Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Robotic-Assisted Laparoscopic Nephroureterectomy Technique

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

Approach Considerations

Ports are placed carefully to allow access to both the upper and lower urinary tract (see the image below).

Port placement 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.

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.

Nephrectomy

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).

Robot is docked at right angle to the table over t 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.

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.[31] 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

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.[47]

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) .[50] Similarly, in a study by Favaretto et al, 70% of laparoscopic nephroureterectomy and 81% of the open counterpart underwent lymphadenectomy.[42] 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.[51] 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.[52]

Next

Laboratory Test

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.

Urine Cytology

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.[55] Ureteral catheterization for urine collection or ureteral wash and brush biopsy may improve accuracy.

CT Urography

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%.[56]

Cystoscopy

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.[59]

Previous
 
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.

References
  1. Sagalowsky AI, Jarrett TW, Flanigan RC. Urothelial tumors of the upper urinary tract and ureter. Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. Campbell-Walsh Urology. 10th. Philadelphia: Saunders; 2011. 2: chapter 53, page 1516. [Full Text].

  2. Anderström C, Johansson SL, Pettersson S, Wahlqvist L. Carcinoma of the ureter: a clinicopathologic study of 49 cases. J Urol. 1989 Aug. 142(2 Pt 1):280-3. [Medline].

  3. Raman JD, Messer J, Sielatycki JA, Hollenbeak CS. Incidence and survival of patients with carcinoma of the ureter and renal pelvis in the USA, 1973-2005. BJU Int. 2011 Apr. 107(7):1059-64. [Medline].

  4. Solsona E, Iborra I, Ricós JV, Dumont R, Casanova JL, Calabuig C. Upper urinary tract involvement in patients with bladder carcinoma in situ (Tis): its impact on management. Urology. 1997 Mar. 49(3):347-52. [Medline].

  5. Rabbani F, Perrotti M, Russo P, Herr HW. Upper-tract tumors after an initial diagnosis of bladder cancer: argument for long-term surveillance. J Clin Oncol. 2001 Jan 1. 19(1):94-100. [Medline].

  6. Herr HW, Cookson MS, Soloway SM. Upper tract tumors in patients with primary bladder cancer followed for 15 years. J Urol. 1996 Oct. 156(4):1286-7. [Medline].

  7. Guinan P, Vogelzang NJ, Randazzo R, Sener S, Chmiel J, Fremgen A. Renal pelvic cancer: a review of 611 patients treated in Illinois 1975-1985. Cancer Incidence and End Results Committee. Urology. 1992 Nov. 40(5):393-9. [Medline].

  8. Raabe NK, Fosså SD, Bjerkehagen B. Carcinoma of the renal pelvis. Experience of 80 cases. Scand J Urol Nephrol. 1992. 26(4):357-61. [Medline].

  9. Murphy GP. The diagnosis and detection of urogenital cancers. Cancer. 1981 Mar 1. 47(5 Suppl):1193-9. [Medline].

  10. Batata M, Grabstald H. Upper urinary tract urothelial tumors. Urol Clin North Am. 1976 Feb. 3(1):79-86. [Medline].

  11. Babaian RJ, Johnson DE. Primary carcinoma of the ureter. J Urol. 1980 Mar. 123(3):357-9. [Medline].

  12. Skinner DG. Technique of nephroureterectomy with regional lymph node dissection. Urol Clin North Am. 1978 Feb. 5(1):252-60. [Medline].

  13. Cummings KB. Nephroureterectomy: rationale in the management of transitional cell carcinoma of the upper urinary tract. Urol Clin North Am. 1980 Oct. 7(3):569-78. [Medline].

  14. McCarron JP, Mills C, Vaughn ED Jr. Tumors of the renal pelvis and ureter: current concepts and management. Semin Urol. 1983 Feb. 1(1):75-81. [Medline].

  15. Bloom NA, Vidone RA, Lytton B. Primary carcinoma of the ureter: a report of 102 new cases. J Urol. 1970 May. 103(5):590-8. [Medline].

