Robotic-Assisted Laparoscopic Nephroureterectomy Periprocedural Care

Updated: Sep 09, 2020
  • Author: Chad R Tracy, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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Periprocedural Care

Patient Preparation

Positioning

In the operative room, after the induction of general anesthesia, a large-bore 3-way catheter is placed in the urethra. We instill 1 g of gemcitabine in 50 cc normal saline (alternatively, one can use mitomycin 40 mg in 40 cc or gemcitabine 2 g in 100 cc) and clamp the catheter. This will dwell for 1 hour. The patient is placed in a modified flank position (60°) with the hip at the "break" of the table (see the image below). An 18 Fr 3-way catheter is placed, which allows for seemless irrigation of chemotherapy into the bladder. Using an Xi robot with the accompanying paired bed (da Vinci® Xi™) can obviate the need for robot undocking prior to any re-positioning if the patient is to be placed in the Trendelenburg position for the bladder cuff portion of the surgery.

Patient in modified flank position for right sided Patient 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 patient's 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 urinary tract urothelial carcinoma (UTUC) 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 urinary tract, local surgical bed, and metastatic sites. Because the risk is highest in the first year after surgery, the protocol is more intense during this period. A risk-stratified approach to follow-up should be adopted based on the surgical outcome, and appropriate patients (pT2-4, N0-3, M0) should be referred to a medical oncologist for consideration of adjuvant chemotherapy

History taking, 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 urinary tract and local surgical bed imaging with computed tomography (CT) urography should be performed every 6 months for the first 2 years, then yearly thereafter. Metastatic evaluation including history taking, physical examination, chest radiography, and a 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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