Robot-assisted nephroureterectomy for upper urinary tract urothelial carcinoma without intraoperative reposition or redocking

The gold standard for treatment of upper urinary tract urothelial carcinoma remains nephroureterectomy with the ipsilateral bladder cuff excision. With the introduction of robot system, robot-assisted surgery has become popular in the management of urological malignancies. We report a single institute experience of robot-assisted nephroureterectomy (RANU) for the treatment of upper urinary tract urothelial carcinoma (UC) without re-docking the robot system or reposition of the patient. The perioperative and oncologic outcomes are discussed.     

Robot-assisted laparoscopic combined nephroureterectomy and cystoprostatectomy: an initial report and review of the literature

Patients presenting with invasive, high-grade, or recurrent bladder cancer and synchronous upper urinary tract malignancy may be considered for simultaneous nephroureterectomy and radical cystectomy. We present the first known reported case of robot-assisted laparoscopic combined nephroureterectomy and cystoprostatectomy, describing a 62-year-old man with recurrent T1 bladder cancer and concomitant upper urinary tract transitional cell carcinoma. Patient underwent robot-assisted laparoscopic combined nephroureterectomy and radical cystoprostatectomy with extended pelvic lymph node dissection and extracorporeal ileal conduit urinary diversion. Robotic surgery was completed successfully without need for conversion to open procedure. There were no operative or perioperative complications. Blood loss (200 ml) and hospital stay (7 days) were less than prior reported laparoscopic experience with combined surgery. Although indications may be rare, robotic nephroureterectomy with simultaneous radical cystoprostatectomy is a feasible and safe surgical option.     

Robot-assisted laparoscopic nephroureterectomy for upper tract urothelial carcinoma (UT-UC)

Upper tract urothelial carcinoma (UT-UC), including tumors evolving from the renal pelvis and ureter, accounts for around 5% of all UCs and 10% of all renal tumor cases. In Taiwan, the incidence of UT-UC is higher than the western countries especially in the female and patients at renal replacement therapy. The standard care of UT-UC is nephroureterectomy with bladder cuff excision. In the past decades, minimally invasive surgery is proved to achieve comparable oncological results as conventional open procedure. Though laparoscopic nephroureterectomy with bladder cuff excision including pure laparoscopic or hand-assisted technique have been very common practice in Taiwan, several institutes have the early experience of robot-assisted nephroureterectomy which is believed to provide 3-D visualization with magnification, better surgical exposure, and safer watertight suture of the cystostomy. In this review, we review the published reports of robot-assisted nephroureterectomy with bladder cuff excision.     

Nephron-sparing surgery with autotransplantation for high-grade upper urinary tract urothelial carcinoma in a patient with solitary kidney

Instead of nephroureterectomy with bladder cuff excision, nephron-sparing surgery can be considered in selected patients with non-muscle invasive upper urinary tract urothelial carcinoma. The role of kidney-sparing surgery has been established for the management of low-grade urothelial carcinoma. We report a solitary kidney patient with high-grade renal pelvis urothelial carcinoma treated with nephron-sparing surgery by ex vivo tumor excision and autotransplantation. The results of the surgery were excellent.     

Robot-assisted laparoscopic nephroureterectomy

BACKGROUND: Laparoscopic nephroureterectomy for upper-tract urothelial tumors is a minimally invasive approach that parallels the open technique in oncologic efficacy. Multiple approaches to manage the distal ureter have been described. We developed a new technique using the daVinci robot system to perform a transvesical excision of the distal ureter and bladder cuff. PATIENTS AND METHODS: Ten consecutive patients with upper-tract urothelial cancer underwent a laparoscopic nephroureterectomy. The daVinci robot was docked through the umbilical, ipsilateral lateral rectus, and an additional contralateral lateral rectus port. The bladder was clam-shelled in a coronal orientation at the dome and the distal ureterectomy performed. RESULTS: Our technique was successful in all ten patients. The mean operative time for the entire case was 4.4 hours. The average hospital stay was 3 days. CONCLUSIONS: Robot-assisted laparoscopic nephroureterectomy is a safe, minimally invasive approach to upper- tract urothelial cancer that reduces the technical challenge of excision of the distal ureter.     

Laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma

OBJECTIVE: Open radical nephroureterectomy has been the standard treatment for upper urinary tract transitional cell carcinoma (TCC). Laparoscopic nephroureterectomy (LN) offers the advantages of a minimally invasive approach. We report our experience with both hand-assisted LN (HALN) and total LN. MATERIAL AND METHODS: A retrospective review was performed of all patients who underwent HALN and LN for the treatment of localized upper urinary tract TCC between 2001 and 2005. Histology of the operative specimen confirmed urothelial carcinoma in all cases. Their demographic data, perioperative parameters and follow-up data were assessed. RESULTS: There were 31 patients with a median age of 71 years (range 39-82 years). The mean operating time was 236 min (range 120-350 min) and mean blood loss was 365 ml (range 200-2000 ml). There were no conversions to open surgery. The mean length of hospitalization was 7 days (range 3-30 days). Clear oncological margins were achieved in 27 cases. The mean duration of follow-up was 28 months (range 2-55 months). CONCLUSIONS: HALN and LN are safe and effective alternatives to open surgery for the treatment of upper urinary tract TCC. Medium-term follow-up showed favourable oncological results. A larger sample size and a longer follow-up period are required before HALN and LN can be considered standard treatments for upper urinary tract TCC.     

Hand-assisted laparoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma.

OBJECTIVE: We report our experience with hand-assisted laparoscopic nephroureterectomy (HALN) for upper urinary tract transitional cell carcinoma and compare our results with a contemporary series of open nephroureterectomy (ON) performed at our institution. METHODS: Between August 1996 and May 2003, 90 patients underwent nephroureterectomy for upper-tract transitional cell carcinoma (TCC). Thirty-eight patients underwent HALN, while 52 had an ON. End-points of comparison included operative time, estimated blood loss (EBL), intraoperative and postoperative complications, length of hospital stay, pathologic grade and stage of tumor, and tumor recurrence. RESULTS: The mean patient age was 72.3 and 70.6 years in the ON and HALN groups, respectively. Mean operative duration was 243 minutes (ON) and 244 minutes (HALN), with an EBL of 478mL in the open group versus 191 mL in the hand-assisted group (P<0.001). No intraoperative complications occurred, but postoperative complications occurred in 4% and 11% of the ON and HALN groups, respectively (P=0.21). The mean hospital duration was 7.1 days (ON) versus 4.6 days (HALN) (P<0.01). No difference existed in the pathologic grade or stage distribution of urothelial tumors between the 2 groups. The mean follow-up was 51.0 months in the ON group and 31.7 months in the HALN group. Recurrence of urothelial carcinoma occurred in 50% of patients who underwent ON and 40% treated by HALN (P=0.38) at a median interval of 9.1 and 7.7 months, respectively, after surgery. CONCLUSION: Hand-assisted laparoscopic nephroureterectomy is an effective modality for the treatment of upper urinary tract urothelial carcinoma. Patients benefited from less intraoperative blood loss and a shorter hospitalization with an equivalent intermediate-term oncologic outcome compared with that of the open approach.     

Peritonealkarzinose nach roboterassistierter radikaler Zystektomie

Among patients with metastatic urothelial cancer of the bladder, 16-25% develop peritoneal carcinomatosis. In the majority of cases peritoneal carcinomatosis is associated with multiple metastatic sites. Peritoneal metastases as the single site of metastatic deposits are rare and they have been described following laparoscopic radical nephroureterectomy or cystectomy. We report on a patient who developed peritoneal carcinomatosis as the single site of metastases 8 months after robotic-assisted radical cystectomy, extended pelvic lymphadenectomy and extracorporeal formation of an ileal neobladder for organ-confined, muscle-invasive and poorly differentiated bladder cancer. The indication for robotic-assisted radical cancer surgery for urothelial carcinoma of the upper or the lower urinary tract in patients with locally advanced or poorly differentiated cancer should be made with caution.     