  16. Phé V, Cussenot O, Bitker MO, Rouprêt M. Does the surgical technique for management of the distal ureter influence the outcome after nephroureterectomy?. BJU Int. 2011 Jul. 108(1):130-8. [Medline].

  17. Komatsu H, Tanabe N, Kubodera S, Maezawa H, Ueno A. The role of lymphadenectomy in the treatment of transitional cell carcinoma of the upper urinary tract. J Urol. 1997 May. 157(5):1622-4. [Medline].

  18. Miyake H, Hara I, Gohji K, Arakawa S, Kamidono S. The significance of lymphadenectomy in transitional cell carcinoma of the upper urinary tract. Br J Urol. 1998 Oct. 82(4):494-8. [Medline].

  19. Skinner DG. Management of invasive bladder cancer: a meticulous pelvic node dissection can make a difference. J Urol. 1982 Jul. 128(1):34-6. [Medline].

  20. Karl A, Carroll PR, Gschwend JE, Knüchel R, Montorsi F, Stief CG. The impact of lymphadenectomy and lymph node metastasis on the outcomes of radical cystectomy for bladder cancer. Eur Urol. 2009 Apr. 55(4):826-35. [Medline].

  21. Dhar NB, Klein EA, Reuther AM, Thalmann GN, Madersbacher S, Studer UE. Outcome after radical cystectomy with limited or extended pelvic lymph node dissection. J Urol. 2008 Mar. 179(3):873-8; discussion 878. [Medline].

  22. Herr HW. Extent of surgery and pathology evaluation has an impact on bladder cancer outcomes after radical cystectomy. Urology. 2003 Jan. 61(1):105-8. [Medline].

  23. Kondo T, Nakazawa H, Ito F, Hashimoto Y, Toma H, Tanabe K. Primary site and incidence of lymph node metastases in urothelial carcinoma of upper urinary tract. Urology. 2007 Feb. 69(2):265-9. [Medline].

  24. Kondo T, Nakazawa H, Ito F, Hashimoto Y, Toma H, Tanabe K. Impact of the extent of regional lymphadenectomy on the survival of patients with urothelial carcinoma of the upper urinary tract. J Urol. 2007 Oct. 178(4 Pt 1):1212-7; discussion 1217. [Medline].

  25. Clayman RV, Kavoussi LR, Figenshau RS, Chandhoke PS, Albala DM. Laparoscopic nephroureterectomy: initial clinical case report. J Laparoendosc Surg. 1991 Dec. 1(6):343-9. [Medline].

  26. Steinberg JR, Matin SF. Laparoscopic radical nephroureterectomy: dilemma of the distal ureter. Curr Opin Urol. 2004 Mar. 14(2):61-5. [Medline].

  27. Matsui Y, Ohara H, Ichioka K, Terada N, Yoshimura K, Terai A. Retroperitoneoscopy-assisted total nephroureterectomy for upper urinary tract transitional cell carcinoma. Urology. 2002 Dec. 60(6):1010-5. [Medline].

  28. Gill IS, Soble JJ, Miller SD, Sung GT. A novel technique for management of the en bloc bladder cuff and distal ureter during laparoscopic nephroureterectomy. J Urol. 1999 Feb. 161(2):430-4. [Medline].

  29. Shalhav AL, Dunn MD, Portis AJ, Elbahnasy AM, McDougall EM, Clayman RV. Laparoscopic nephroureterectomy for upper tract transitional cell cancer: the Washington University experience. J Urol. 2000 Apr. 163(4):1100-4. [Medline].

  30. Wong C, Leveillee RJ. Hand-assisted laparoscopic nephroureterectomy with cystoscopic en bloc excision of the distal ureter and bladder cuff. J Endourol. 2002 Aug. 16(6):329-32; discussion 332-3. [Medline].

