Robotic-Assisted Laparoscopic Nephroureterectomy Technique
- Author: Chad R Tracy, MD; Chief Editor: Edward David Kim, MD, FACS more...
Ports are placed carefully to allow access to both the upper and lower urinary tract (see the image below).
A 12-mm camera port is placed at the level of the umbilicus and lateral; this port is moved farther laterally in morbidly obese patients to allow for the instruments to reach the target organs. Three 8-mm robotic trocars are placed under direct vision.
The first port (A) is in the midclavicular line 2-3 cm below the costal margin, and the second port (B) is placed roughly at the level of the camera port, laterally along the anterior axillary line. The third robotic port (C) is placed in mid-clavicular line about 8 cm below the camera port, and a 12-mm assistant port is placed in the midline a 5-8 cm above the umbilicus. If needed, another 5-mm assistant port is similarly placed below the umbilicus. The assistant ports might be moved to the other side of the midline, especially in thin patients, to allow minimum distance between the trocars. For right-sided tumors, an additional 5-mm port is placed in the midline just below the xiphoid process for liver retraction.
Once the ports are placed, the robot is docked at a right angle to the table over the patient’s back (see the image below).
During the nephrectomy portion, the console surgeon primarily uses monopolar scissors through port A and fenestrated bipolar or PK forceps (Gyrus ACMI; Southborough, MA) through port B; port C is used as fourth arm for lateral traction of the lower pole of the kidney to facilitate hilar dissection.
Nephrectomy is performed in the same fashion as described by Clayman et al for laparoscopic radical nephrectomy. Briefly, after reflecting the colon medially, the ureter is identified off of the lower pole of the kidney. Careful attention is paid to keeping the peri-ureteric tissue with the ureter in order to allow an adequate margin in the event of ureteral invasion by the malignancy. Once the ureter is identified, a 10mm Hem-o-lok clip (Teleflex Medical; Research Triangle Park, NC) is placed around the ureter to prevent tumor from traveling down the ureter during manipulation.
The ureter is swept upward off of the psoas muscle and followed superiorly to the renal hilum. At the authors’ institution, the authors prefer to dissect free the renal artery and vein and ligate them individually with a vascular stapler. Once the perinephric attachments are free, dissection carries on along the ureter as distal as possible toward the iliac vessels.
Lymphadenectomy is performed based upon the grade and stage of the disease. When performed, apart from hilar lymph nodes, paracaval and retrocaval lymph nodes are removed on the right side and para-aortic lymph nodes for left-sided tumors using a "split" and "roll" technique similar to that described by Sheinfeld et al.
Excision of Distal Ureter with Bladder Cuff
After completion of nephrectomy with or without lymphadenectomy, the robotic arms are undocked without moving the patient cart. Once undocked, the table may be rotated to a more supine position if desired. Port B now carries monopolar scissors and becomes the surgeon’s right arm and port C carries bipolar forceps and becomes the surgeon’s left arm. Port A is used as a fourth arm to assist in cystotomy and final repair.
In this new configuration, the ureter is dissected down to the ureterovesical junction. Retrograde filling of the bladder may be performed at this stage in order to better identify the ureterovesical junction. A bladder "hitch" stitch is performed by placing a suture anterior to the planned area of bladder cuff resection and then passing the suture through the peritoneum of the anterior abdominal wall. This stitch allows the bladder to stay elevated and prevents posterior migration of the bladder following cystotomy. An inferior stay suture may be placed inferiorlytomark the area of future cystotomy. A 1-cm cuff of bladder is carefully excised around the ureteric orifice, and the specimen is then placed in the Endocatch bag (Auto Suture; Norwalk, CT).
Repair of Cystotomy
The bladder is closed in 2 layers with 3-0 running Vicryl sutures, and closure is tested by filling bladder to 120 mL. A perivesical drain is left in the vicinity of the repair; however, some surgeons leave no drain if no leakage is demonstrated. The specimen is retrieved, and the incision is closed in standard fashion. We do not routinely close port sites up to 12 mm in size, unless they are in the midline. A Foley catheter is left indwelling for 7-10 days postoperatively.
Advantages of Minimally Invasive Approaches
Open radical nephroureterectomy has long been considered the criterion standard for the treatment of upper tract TCC. However, considerable morbidity is related to the procedure, considering the need to perform nephrectomy and excision of the bladder cuff through an extended flank incision or 2 separate incisions. Since the first performance of laparoscopic nephroureterectomy in 1991, several studies have established its benefits in terms of decreased perioperative morbidity and shortened convalescence in comparison with open surgery.
