Robot-assisted Radical Nephroureterectomy Research Articles

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

Fate of residual ureteral stump in patients undergoing robot-assisted radical nephroureterectomy for high-risk upper tract urothelial carcinoma.

BackgroundManagement of the distal ureter in radical nephroureterectomy and bladder cuff excision (RNUBCE) is paramount, directly influencing oncologic outcomes. Herein, we analyze the natural history of patients who have undergone robotic radical nephroureterectomy without formal bladder cuff excision and retained ureteral stump and compare this cohort with patients undergoing formal RNUBCE for high-risk upper tract urothelial carcinoma (UTUC).MethodsFrom February 2008 to October 2018, all patients who underwent robotic RNUBCE by multiple surgeons in a single institution for high-risk UTUC were reviewed. Preoperative, perioperative, and postoperative variables were investigated. Overall survival, cancer specific survival, local recurrence-free survival, distant recurrence-free survival, and bladder recurrence-free survival were compared between the two cohorts. Further management treatments were explored for patients with retained ureteral stump. Follow-up consisted of abdominopelvic/chest imaging and cystoscopy at regular intervals.ResultsA total of 105 patients underwent robotic RNU during the above time period. Of patients with documented 6-month follow-up, approximately 6.6% of patients had retained ureteral stump. Median follow-up for the entire cohort was 31.5 months with a range of 6 to 114.2 months. Factors that precluded formal BCE were densely, fibrotic reaction near the ureterovesical junction due to prior vascular or pelvic surgery in 5 patients, severe pyonephrosis and continued anesthetic risk in one patient, and surgeon choice (patient co-morbidities) in another patient. Three patients died with metastatic disease and one patient succumbed to cardiovascular compromise. Two additional patients developed local recurrence only at the level of the ureteral stump, with one patient undergoing eventual distal excision, contralateral RNUBCE and radical cystectomy.ConclusionsIn these cases, responsibilities assumed by the surgeon demand the utmost in judgement and skill; however, at times, circumstances prevail such as patient factors and nature/biology of the disease. These factors may prevent adequate excision the complete ureter, ureterovesical junction, and bladder cuff at the time of RNU. In this robotic cohort of patients undergoing RNUBCE for UTUC, not excising the most distal part of the ureter directly translates to inferior oncologic outcomes. Complete ureteral excision with bladder cuff should be performed where possible as this is an integral part of the radical nephroureterectomy. Also, if feasible, adjunctive chemotherapy/immunotherapy treatments should be considered.

220P - An outcome analysis of robotassisted radical nephroureterectomy with extended template lymphadenectomy for upper tract urothelial carcinoma

BackgroundThe leading treatment option for nonmetastatic upper tract urothelial carcinoma in current era is robotassisted radical nephroureterectomy (RANU) with extended template lymphadenectomy (ELND). Due to the rarity of this disease, there is a lack of consensus regarding the best approach and the extent of lymphadenectomy. We report our technique and its initial outcomes from the retrospective evaluation of a prospectively maintained database of 22 consecutive cases of RANU + ELND. MethodsRANU was performed in 22 patients (including two patients with simultaneous radical cystectomy) with the da Vinci Xi system. Pelvic and upper ureteric tumors were operated without redocking or repositioning, using the port hopping feature. For the lower ureteric tumors, the patient was repositioned and the robot was redocked to ensure completeness of pelvic lymphadenectomy. ELND was performed in all the patients as per the templates described in previous studies. ResultsMedian age was 61.72 years (range 46–76). Median console time and blood loss were 170 min (range 156–270) and 150 cc (range 25–500), respectively. Median hospital stay was 3 days (range 2–8). One patient developed paralytic ileus in the postoperative period (Clavien Dindo Grade 1). None had a positive surgical margin and the median lymph node yield was 22.5 (range 7–47). One patient had a papillary renal cell carcinoma and one patient had no evidence of malignancy in final histopathology report. Median followup was 10.5 months during which one patient developed metastatic systemic recurrence. All other patients were disease free at the last followup.Table220P Demographic profile, intraoperative, and postoperative dataUnlabelled ImageNumber of RANU cases, (n)22Side right:left11:11Location Renal pelvic and upper ureteric Mid ureteric Lower ureteric12 4 6Open conversion1 (only for pelvic part of surgery)Median length of stay (range), days3 (28)Templatebased lymphadenectomy22 (100%)Median lymph node yield (range)22.5 (range 7–47)Margin positivity0%Pathological grade* High grade Low grade12 8Pathological T stage* pTa pT1 pT2 pT31 9 2 8Pathological Lymph node status N0 N117 5Adjuvant chemotherapy6Recurrence1*One patient had a papillary renal cell carcinoma and one patient had no evidence of malignancy in final histopathology report. ConclusionsA robotic approach to radical nephroureterectomy with ELND is feasible and safe and does not appear to compromise the shortterm oncological outcomes as defined by lymph node yields and margin positivity. At the same time, it offers the benefits of minimal invasion and results in swifter patient recovery from this extensive surgery. Legal entity responsible for the studyThe authors. FundingHas not received any funding. DisclosureAll authors have declared no conflicts of interest.