  31. Clayman RV, Garske GL, Lange PH. Total nephroureterectomy with ureteral intussusception and transurethral ureteral detachment and pull-through. Urology. 1983 May. 21(5):482-6. [Medline].

  32. Rose K, Khan S, Godbole H, Olsburgh J, Dasgupta P,. Robotic assisted retroperitoneoscopic nephroureterectomy -- first experience and the hybrid port technique. Int J Clin Pract. 2006 Jan. 60(1):12-4. [Medline].

  33. Nanigian DK, Smith W, Ellison LM. Robot-assisted laparoscopic nephroureterectomy. J Endourol. 2006 Jul. 20(7):463-5; discussion 465-6. [Medline].

  34. Hu JC, Silletti JP, Williams SB. Initial experience with robot-assisted minimally-invasive nephroureterectomy. J Endourol. 2008 Apr. 22(4):699-704. [Medline].

  35. Park SY, Jeong W, Ham WS, Kim WT, Rha KH. Initial experience of robotic nephroureterectomy: a hybrid-port technique. BJU Int. 2009 Dec. 104(11):1718-21. [Medline].

  36. Hemal AK, Stansel I, Babbar P, Patel M. Robotic-assisted nephroureterectomy and bladder cuff excision without intraoperative repositioning. Urology. 2011 Aug. 78(2):357-64. [Medline].

  37. Hall MC, Womack S, Sagalowsky AI, Carmody T, Erickstad MD, Roehrborn CG. Prognostic factors, recurrence, and survival in transitional cell carcinoma of the upper urinary tract: a 30-year experience in 252 patients. Urology. 1998 Oct. 52(4):594-601. [Medline].

  38. Micali S, Celia A, Bove P, De Stefani S, Sighinolfi MC, Kavoussi LR. Tumor seeding in urological laparoscopy: an international survey. J Urol. 2004 Jun. 171(6 Pt 1):2151-4. [Medline].

  39. Manabe D, Saika T, Ebara S, Uehara S, Nagai A, Fujita R, et al. Comparative study of oncologic outcome of laparoscopic nephroureterectomy and standard nephroureterectomy for upper urinary tract transitional cell carcinoma. Urology. 2007 Mar. 69(3):457-61. [Medline].

  40. Capitanio U, Shariat SF, Isbarn H, Weizer A, Remzi M, Roscigno M. Comparison of oncologic outcomes for open and laparoscopic nephroureterectomy: a multi-institutional analysis of 1249 cases. Eur Urol. 2009 Jul. 56(1):1-9. [Medline].

  41. Greco F, Wagner S, Hoda RM, Hamza A, Fornara P. Laparoscopic vs open radical nephroureterectomy for upper urinary tract urothelial cancer: oncological outcomes and 5-year follow-up. BJU Int. 2009 Nov. 104(9):1274-8. [Medline].

  42. Favaretto RL, Shariat SF, Chade DC, Godoy G, Kaag M, Cronin AM. Comparison between laparoscopic and open radical nephroureterectomy in a contemporary group of patients: are recurrence and disease-specific survival associated with surgical technique?. Eur Urol. 2010 Nov. 58(5):645-51. [Medline].

  43. Simone G, Papalia R, Guaglianone S, Ferriero M, Leonardo C, Forastiere E. Laparoscopic versus open nephroureterectomy: perioperative and oncologic outcomes from a randomised prospective study. Eur Urol. 2009 Sep. 56(3):520-6. [Medline].

  44. Terakawa T, Miyake H, Hara I, Takenaka A, Fujisawa M. Retroperitoneoscopic nephroureterectomy for upper urinary tract cancer: a comparative study with conventional open retroperitoneal nephroureterectomy. J Endourol. 2008 Aug. 22(8):1693-9. [Medline].

  45. Ariane MM, Colin P, Ouzzane A, Pignot G, Audouin M, Cornu JN. Assessment of Oncologic Control Obtained After Open Versus Laparoscopic Nephroureterectomy for Upper Urinary Tract Urothelial Carcinomas (UUT-UCs): Results from a Large French Multicenter Collaborative Study. Ann Surg Oncol. 2011 Jun 21. [Medline].