The superiority of laparoscopic nephrectomy for renal cell carcinoma in terms of shorter convalescence and better cosmetic results is an established fact in urologic practice. It seems reasonable to expect similar cosmetic and morbidity benefits with laparoscopic nephroureterectomy as compared to open surgery. In fact, several studies have documented these benefits. Minimally invasive nephroureterectomy reduces incision length, operative blood loss, postoperative pain, length of hospital stay, convalescence, and eventually cost.[48, 49]
Robot-assisted nephroureterectomy, being essentially a laparoscopic procedure, is likely to have advantages similar to laparoscopic surgery in terms of decrease in perioperative morbidity. In addition, the da Vinci surgical robot provides some additional advantage over a standard laparoscopic nephroureterectomy, namely increased degrees of freedom, 3-dimensional vision, movement scaling, and tremor filtration. The EndoWrist of robotic instruments are especially suited for the dissection of the distal ureter and bladder cuff, which are difficult to access in the close confines of the pelvic cavity. Robotic assistance also provides ease of intracorporeal suturing, which helps in the subsequent water-tight repair of the cystotomy.
The role and extent of retroperitoneal lymph node dissection has been a topic of debate, and it becomes more important in the era of minimally invasive surgery. For a disease that closely resembles bladder cancer, it appears reasonable to apply the bladder cancer paradigm and perform lymphadenectomy, especially in higher-risk cases, while the evidence continues to mature. Thus, an important question is, how good of a lymphadenectomy can one perform with the laparoscopic technique?
Busby et al demonstrated the feasibility of lymphadenectomy with laparoscopic nephroureterectomy compared to open approach (6 nodes vs 3 nodes, respectively; p = 0.01) . Similarly, in a study by Favaretto et al, 70% of laparoscopic nephroureterectomy and 81% of the open counterpart underwent lymphadenectomy. No difference existed in the lymph node yield when comparing the 2 techniques (median number was 8 in each group) and no difference was seen between right or left side.
In expert hands, therefore, lymph node dissection can be performed by either the laparoscopic or open approach. Although the adequacy of laparoscopic lymph node dissection is uncertain in nonexpert hands, recent reports detail feasibility and adequacy of robot-assisted lymphadenectomy for renal cell carcinoma. In this single surgeon experience, the mean time for lymphadenectomy was 31 minutes and mean lymph node yield was 13.9 nodes. Whether robotic assistance can actually improve lymph node yield compared to traditional laparoscopic surgery remains to be seen.
Trudeau et al compared short-term outcomes and costs between robotic-assisted nephroureterectomy and laparoscopic radical nephroureterectomy in a population-based cohort of patients that included 1914 individuals who were treated for upper-tract urothelial carcinoma between 2008 and 2010. In multivariable analyses, no significant differences were observed in postoperative transfusion and length of stay between the 2 approaches. Patients undergoing robot-assisted nephroureterectomy were less likely to experience complications than were the patients who underwent laparoscopic nephroureterectomy. Utilization of the robotic approach was associated with substantially higher costs. The study was limited by the lack of adjustment for tumor stage and grade. The authors concluded that robot-assisted nephroureterectomy is associated with lower odds of perioperative complications compared nephroureterectomy, but at higher costs.
Preoperative workup includes cystoscopy to rule out a synchronous bladder tumor, CT urogram, urine cytology, and serum electrolytes, complete blood count, liver function studies, and a chest radiograph. Bone scan is performed for symptomatic cases or when serum alkaline phosphatase is elevated. Most surgeons base the diagnosis on ureteroscopy and biopsy of the lesion, although a similar diagnosis could be made with positive cytology and filling defect on imaging.
The choice for bowel preparation and evacuation is generally based on surgeon preference. At the authors’ institution, the authors prefer to evacuate the bowel by having patients on a liquid diet for 24 hours prior to the surgery as well as having them self-administer a bottle of magnesium citrate the day prior to surgery. More significant mechanical preparation (polyethylene glycol-electrolyte solution) and/or antibiotic preparation are generally not necessary for this procedure.
Sensitivity of urine cytology is directly related to tumor grade; it ranges from about 20% for grade I tumors, 45% for grade II tumors, to 75% for grade III tumors.[53, 54] In a recent study from a tertiary academic institution, the sensitivity rates of urine cytology were reported to increase with stage; 30.6% in pTa, 60.5% in patients with CIS, 62.9% in pT1, and 69.6% in pT2 and higher-stage tumors. Ureteral catheterization for urine collection or ureteral wash and brush biopsy may improve accuracy.
CT urography is the radiologic investigation of choice. The sensitivity of detecting upper tract lesion has been reported to be close to 100%, with a specificity of 60%.
This is performed to rule out a synchronous bladder tumor and to gain access to the upper tract of the diseased side.
Ureteroscopy and Biopsy
These procedures allow for visualization and direct biopsy of upper tract lesion. Evidence of good histologic correlation (78% to 92%) exists between ureteroscopic biopsy and final pathology.[57, 58] The small size of a biopsy specimen limits its utility in stage determination. One should keep in mind the limited but real risk of tumor seeding, extravasation, and dissemination with ureteroscopy.
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