Robotic-assisted nephroureterectomy and bladder cuff excision without intraoperative repositioning

Abstract

Objective: To present surgical tips and describe a novel technique for successful performance of robotic nephroureterectomy with bladder cuff excision (RNUBCE). We report a technique of RNUBCE without intraoperative patient repositioning or redocking of the robot.

Materials and methods: Nephroureterectomy with bladder cuff excision is the standard management of high-grade or bulky upper tract transitional cell carcinoma. Lymphadenectomy is performed when clinically indicated. Fifteen patients underwent RNUBCE between January 2009 and May 2010. Several key points to this operation contribute to its success. Ports are strategically placed to allow access to the kidney, ureter, and bladder. The ureter is clipped, though not divided, immediately after ligating the renal hilum to minimize the risk of tumor seeding resulting from manipulation of the kidney. In cases of ureteric tumors, wide dissection of the ureter is carried out to avoid a positive margin or entry into the ureter. Bladder stay sutures are placed lateral to the ureterovesical junction to prevent retraction of the bladder once the bladder cuff is excised. If desired, a partial excision of the cuff can be performed with the ureter acting as a bucket handle.

Results: All procedures were performed successfully without complications. Mean total operative time was 184 minutes, estimated blood loss was 103 mL, and mean hospital stay was 2.7 days. Short-term oncological outcomes have revealed no recurrences.

Conclusions: RNUBCE, with lymphadenectomy when clinically indicated, provides a viable treatment option for patients with upper tract transitional cell carcinoma.