Robotic-Assisted Laparoscopic Nephroureterectomy Technique

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

Approach Considerations

Robot choice

With the growth in robotic technology, multiple robotic platforms can be utilized for nephroureterectomy. The platforms include the following 3 broadly different categories:

  • Fixed base: da Vinci ® S™, Si™, and X™ 
  • Mobile base: da Vinci ® Xi™
  • Single Port: da Vinci ® SP™

The nuances of port placement will be individually discussed below; however, the operative steps and principles remain the same. Utilization of the da Vinci® Xi™ and SP™ does not require robot redocking. 

Fixed base port placement

Ports are placed carefully to allow access to both the upper and lower urinary tract (see the images 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 (Figure A) is in the midclavicular line 2-3 cm below the costal margin, and the second port (Figure B) is placed roughly at the level of the camera port, laterally along the anterior axillary line. The third robotic port (Figure C) is placed in the mid-clavicular line about 8 cm below the camera port, and a 12-mm assistant port is placed in the midline about 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.

DaVinci Xi™ port placement

Xi™ port placement is performed in a straight, cascading line either in an oblique fashion (Figures A and B)  or a straight cranial/caudal fashion (Figure C and D)  from starting approximately 2 cm caudal to the costal angle. A 12 mm assistant port is placed in a similar location as with the Si™ system and can be moved laterally as needed to accommodate for the more rotund abdomen. For right-sided tumors, a 5 mm sub-xiphoid liver retractor may be employed. 

Figure A

Right-sided port placement for oblique Xi nephrour Right-sided port placement for oblique Xi nephroureterectomy: nephrectomy portion. Four 8-mm robotic trocars (green and blue circles) are placed in an oblique, straight line starting from 2 cm below the costal margin just lateral to the edge of the rectus sheath. Courtesy of Bridget A Fahey, PhD, University of Iowa Health Care.

Figure B

Right-sided port placement for Xi nephroureterecto Right-sided port placement for Xi nephroureterectomy: ureterectomy and bladder cuff portion. Note the camera port shifts down. Courtesy of Bridget A Fahey, PhD, University of Iowa Health Care.

Figure C

Right-sided port placement for in-line Xi nephrour Right-sided port placement for in-line Xi nephroureterectomy: nephrectomy portion. Four 8-mm robotic trocars (gray and blue circles) are placed in an oblique, straight line starting from 2 cm below the costal margin just lateral to the edge of the rectus sheath. Courtesy of Bridget A Fahey, PhD, University of Iowa Health Care.

Figure D

Right-sided port placement for in-line Xi nephrour Right-sided port placement for in-line Xi nephroureterectomy: ureterectomy portion. Note the camera port shifts down. Courtesy of Bridget A Fahey, PhD, University of Iowa Health Care.

DaVinci SP™ port placement

To date, only one study has examined the role of single port nephroureterectomy. This was performed with a homemade port and using the S™ robotic platform. The surgeons noted that the operation was difficult and resulted in more blood loss and transfusions than a multi-port approach. [68]  A description of the SP™ platform has not yet been reported on for robotic nephroureterectomy. 

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). The robot shuld be docked perpendicular to the table with the Xi platform as the boom may be rotated to accomodate any necessary angle differences.

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 the 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. [49] 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 10 mm 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 the psoas muscle and followed superiorly to the renal hilum, which should be isolated and divided using 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. Apart from the hilar lymph nodes, the 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. [69]  For ureteral tumor involvement, an ipsilateral pelvic lymph node dissection should also be considered. 

Excision of distal ureter with bladder cuff

After completion of nephrectomy with or without lymphadenectomy, the robotic arms are undocked (fixed base robot) without moving the patient cart. Once undocked, the table may be rotated to allow the robot to angle down to the pelvis. 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.

If the Xi is used, the ports are simply reconfigured as above in Figures B and D without undocking the robot. If necessary, the robot can be briefly undocked and the boom rotated to angle toward the pelvis. Intravesical chemotherapy should already be drained. At this time, we hook a second insufflating device to the catheter with a set pressure of 5 mm Hg. This allows for some distension of the bladder with carbon dioxide rather than a fluid and allows entry into the bladder in a more controlled fashion. 

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 inferiorly to mark the area of the 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 or absorbable barbed sutures, and closure is tested by filling the 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 either via extension of the midline 12 mm port or via a Gibson incision incorporating the most caudal robotic port. 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 urinary tract urothelial carcinoma (UTUC). 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. [70, 71]

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 advantages over a standard laparoscopic nephroureterectomy, namely increased degrees of freedom, 3-dimensional vision, movement scaling, and tremor filtration. The EndoWrist of robotic instruments is 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 an open approach (6 nodes vs 3 nodes, respectively; P = 0.01). [72] Similarly, in a study by Favaretto et al, 70% of patients who had laparoscopic nephroureterectomy and 81% of those who had the open counterpart underwent lymphadenectomy. [63] 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 the 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. [73] 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 with nephroureterectomy, but at higher costs. [59]

As robotic nephroureterectomy has matured, so have the supporting data. A moderate-sized, retrospective study demonstrated no differences in oncologic outcomes between surgical approaches, with improved blood loss, shorter hospital stay, and less analgesic usage when robotic nephroureterectomy was used compared to the open approach. [1]  Series at multiple institutions were assessed in a systematic review of 50 articles, which demonstrated that robot-assisted nephroureterectomy had comparable oncologic outcomes with less blood loss compared to open surgery, although the paucity of robotic studies and the retrospective nature of the data made interpretation inconclusive. [2]

Given that the novelty of the robotic approach has waned, the current debate now focuses on the robotic platform employed. The da Vinci® Xi™ platform generally allows for greater subjective surgeon comfort and shorter operative time  than the da Vinci® Si™, likely owing to obviation of the need to dock the robot twice. [74, 75]  It is our preference to utilize the Xi robot for this surgery. 

 

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Laboratory and Imaging Studies

The preoperative workup includes cystoscopy to rule out a synchronous bladder tumor, computed tomography (CT) urography, urine cytology, serum electrolyte measurement, complete blood cell count, liver function studies, and a chest radiograph. A bone scan is performed for symptomatic cases or when the serum alkaline phosphatase level 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 a filling defect on imaging.

The choice for bowel preparation and evacuation is generally based on surgeon preference. At the authors’ institution, we no longer employ bowel preparation prior to laparoscopic surgery. More significant mechanical preparation (polyethylene glycol-electrolyte solution) and 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. [76, 77] In a 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 carcinoma in situ (CIS), 62.9% in pT1, and 69.6% in pT2 and higher-stage tumors. [78] 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 lesions has been reported to be close to 100%, with a specificity of 60%. [79]

Cystoscopy

Cystoscopy 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 a good histologic correlation (78% to 92%) exists between ureteroscopic biopsy and final pathology. [80, 81] 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. [82]

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