Laparoscopic radical cystoprostatectomy with bilateral nephroureterectomy: initial report

OBJECTIVES: To present our experience with laparoscopic radical cystoprostatectomy and bilateral nephroureterectomy for organ-confined, muscle-invasive transitional cell carcinoma (TCC) of the bladder in two patients with dialysis-dependent end-stage renal disease (ESRD). PATIENTS AND METHODS: Two men aged 77 and 65 years with organ-confined, muscle-invasive TCC of the urinary bladder and pre-existing dialysis-dependent ESRD underwent laparoscopic bilateral pelvic lymphadenectomy, radical cystoprostatectomy and bilateral nephroureterectomy. Urine spillage was avoided and en bloc urothelial integrity between the bladder and the two renal specimens was maintained throughout the procedure. The intact, entrapped specimens were removed en bloc via a Pfannenstiel incision at the end of the procedure. RESULTS: The total operative duration was 573 and 660 min, respectively, including repositioning and re-draping between each major step. Blood loss was 350 and 1000 mL, respectively. Both patients tolerated the procedure well and there were no intraoperative complications. The first patient resumed oral intake 3 days after surgery and was discharged home after 5 days. The second patient's course after surgery was complicated by a prolonged adynamic ileus and infection of the catheter placed for continuous ambulatory peritoneal dialysis. He was discharged 28 days after surgery and died from unknown causes at 30 days. CONCLUSIONS: To our knowledge, this is the first report of radical urotheliectomy, consisting of bilateral pelvic lymph node dissection, radical cystoprostatectomy, and bilateral nephroureterectomy, using entirely intracorporeal laparoscopic techniques.     

Port-site metastasis after retroperitoneoscopy-assisted nephroureterectomy and cystectomy for bladder cancer invading the ureter: a case report

We report a case of port-site metastasis of bladder cancer after left retroperitoneoscopy-assisted nephroureterectomy and cystectomy. The patient was a 73-year-old man with a chief complaint of gross hematuria. The diagnosis was invasive bladder cancer with bone metastasis. He received two courses of chemotherapy (methotrexate, vinblastine, adriamycin, cisplatin), and this resulted in resolution of the bone metastases. Two months later, abdominal and pelvic computed tomography showed a bladder tumor invading the left lower ureter with hydronephrosis. Left retroperitoneoscopy-assisted nephroureterectomy and cystectomy were performed. The patient was unable to undergo systemic chemotherapy because of renal dysfunction. Four months later, a lateral abdominal wall tumor was found at a port-site, and needle biopsy confirmed this to be metastatic urothelial carcinoma. Clinicians need to be aware of port-site metastasis, particularly in patients with UC, and take steps to prevent it during laparoscopic procedures.     

腹直肌直线套管法单机位机器人辅助腹腔镜肾输尿管切除术的疗效分析

单机位机器人辅助腹腔镜肾输尿管切除术处理输尿管远端和膀胱时难度较大。我院对32例输尿管癌患者行腹直肌直线套管法单机位机器人辅助腹腔镜下肾输尿管切除术,手术难度低,手术时间短,出血量少,手术损伤小。该手术方式是治疗输尿管癌的一种安全有效的微创手术方法。     

Hand-assisted laparoscopic nephroureterectomy with cystoscopic en-bloc excision of the distal ureter and bladder cuff and isthmusectomy in a horseshoe kidney for invasive urothelial carcinoma of the renal pelvis

Upper tract invasive urothelial carcinoma and horseshoe kidneys are familiar to the practicing urologist but relatively rare individual entities. The complication of managing them when they coexist in the same patient can be challenging. Herein, we present the first reported case in which an upper tract invasive urothelial carcinoma in a horseshoe kidney was successfully managed with a combined hand-assisted laparoscopic nephroureterectomy and isthmusectomy with cystoscopic en-bloc excision of the distal ureter and bladder cuff. This highlights the fact that complex anatomy can be managed in a completely minimally invasive fashion, and sound oncologic principles can still be maintained.     