  46. Stewart GD, Humphries KJ, Cutress ML, Riddick AC, McNeill SA, Tolley DA. Long-term comparative outcomes of open versus laparoscopic nephroureterectomy for upper urinary tract urothelial-cell carcinoma after a median follow-up of 13 years*. J Endourol. 2011 Aug. 25(8):1329-35. [Medline].

  47. Sheinfeld J, Bosl GJ. Surgery of testicular tumors. Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA. Campbell-Walsh Urology. 10th. Philadelphia: Saunders; 2011. 1: chapter 30, page 878. [Full Text].

  48. Meraney AM, Gill IS. Financial analysis of open versus laparoscopic radical nephrectomy and nephroureterectomy. J Urol. 2002 Apr. 167(4):1757-62. [Medline].

  49. Rassweiler JJ, Schulze M, Marrero R, Frede T, Palou Redorta J, Bassi P. Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma: is it better than open surgery?. Eur Urol. 2004 Dec. 46(6):690-7. [Medline].

  50. Busby JE, Brown GA, Matin SF. Comparing lymphadenectomy during radical nephroureterectomy: open versus laparoscopic. Urology. 2008 Mar. 71(3):413-6. [Medline].

  51. Abaza R, Lowe G. Feasibility and adequacy of robot-assisted lymphadenectomy for renal-cell carcinoma. J Endourol. 2011 Jul. 25(7):1155-9. [Medline].

  52. Trudeau V, Gandaglia G, Shiffmann J, Popa I, Shariat SF, Montorsi F, et al. Robot-assisted versus laparoscopic nephroureterectomy for upper-tract urothelial cancer: A population-based assessment of costs and perioperative outcomes. Can Urol Assoc J. 2014 Sep. 8(9-10):E695-701. [Medline]. [Full Text].

  53. Murphy WM, Soloway MS. Developing carcinoma (dysplasia) of the urinary bladder. Pathol Annu. 1982. 17 (Pt 1):197-217. [Medline].

  54. Konety BR, Getzenberg RH. Urine based markers of urological malignancy. J Urol. 2001 Feb. 165(2):600-11. [Medline].

  55. Bolenz C, West AM, Ortiz N, Kabbani W, Lotan Y. Urinary cytology for the detection of urothelial carcinoma of the bladder-a flawed adjunct to cystoscopy?. Urol Oncol. 2011 Mar 15. [Medline].

  56. Caoili EM. Imaging of the urinary tract using multidetector computed tomography urography. Semin Urol Oncol. 2002 Aug. 20(3):174-9. [Medline].

  57. Keeley FX, Kulp DA, Bibbo M, McCue PA, Bagley DH. Diagnostic accuracy of ureteroscopic biopsy in upper tract transitional cell carcinoma. J Urol. 1997 Jan. 157(1):33-7. [Medline].

  58. Guarnizo E, Pavlovich CP, Seiba M, Carlson DL, Vaughan ED Jr, Sosa RE. Ureteroscopic biopsy of upper tract urothelial carcinoma: improved diagnostic accuracy and histopathological considerations using a multi-biopsy approach. J Urol. 2000 Jan. 163(1):52-5. [Medline].

  59. Hendin BN, Streem SB, Levin HS, Klein EA, Novick AC. Impact of diagnostic ureteroscopy on long-term survival in patients with upper tract transitional cell carcinoma. J Urol. 1999 Mar. 161(3):783-5. [Medline].

  60. Muntener M, Schaeffer EM, Romero FR, Nielsen ME, Allaf ME, Brito FA. Incidence of local recurrence and port site metastasis after laparoscopic radical nephroureterectomy. Urology. 2007 Nov. 70(5):864-8. [Medline].

 
Previous
Next
 
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.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.