P093 - An outcome analysis of robot-assisted radical nephroureterectomy with extended template lymphadenectomy for upper tract urothelial carcinoma

P093 - An outcome analysis of robot-assisted radical nephroureterectomy with extended template lymphadenectomy for upper tract urothelial carcinoma

PE59 - Is robot-assisted radical nephroureterectomy with bladder cuff excision superior to pure laparoscopic approach in the treatment of upper urinary tract urothelial carcinoma?

PE59 - Is robot-assisted radical nephroureterectomy with bladder cuff excision superior to pure laparoscopic approach in the treatment of upper urinary tract urothelial carcinoma?

Robot-assisted radical nephroureterectomy with extended template lymphadenectomy for upper tract urothelial carcinoma: An outcome analysis.

Introduction:Robot-assisted radical nephroureterectomy (RANU) with extended template lymphadenectomy (E-LND) is the leading treatment option for nonmetastatic upper tract urothelial carcinoma. Due to the rarity of this disease, there is a lack of consensus regarding the best approach and the extent of lymphadenectomy. We report our technique and its initial outcomes from the retrospective evaluation of a prospectively maintained database of 11 consecutive cases of RANU + E-LND. To the best of our knowledge, our series represents the first published experience of this procedure from India.Materials and Methods:RANU was performed in 11 patients (including two patients with simultaneous radical cystectomy) with the da Vinci Xi system. Pelvic and upper ureteric tumors were operated without re-docking or repositioning, using the port hopping feature. For the lower ureteric tumors, the patient was repositioned and the robot was re-docked to ensure completeness of pelvic lymphadenectomy. E-LND was performed in all the patients as per the templates described in previous studies.Results:Median age was 67.5 years (range 52–71). Median console time and blood loss were 170 min (range 156–270) and 150 cc (range 25–500), respectively. Median hospital stay was 3 days (range 2–8). One patient developed paralytic ileus in the postoperative period (Clavien Dindo Grade 1). None had a positive surgical margin and the median lymph node yield was 22.5 (range 7–47). Median follow-up was 9 months during which one patient developed metastatic systemic recurrence. All other patients were disease free at the last follow-up.Conclusions:A robotic approach to radical nephroureterectomy with E-LND is feasible and safe and does not appear to compromise the short-term oncological outcomes as defined by lymph node yields and margin positivity. At the same time, it offers the benefits of minimal invasion and results in swifter patient recovery from this extensive surgery.

Evaluation of Perioperative Complications and Outcomes of Robot-assisted Radical Nephroureterectomy and Bladder Cuff Excision in a Tertiary Center