达芬奇Xi系统在单一体位经腹腔肾输尿管切除术中的应用

目的探讨达芬奇Xi系统单一体位经腹腔肾输尿管全长切除术在治疗上尿路尿路上皮癌中的可行性及安全性。 方法回顾性分析青岛市市立医院东院区2019年11月至2020年11月收治的11例患者资料。其中男7例,女4例,年龄50~77岁。肾盂癌5例,输尿管癌5例,肾盂癌合并输尿管癌1例。肿瘤位于左侧6例,右侧5例。应用达芬奇Xi系统,术中不变换体位。 结果11台手术均顺利应用达芬奇Xi系统完成,无中转开放或腹腔镜手术。术中出血量30~300 ml。手术时间110~210 min。术后住院时间8~13 d。术后无ClavienⅡ级以上并发症。术后随访时间0~12个月,失访2例,无死亡及肿瘤复发病例。 结论单一体位经腹腔肾输尿管切除术能较好地发挥达芬奇Xi系统的优势,手术时间明显较短,术后恢复快,肿瘤切除效果较好,短期随访结果满意。     

原发性输尿管淋巴上皮样癌一例报告并文献复习

目的 探讨原发性上尿路淋巴上皮样癌的临床表现、病理特点、治疗和预后. 方法 原发性输尿管淋巴上皮样癌患者1例.女,81岁.间断无痛性全程肉眼血尿1个月就诊.CT尿路造影提示左输尿管盆腔段腔内可见长约2.5 cm类圆形软组织密度影.行腹腔镜下左输尿管癌根治术. 结果大体标本:纵行打开输尿管,距输尿管远端3.5 cm处见2.5 cm×2.0 cm隆起肿物,切面灰白,质稍硬,实性.镜检:肿瘤细胞呈巢状分布,体积较大,胞质丰富,核大,圆形,空泡状,核仁明显,间质内大量小淋巴细胞浸润.病理诊断:输尿管淋巴上皮样癌,浸及深肌层,病理分期pT2N0M0.原位杂交技术EBER为阴性.随诊3个月未见肿瘤复发及转移. 结论原发性上尿路淋巴上皮样癌罕见,需经病理组织学检查确诊.根治手术为主要治疗手段,预后优于其他类型尿路上皮癌.     

Initial experience with robot-assisted minimally-invasive nephroureterectomy

PURPOSE: Various techniques have been described for laparoscopic nephroureterectomy. We reviewed our initial experience of laparoscopic nephroureterectomy with robot-assisted extravesical excision of the distal ureter and bladder cuff. MATERIALS AND METHODS: Nine consecutive patients aged 43 to 83 years underwent laparoscopic nephroureterectomy for transitional cell carcinoma (TCC) between August 2005 and March 2007. The first five patients were repositioned after laparoscopic nephrectomy from flank to lithotomy position to dock the robot for excision of the distal ureter and bladder cuff by a single surgeon. In contrast, the last four patients remained in flank position throughout the entire procedure, with the robot docked in flank position following laparoscopic nephrectomy. A two-layer closure re-approximated the cystotomy and a urethral catheter was left in place for a mean of 5 days. RESULTS: Eight men and one woman with a mean age of 64.2 years and mean body mass index (BMI) of 28.4 kg/m(2) underwent flexible cystoscopy and laparoscopic nephroureterectomy for five right-sided and four left-sided tumors. Mean operative time was 303 minutes (range 210-430 minutes), estimated blood loss was 211 mL (range 50-700 mL), and mean length of hospital stay was 2.3 days. Pathologic staging revealed T(3) for five (55.6%), T(a) for two (22.2%), carcinoma in situ (CIS) for two (22.2%) patients, and high-grade disease for seven (77.8%) patients. With a mean follow-up of 16.2 months (range 4.3-24.3 months), three patients with a history of bladder cancer have experienced recurrence in the bladder, and one of the three has also developed metastatic disease. CONCLUSIONS: Laparoscopic nephroureterectomy with robot-assisted extravesical excision of the distal ureter and bladder cuff appears to be a feasible alternative for patients with TCC of the upper urinary tract.     

