V761 ROBOTIC-ASSISTED MANAGEMENT OF UPPER TRACT UROTHELIAL CARCINOMA

Article Outline

• INTRODUCTION AND OBJECTIVES
• METHODS
• RESULTS
• CONCLUSIONS
• Copyright

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INTRODUCTION AND OBJECTIVES 

Robotic-assisted approaches for upper tract urothelial carcinoma are gaining popularity. Challenges include patient positioning, management of the distal ureteral segment and ureteral reimplantation. We present robotic-assisted techniques of nephroureterectomy without patient repositioning as well as distal ureterectomy with ureteral reimplantation.

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METHODS 

For nephroureterectomy, the patient's torso is secured in the modified flank position, and the lower body in placed in the modified dorsal lithotomy position with the ipsilateral leg straight and the contralateral leg bent at the knee. Two 12mm ports and four 8mm ports are placed and the robot is docked coming over the patients ipsilateral shoulder with a 30 degree up lens. The nephrectomy and proximal ureterectomy are completed. The robot is then brought between the patient's legs for the distal ureterectomy, intracorporeal bladder cuff and bladder closure without patient repositioning or placing additional ports. For distal ureterectomy with ureteral reimplantation, the patient is placed in the modified dorsal lithotomy position, and two 12mm ports and three 8mm ports are placed. The robot with 0 degree lens is docked between the patient's legs. The ureterectomy and bladder closure is completed. A stented ureteroneocystotomy is performed, with the use of psoas hitch or Boari flap as needed.

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RESULTS 

Eleven robotic-assisted nephroureterctomies have been performed using this technique. The average operative time has been 300±64 minutes, estimated blood loss (EBL) 342±248 cubic centimeters, average length of stay (LOS) 2.5±0.8 days and average catheter drainage time 9.5±2.7 days. Pathology has included Ta(3), T1(2), T2(1), T3(4) and T4(1) tumors. There has been a focally positive margin in a T3 and T4 tumor. Complications have included deep vein thrombosis(1), atrial fibrillation(1) and urinary retention(1). Three distal ureterectomies, including psoas hitch(1) and Boari flap(1) ureteroneocystotomy have been completed, with average operative time of 310±61 minutes, average EBL 66±28 cubic centimeters and average LOS 1.3±0.6 days. Pathology has included T0(2) and T1(1) tumors, with no positive margins and no complications to report.

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CONCLUSIONS 

Robotic-assisted approaches to upper tract urothelial carcinoma are possible without the need for patient repositioning and with the added benefits of a secure intracorporeal bladder cuff and water-tight bladder closure. Clinical and oncologic outcomes are similar to laparoscopic techniques.