Current Status of Robot Assisted Laparoscopic Radical Nephroureterectomy for Management of Upper Tract Urothelial Carcinoma

Lich-Gregoir vesico-ureteral reimplantation for duplex kidney anomalies in the pediatric population: a retrospective cohort study between laparoscopic and open surgery

BACKGROUND

The aim of the study is to compare the Lich-Gregoir vesico-ureteral reimplantation in laparoscopy and open surgery.

METHODS

In this case control study, we enrolled pediatric patients who were diagnosed with unilateral duplex kidney and had underwent surgical treatment. The surgical treatments were either conventional open surgery or laparoscopic surgery. We collected the basic demographic data and extracted the operative-related statistics such as operation time, blood loss, length of hospital stay, pain level, and post-operative complications. The two groups were compared using Student's t-test.

RESULTS

A total of 90 subjects were enrolled. Of the enrolled subjects, 35 underwent open surgery and 55 underwent laparoscopic surgery. There were no observable difference in the basic demographics between two groups (P>0.05). The duration of operation in laparoscopic surgery group was significantly shorter than in the open surgery group (95.60±5.25 vs. 108.70±3.12 min, P=0.040). It was also noted that the amount of blood loss, length of hospital stay, drainage level, and the mean visual analog scale in laparoscopic group were significantly lower (P<0.05). The total incidence of complications in the laparoscopic and open surgery groups were 16.36% and 37.14%, respectively.

CONCLUSIONS

Laparoscopic Lich-Gregoir vesico-ureteral reimplantation surgery management can be successful, clinically effective, and safe for pediatric population with functional duplex kidneys, and is better than the open surgery techniques.

Bladder recurrence of primary upper tract urinary carcinoma following nephroureterectomy, and risk of upper urinary tract recurrence after ureteral stent positioning in patients with primary bladder cancer

Upper tract urinary carcinoma (UTUC) and bladder cancer (BCa) share similar biological, histological and pathological characteristics. These resemblances could explain the high rate of synchronous and metachronous tumors affecting both upper urinary tract and bladder. In patients affected by primary UTUC bladder recurrence is quite common and it represents one of the major concerns during the follow-up of patients who underwent radical nephroureterectomy. Conversely, UTUC recurrence after primary non-muscular invasive BCa is a relatively rare event. Moreover, there is no clear evidence on whether the use of Double-J stenting as drainage in patients affected by BCa increases the risk of UTUC recurrence. The aim of the current study was to summarize the most recent evidence regarding the bladder recurrence after UTUC surgical treatment, and the UTUC recurrence after stent positioning in patients affected by primary BCa.

Laparoscopic vs robotic nephroureterectomy: Is it time to re-establish the standard? Evidence from a systematic review

OBJECTIVE

To conduct a systematic review of comparative studies of laparoscopic nephroureterectomy (LNU), the standard management for upper urothelial tumours, and robot-assisted NU (RANU) that has emerged as a viable alternative.

METHODS

MEDLINE, EMBASE and the Cochrane Library were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify all studies reporting on both LNU and RANU for upper urothelial tract tumours.

RESULTS

In all, 1630 patients were included, of which 838 underwent LNU and 792 RANU. Three studies reported on mean operative time and found it to be less in LNU, with two reporting this to be significant (RANU 298 vs LNU 251 min, P = 0.03; 306 vs 234 min, respectively, P < 0.001). Both studies reporting on median node count found this to be higher in the robotic groups: RANU 5.5 vs LNU 1.0 and RANU 21 vs LNU 11. Positive surgical margins (RANU 1.69% vs LNU 7.06%, P = 0.18), bladder recurrence (24.6% vs 36.89%, P = 0.09), and distant metastases (27.50% vs 17.50%, P = 0.29) were not significantly different between the two techniques. Disease-specific mortality did not differ between the two techniques (RANU 7.5% vs LNU 12.5%, P = 0.46), but postoperative mortality was reduced in RANU (0.14% vs 1.32%, P = 0.03). Overall complication rates were statistically lower in RANU, at 12.5% vs 18.8% (P < 0.001).