Role of lymphadenectomy in the management of urothelial carcinoma of the bladder and the upper urinary tract

The role of lymphadenectomy has been controversial in urological malignancies. Urothelial carcinoma of the bladder and upper urinary tract has a high potential to spread through the lymphatic network compared with other malignancies, including renal cell carcinoma or prostate cancer. In urothelial carcinoma of the bladder, lymphadenectomy of pelvic nodes had been considered as the standard procedure when radical cystectomy was carried out. Recently, many investigators have examined the influence of its extent, and the majority of the studies have supported the beneficial role of extended lymphadenectomy in accurate staging or in improving patient survival. Although randomized controlled trials are required to establish a greater level of evidence, more urological surgeons have already noticed the necessity for extended lymphadenectomy in bladder cancer. In contrast to bladder cancer, there have been far fewer studies on urothelial carcinoma of the upper urinary tract. This might be because of the smaller number of the patients with urothelial carcinoma of the upper urinary tract and the lack of understanding of regional nodes. However, studies of lymph node mapping and the retrospective analyses with respect to the benefit of lymphadenectomy have been carried out in urothelial carcinoma of the upper urinary tract by some investigators, although the results are still controversial. However, the results from multi‐institutional studies by high volume centers have supported the beneficial role of lymphadenectomy in urothelial carcinoma of the upper urinary tract, as it has been proposed in bladder cancer. Thus, lymphadenectomy for urothelial carcinoma of the bladder and the upper urinary tract might have a potential role in staging and improving the oncological outcomes.     

Radikale Zystektomie – pro robotisch

The standard therapy for muscle invasive bladder cancer is radical cystectomy and urinary diversion. For open surgery this procedure has notable perioperative morbidity. Performing laparoscopic cystectomy can reduce this morbidity. So far it remains unclear, whether the oncologic outcome of the laparoscopic approach is comparable to open surgery or not due to a lack of long-term follow-up data. Important surgical steps, such as extended lymphadenectomy, sparing of the neurovascular bundle for preservation of potency, preparation of the urethra for orthotopic neobladder and intracorporeal construction of a urinary diversion can be achieved much more easily with a robot-assisted approach than with conventional laparoscopy. Furthermore, the learning curve for robot-assisted cystectomy is much steeper. Therefore, if a laparoscopic cystectomy is performed, it should be performed using a robot-assisted approach.     

Modified transurethral technique for the management of distal ureter during laparoscopic assisted nephroureterectomy

INTRODUCTION: Laparoscopic assisted nephroureterectomy is a well established technique for managing the upper urinary tract urothelial cancer. However, management of the distal ureter remains a controversial issue. We describe a modified method of cystoscopic loop ligation and detachment of the distal ureter. TECHNICAL CONSIDERATION: We performed transperitoneal laparoscopic assisted nephroureterectomy in 13 patients. The lower end of the ureter was managed perurethrally using our modified technique. We circumscribed the ureteric orifice with a bladder cuff using a Collins knife. We ligated the ureteric stump via cystoscope to avoid urine spillage from the upper tract. We achieved the complete excision of the distal ureter with a bladder cuff in all cases with our modified technique. CONCLUSIONS: Our modified technique appears to be a simple, less invasive, and oncologically safe method to manage the distal ureter perurethrally.     

The nephroureterectomy: a review of technique and current controversies

The nephroureterectomy (NU) is the standard of care for invasive upper tract urothelial carcinoma (UTUC) and has been around for well over one hundred years. Since then new operative techniques have emerged, new technologies have developed, and the surgery continues to evolve and grow. In this article, we review the various surgical techniques, as well as present the literature surrounding current areas of debate surrounding the NU, including the lymphatic drainage of the upper urinary tract, management of UTUC involvement with the adrenals and caval thrombi, surgical management of the distal ureter, the use of intravesical chemotherapy as well as perioperative systemic chemotherapy, as well as various outcome measures. Although much has been studied about the NU, there still is a dearth of level 1 evidence and the field would benefit from further studies.