Purpose: For patients with localized upper tract urothelial carcinoma (UTUC), radical nephroureterectomy with ipsilateral bladder cuff excision (RNU + BCE) is the standard treatment. In recent years, robot-assisted RNU with BCE (RaRNU + BCE) has been another choice of surgical intervention. This article was aimed to analyze the efficacy and perioperative outcomes regarding RaRNU + BCE through a single institutional experience. Patients and Methods: From March 2012 to November 2015, a total of 54 patients with UTUC were treated with RaRNU + BCE at Taipei Veterans General Hospital. We collected demographic data, histopathological reports, perioperative complications, and oncologic outcomes. Results: A total of 54 patients were included in our study. The mean age was 71.9 ± 9.9 (range 48–88) and the mean body mass index was 23.5 ± 2.9 (range: 16.4–30.8). The mean operating time was 314 min (RaRNU: 133.9 ± 41.4 min and RaBCE: 72.9 ± 25.7 min). The mean first docking time was 26.8 ± 7.7 min and the mean second docking time was 16.5 ± 6.7 min. The mean EBL was 87.7 ml. Pathological stage distribution was 22.2%, 27.8%, 13.0%, 31.5%, and 5.6% in pTa, pT1, pT2, pT3, and pT4, respectively. Complications occurred in 7 cases (13%), with 4 Grade I and 3 Grade II by Clavien-Dindo classification. Positive tumor involvement at bladder cuff was noted in three patients, and the bladder recurrence rate was 29.6%. Local recurrence, lymph node metastasis, and distant metastasis were all noted for two patients, respectively. The cancer-specific and overall survival rate was 98.1% and 96.3%. Conclusions: Our experience showed that RaRNU + BCE is a technically feasible and safe procedure for selected patients with UTUC.

Evaluation of peri-operative complications and outcomes of robot-assisted radical nephroureterectomy and bladder cuff excision in a tertiary center

ObjectiveFor patients with localized upper tract urothelial carcinoma (UTUC), radical nephroureterectomy with ipsilateral bladder cuff excision (RNU + BCE) is the standard treatment. In recent years, robot-assisted RNU with BCE (RaRNU + BCE) has been another choice of surgical intervention. This article was aimed to analyze the efficacy and peri-operative outcomes regarding RaRNU + BCE via a single institutional experience. Materials and methodsFrom March 2012 to November 2015, total 54 patients with UTUC were treated with RaRNU + BCE at Taipei Veterans General Hospital. We collected demographic data, histopathological reports, peri-operative complications and oncologic outcomes. ResultsTotal 54 patients were included in our study. The mean age was 71.9 ± 9.9 (range 48–88) and the mean body mass index was 23.5 ± 2.9 (range 16.4–30.8). The mean operating time was 314 min (RaRNU: 133.9 ± 41.4 min, RaBCE: 72.9 ± 25.7 min). The mean first docking time was 26.8 ± 7.7 min and the mean second docking time was 16.5 ± 6.7 min. The mean EBL was 87.7 ml. Pathological stage distribution was 22.2%, 27.8%, 13.0%, 31.5% and 5.6% in pTa, pT1, pT2, pT3 and pT4, respectively. Complications occurred in 7 cases (13%), with 4 grade I and 3 grade II by Clavien-Dindo classification. Positive tumor involvement at bladder cuff was noted in 3 patients, and the bladder recurrence rate was 29.6%. Local recurrence, lymph node metastasis, and distant metastasis were all noted for 2 patients respectively. The cancer-specific and overall survival rate was 98.1% and 96.3%. ConclusionOur experience showed RaRNU + BCE is an technically feasible and safe procedure for selected patients with UTUC.

Radical Nephroureterectomy Without Patient or Port Repositioning Using the Da Vinci Xi Robotic System: Initial Experience

To report our initial experience on robot-assisted radical nephroureterectomy, using the da Vinci Xi robotic system without patient or port repositioning. The patients were in a modified flank position. A Bugbee electrode was used to cauterize and mark the ureteral orifice, aiding in the final robotic excision of the distal ureter. For the first step of the procedure, the second robotic arm holds the scope, the fourth robotic arm holds Port #1 (monopolar curved scissors), the first robotic arm holds Port #2 (Fenestrated bipolar forceps), and the third robotic arm holds Port #4 (Prograsp forceps). After completion of nephrectomy, all robotic arms were released and reconfigured. In the new setting, the third robotic arm and second robotic arm were switched between the camera port and the fourth port. The first port remained working with the monopolar curved scissors whereas Prograsp forceps was moved to the second port and fenestrated bipolar forceps was moved to the third port. Two patients underwent 2 successful radical nephroureterectomies with the above-mentioned technique. The console time for the first patient was 150 minutes whereas the estimated blood loss was 200 mL. The console time and blood loss for the second patient were 140 minutes and 300 mL, respectively. The hospitalization time and catheter removal time were 3 days for both patients and no complications were observed. The use of the da Vinci Xi robotic system enabled us to perform both nephrectomy and distal ureterectomy and/or bladder cuff excision without any repositioning of the patient or trocars.