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Robotic-Assisted Laparoscopic Nephroureterectomy Periprocedural Care

  • Author: Chad R Tracy, MD; Chief Editor: Edward David Kim, MD, FACS  more...
 
Updated: Dec 26, 2014
 

Patient Preparation

Positioning

In the operative room, after the induction of general anesthesia and placement of an 18-Fr Foley catheter, the patient is placed in a modified flank position (60°) with the hip at the "break" of the table (see the image below).

Patient in modified flank position for right sidedPatient in modified flank position for right sided nephro-ureterectomy.

A minimal amount of table flexion allows opening up of the operative field and facilitates port placement. The modified flank helps allow access to the kidney as well as the bladder. All pressure points are carefully padded, and the patient is secured to the table with 3-inch cloth tape and foam. The patients upper arm is secured with a Krauss arm support (Steris Corporation; Mentor, OH), being careful to keep the arm support as low as possible in order to prevent collision with the robotic arms.

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Monitoring & Follow-up

The propensity of upper-tract TCC to have multifocal recurrence and metastatic spread makes close follow-up a critical part of disease management. Organs at risk are the bladder, contralateral upper tract, local surgical bed, and metastatic sites. Because the risk is highest in the first year after the surgery, protocol is more intense during this period.

History, physical examination, urine cytology, and cystoscopy should be performed every 3 months for the first year, every 6 months for the next 2 years, and then yearly thereafter. Contralateral upper tract and local surgical bed imaging via CT urogram should be performed every 6 months for the first 2 years, then yearly thereafter. Metastatic evaluation including history, physical examination, chest radiography, and comprehensive metabolic profile including liver enzymes should be done every 3 months for the first year, every 6 months for the next 2 years, then yearly until 5 years. Additional metastatic workup is based on clinical suspicion.

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Contributor Information and Disclosures
Author

Chad R Tracy, MD Assistant Professor, Department of Urology, University of Iowa, Roy J and Lucille A Carver College of Medicine

Chad R Tracy, MD is a member of the following medical societies: American Medical Association, American Urological Association, Endourological Society

Disclosure: Nothing to disclose.

Coauthor(s)

Sundeep Deorah, MD, MPH Fellow in Urologic Oncology, Department of Urology, University of Iowa, Roy J and Lucille A Carver College of Medicine

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

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Patient in modified flank position for right sided nephro-ureterectomy.
Port placement for right sided nephro-ureterectomy. Robotic ports A and B are utilized as the right and left arms for the nephrectomy portion of the procedure. Robotic ports B and C are utilized for distal ureterectomy and bladder cuff excision. Note the 5 mm sub-xiphisternal port used for liver retraction for right sided tumors.
Robot is docked at right angle to the table over the patient's back. This allows for access to both the upper and lower urinary tracts without the need to move the patient cart.
 
 
 
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