CONCLUSIONS

This review suggests these techniques are equivalent in terms of perioperative and oncological performance. Furthermore, there may be a lower overall complication rate, as well as postoperative mortality in the robotic group. Further research in the form of a randomised controlled trial is warranted.

Transurethral resection versus open bladder cuff excision in patients undergoing nephroureterectomy for upper urinary tract carcinoma: Operative and oncological results

Objectives

To evaluate the impact of distal ureter management on oncological results after open nephroureterectomy (ONU) comparing transurethral resection of the intramural ureter to conventional open excision, as controversy still exists about the method of choice for managing the distal ureter and bladder cuff during ONU.

Patients and methods

We retrospectively collected data from 378 patients who underwent ONU for upper urinary tract transitional cell carcinoma (UUT-TCC) from 1988 to 2009. Patients were divided into two subgroups according to the type of operation performed. Group A comprised 192 patients who had ONU with open resection of the bladder cuff from 1988 to 1997. Group B comprised 186 patients in whom transurethral resection of the intramural ureter plus single incision ONU was performed between 1998 and 2009. The mean operative time, hospital stay, duration of catheterisation, bladder recurrence rates, and cancer-specific survival (CSS) were assessed.

Results

The total operative time was statistically significantly less in the endoscopic group (Group B). For catheterisation, patients treated with an open approach (Group A) had a statistically significantly shorter duration of postoperative catheterisation. There was no statistical difference between Groups A and B for the bladder recurrence rate (Group A 24% vs 27% in Group B, P = 0.51). There was no difference in CSS at the 5-year follow-up.

Conclusions

ONU with transurethral resection of the intramural ureter up to the extravesical fat followed by ureter extraction is an oncologically safe and technically feasible operation.

Robotic assisted adrenalectomy: Is it ready for prime time?

Adrenal surgery is undergoing continuous evolution and minimally invasive surgery is increasingly being used for the surgical management of adrenal masses. With robotic-assisted surgery being a widely accepted surgical treatment for many urological conditions such as prostate carcinoma and renal cell carcinoma, the use of the robot has been expanded to include robotic-assisted adrenalectomy, offering an alternative minimally invasive platform for adrenal surgery. We performed a literature review on robotic-assisted adrenalectomy, reviewing the current surgical techniques and perioperative outcomes.

Operative technique and early experience for robotic-assisted laparoscopic nephroureterectomy (RALNU) using da Vinci Xi

Purpose

Robotic-assisted laparoscopic nephroureterectomy (RALNU) has been previously utilized for management of upper tract urothelial carcinoma. The da Vinci Xi surgical system was released in April of 2014. We describe our operative technique and early experience for RALNU using the da Vinci Xi system highlighting unique features of this surgical platform.

Materials and methods

A total of 10 patients with a diagnosis of upper tract urothelial carcinoma underwent RALNU using the da Vinci Xi system between April and November of 2014. A novel, oblique “in line” robotic trocar configuration was utilized to access the upper abdomen (nephrectomy portion) and pelvis (bladder cuff excision) without undocking. The port hopping feature of da Vinci Xi was utilized to facilitate optimal, multi-quadrant visualization during RALNU.

Results

Robotic-assisted laparoscopic nephroureterectomy was successfully completed without open conversion in all 10 patients. Mean operative time was 184 min (range 140–300 min), mean estimated blood loss was 121 cc (range 60–300 cc), and mean hospital stay was 2.4 days. Final pathology demonstrated high grade urothelial carcinoma in all patients. Surgical margins were negative in all patients. No intra-operative complications were encountered. One patient developed a pulmonary embolus after being discharged. No patients required a blood transfusion. Mean patient follow-up was 130 days (range 15–210 days).

Conclusion

The use of da Vinci Xi with a novel, oblique “in line” port configuration and camera port hopping technique allows for an efficient and reproducible method for RALNU without the need for repositioning the patient or the robot during surgery.

Electronic supplementary material

The online version of this article (doi:10.1186/s40064-015-1076-6) contains supplementary material, which is available to authorized users.

