Distal ureterectomy techniques in laparoscopic and robot-assisted nephroureterectomy: Updated review

Abstract

Controversies exist about the best method for managing the distal ureter during the laparoscopic (LNU) and robot-assisted nephroureterectomy (RANU). Therefore, PubMed, Scopus and Web of Science databases were searched in order to identify articles describing the management of distal ureter during LNU or RANU in patients suffering from upper urinary tract urothelial cell carcinoma. Forty seven articles were selected for their relevance to the subject of this review. The approaches that are usually performed regarding the distal ureter management are open excision, transurethral resection of ureteral orifice (Pluck Technique), ureteric intussusception and pure LNU or pure RANU. Pure LNU and RANU with complete laparoscopic dissection and suture reconstruction of ureter and bladder cuff seems to be better tolerated than open nephroureterectomy providing equal efficacy, without deteriorating the oncological outcome, however evidence is poor. 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, while stapling technique is correlated with the increased risk of positive surgical margins. The open resection of the distal ureter in continuity with the bladder cuff is considered the most reliable approach, preferred in our practice as well, however the existing data are based on retrospective and non-randomized studies.

Keywords: Laparoscopy approach; nephroureterectomy; robotics; upper urinary tract urothelial cell carcinoma.

Figure 1

Configuration of robotic arms according to Tracy CR description, which allows to complete left robot-assisted nephroureterectomy without repositioning the patient. A 12-mm camera port (■) is placed at the level of umbilicus and three 8-mm robotic trocars (●) are placed in the mid-clavicular line 2– 3 cm below the costal margin (a), laterally along the anterior axillary line at the level of the camera port (b) and in the mid-clavicular line about 8 cm below the camera port (c), respectively. A fifth 12-mm assistant port (▲) is placed in the midline 5–8 cm above the umbilicus. After completion of nephrectomy, the robotic arms are undocked without moving the patient cart and a change in the instruments is made afterward, so in case of left ureterectomy Port B carries bipolar forceps and becomes the surgeon's left arm, while port C carries monopolar scissors and becomes the surgeon's right arm. Port A can be used as a fourth arm to assist in cystostomy and final repair

Figure 2

Robot-assisted nephroureterectomy without patient's repositioning, using a hybrid port. A 12-mm camera port (■) is placed at the superior umbilical region and two 8-mm robotic ports (●) are placed at the lateral rectus margin (first), 3–4 cm below the umbilicus and in the midline between the umbilicus and the xiphoid process (second). A dual 8–12-mm assistant hybrid port (◙) is placed between the umbilicus and pubic symphysis, which allows to be intubated with an 8-mm robotic arm. After the robotic nephrectomy is completed, the robotic axis is switched for the distal ureterectomy and the configuration of robotic ports is changed. Thus, the port for first robotic instrument arm during nephrectomy becomes an assistant port during bladder cuff excision, the port for the second robotic instrument arm becomes the dominant hand and the assistant port is converted to the nondominant hand