standardisation of oncologic outcomes reporting following open, laparoscopic or robot-assisted radical nephroureterectomy

Robot-assisted versus open radical nephroureterectomy for urothelial carcinoma of the upper urinary tract: A retrospective cohort study across ten years

PurposeRadical nephroureterectomy is the gold standard of treatment for high-risk non-metastatic urothelial carcinoma of the upper urinary tract. However, the optimal surgical approach remains a controversial debate. This study compared the perioperative and oncological outcomes of open and robot-assisted radical nephroureterectomies. Methods131 consecutive radical nephroureterectomies (66 robot-assisted nephroureterectomies vs. 65 open nephroureterectomies) for urothelial carcinoma of the upper urinary tract at a single tertiary referral center were included from 2009 to 2019. The perioperative and oncological outcomes were compared between both surgical approaches, including logistic regression analysis, propensity score matching, Kaplan Meier analyses, and Cox regression models. ResultsOverall, robot-assisted surgery had less blood loss (150 ml vs. 250, p = 0.004) and less positive surgical margins (1.5% vs. 15.4%, p = 0.004) at a comparable operating time (robotic 188min vs. 178). Any grade complications were more frequent after open surgery (40.9% vs. 63.1%, p = 0.011), and the length of stay was shorter after robotic nephroureterectomy (9 days vs. 12, p < 0.001). These differences remained significant in the propensity score matched analysis, except for the complication rates, which were still lower for the robotic approach, but no longer significant. At a median follow-up of 30.9 months (range 1.4–129.5), neither the progression-free survival (PFS, 2-year: robotic 66.7% vs. open 55.3%), nor the overall survival differed significantly (OS, 2-year: robotic 76.2% vs. open 68.4%). In the Cox regression, the surgical approach did not impact the PFS or OS. Lymph node metastases (HR 3.32, p = 0.008) had the strongest impact on the PFS besides patient age (HR 1.51 per 10 years, p = 0.025) and prior cystectomy (HR 2.42, p = 0.026) in the multivariate analysis. ConclusionsRobot-assisted radical nephroureterectomy had significant perioperative advantages at comparable oncological outcomes compared to open surgery for the treatment of urothelial carcinoma of the upper urinary tract at a high volume center, experienced in robotic surgery.

Safety and feasibility of early single-dose mitomycin C bladder instillation after robot-assisted radical nephroureterectomy.

To assess the safety and feasibility of early single-dose mitomycin C (MMC) bladder instillation after robot-assisted radical nephroureterectomy (RARNU) at a tertiary kidney cancer centre. RARNU with bladder cuff excision and subsequent MMC bladder instillation to reduce recurrence risk is the 'gold standard' for high-risk upper urinary tract urothelial carcinoma (UUTUC). We adapted a RARNU technique with precise distal ureteric dissection, bladder cuff excision and watertight bladder closure. We retrospectively reviewed all patients undergoing RARNU for UUTUC at our centre performed as a standardised transperitoneal procedure comprising of: bladder cuff excision, two-layer watertight closure and intraoperative bladder leak test; without re-docking/re-positioning of the robotic surgical system. Patient demographics, the timing of MMC instillation, adverse events (surgical and potentially MMC-related) and length of stay (LOS) were assessed according to the Clavien-Dindo classification. A total of 69 patients underwent a RARNU with instillation of MMC. The median (interquartile range [IQR]) age was 70(62-78) years. The median (IQR) day of MMC instillation was 2(1-3)days and the median (IQR) LOS was 2(2-4)days, with urethral catheter removal on day of discharge in all cases. Only Grade I Clavien-Dindo complications occurred in seven patients (10%); five had ileus, one a wound infection and one a self-limiting delirium, all managed conservatively. No adverse events potentially related to MMC instillation were noted within 30days postoperatively. The use of intravesical MMC instillation given in the immediate postoperative period appears feasible and safe in patients undergoing RARNU with intraoperative confirmation of a water-tight closure ensuring early catheter-free discharge, with no significant adverse events. The potential reduction in intravesical recurrence in patients receiving early MMC needs to be assessed with longitudinal follow-up studies.

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

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