First completely robot-assisted retroperitoneal nephroureterectomy with bladder cuff: a step-by-step technique

Abstract

Introduction: While various surgical techniques have been reported for open and minimally invasive treatment of upper tract urothelial cancer (UTUC), the procedure of robot-assisted nephroureterectomy (NU) with bladder cuff has never been reported using only retroperitoneum without entering abdominal cavity. We developed a novel port placement and technique allowing to perform robot-assisted NU by a unique retroperitoneal approach.

Methods: Between February and June 2021 patients with history of UTUC were treated by robot-assisted NU completely restricted to retroperitoneal space using a singular trocar placement and a two-step docking without relocation of the surgical robot. Patient characteristics, perioperative outcomes and short-term follow-up were prospectively analyzed.

Results: The analysis included five patients [median age: 73 years; BMI: 27.2 kg/m²; Charlson comorbidity index 5]. All five patients had UTUC with a mean tumor size of 3.02 cm (range 0.9-6.0). UTUC was localized to distal ureter in two and to kidney in three cases. No positive surgical margins were noted for all patients with UTUC [1 low-grade and 4 high-grade]. Retroperitoneal lymphadenectomy in three patients did not reveal positive nodes. No intraoperative adverse events exceeding EAUiaiC classification ≥ 2 were observed, while median EBL was 150 ml (IQR 100-250). No patient experienced postoperative complications exceeding Clavien-Dindo classification ≥ 3a. Median hospital stay was 5.4d without any 30-d readmission.

Conclusion: We demonstrate safety and feasibility of the first entire robot-assisted retroperitoneal nephroureterectomy (RRNU) with bladder cuff. This surgical technique is easily reproducible, while surgical outcomes are similar to other established techniques.

Keywords: Bladder cuff; DaVinci; Nephroureterectomy; Retroperitoneal; Robotic surgery; Trocar placement.

Fig. 1

Patient position. The patient is placed in a 90° flank position with moderate table flexion (15°) and both arms were positioned perpendicular to the torso

Fig. 2

Trocar placement for nephrectomy portion and management of the bladder cuff. A Illustration of port arrangement with Hasson trocar (Nr.1), standard 8-mm DaVinci^R-trocar (Nr.2 + 3 + 4) and 12-mm assistant port (Nr.5). B Trocar placement for four-arm configuration for nephrectomy portion with camera view towards cranial. C Trocar placement for three-arm configuration for dissection of the bladder cuff with camera view towards caudal after re-docking and 180° turnaround of the main robotic joint

Fig. 3

Intraoperative Surgical steps for left side RRNU. A Preparation of renal artery from dorsal before clipping using a clip applier (Hem-o-lok Teleflex^R) for nephrectomy portion. B Dissection of the middle ureter with view to paravesical space after nephrectomy (the kidney is already mobilized towards cranial) and after re-docking DaVinci Xi^R. The proximal and middle ureter were released by sharp and blunt dissection. C View at the bladder wall with step-by-step dissection of detrusor muscle fibers along the prevesical ureter. The distal ureter has been already clipped below the tumor using a Hem-o-lok clip. D Management of bladder cuff with excision of detrusor muscle till urothelial mucosa is exposed. Previous inserted Double-J is exposed after opening the bladder wall. E Before complete dissection of the bladder cuff an attachment suture (V-Loc 3-0; Covidien^R) is placed to medial margin of ureteral orifice to prevent retraction of the bladder. F View at the completed bladder cuff after closure of the bladder defect using the attachment suture (V-Loc 3-0; Covidien^R). The clipped ureter including the Double-J is being inserted in a retrieval bag