Concurrent upper and lower urinary tract robotic surgery: A case series

The da Vinci Surgical System (Intuitive Surgical Inc.) continues to develop as a platform in urological surgery. Synchronous upper and lower urinary tract tumours requiring extirpative surgery are not uncommon. We report the first case robotic series of combined complex upper and lower urinary tract surgery. Six high-risk anaesthetic patients with a median age of 71 years and apparent synchronous upper and lower urinary tract pathologies underwent concurrent robotic surgery. Five underwent robotic nephroureterectomy and robotic-assisted radical cystectomy (RARC); 1 had combined robotic nephroureterectomy and robotic-assisted radical prostatectomy (RALP). The mean length of stay was 10 days, with an average blood loss of 416.7 mL. The median console time for nephroureterectomy, RALP and RARC was 90, 90 and 210 minutes, respectively. Four patients had intra-corporeal ileal conduit urinary diversion. There were no Clavien grade 3, 4, or 5 complications. In all patients, 30- and 90-day mortality was nil. Margins were clear in the entire cohort. We concluded that combined upper and lower urinary tract robotic surgery is safe and technically feasible with acceptable complications and oncological outcomes.

Clinical pathway after robotic nephroureterectomy: omission of pelvic drain with next-day catheter removal and discharge

OBJECTIVE

To determine the feasibility of applying a postoperative clinical pathway after robotic nephroureterectomy (RNU) targeting safe omission of a pelvic drain and removal of the bladder catheter on the day after surgery with hospital discharge on postoperative day 1 (POD#1).

METHODS

We reviewed a prospectively collected database of all RNUs performed by a single surgeon (R.A.) since institution of our clinical pathway in 2008 that includes pelvic drain omission, bladder catheter removal the morning after surgery, and discharge on POD#1. Patient demographics, and perioperative and postoperative outcomes were evaluated. Ability to adhere to the pathway and achieving the described parameters and whether any resulting complications occurred were determined.

RESULTS

RNU was performed in 29 patients with mean age and body mass index of 69 years (50-90 years) and 30 kg/m(2) (19-41 kg/m(2)), respectively. No patient required a pelvic drain, and 2 were discharged with a catheter. All but 2 patients (93%) were discharged on POD#1. Overall, successful pathway application was achieved in 26 of 29 patients (90%) including no drain, catheter removal on the morning after surgery, and discharge on POD#1. No patient developed urine leak or other complications related to early catheter removal.

CONCLUSION

Our clinical pathway after RNU allows safe omission of a pelvic drain with early discontinuation of the bladder catheter and discharge on the POD#1 in most patients. To our knowledge, similar pathways have not been previously achieved with nephroureterectomy by any approach, but should be considered by surgeons treating urothelial carcinoma of the upper urinary tract.

Laparoendoscopic single-site (LESS) robot-assisted nephroureterectomy: comparison with conventional multiport technique in the management of upper urinary tract urothelial carcinoma

OBJECTIVE

To compare the peri-operative, pathological and oncological outcomes of laparoendoscopic single-site (LESS) robot-assisted nephroureterectomy (LESS-RALNU) with those of multiport robot-asssisted nephroureterectomy (M-RALNU).

PATIENTS AND METHODS

A total of 38 patients with upper urinary tract urothelial carcinoma underwent LESS-RALNU (n = 17) or M-RALNU (n = 21) by a single surgeon at a tertiary institution. Data were obtained from a prospectively maintained database.

RESULTS

Patients' demographics and tumour characteristics were similar between the M-RALNU and LESS-RALNU groups. The mean follow-up was 48.4 months for M-RALNU and 30.9 months for LESS-RALNU (P = 0). The mean operating time, estimated blood loss and length of hospitalization for M-RALNU and LESS-RALNU were 251 min, 192 mL, 6.5 days and 247 min, 376 mL and 5.4 days, respectively (P > 0.05). Overall, there were no significant differences in complication rates, although three patients in the LESS-RALNU group required blood transfusion, whereas no patient in the M-RALNU group did (P = 0.081). The proportion of patients with bladder recurrence, local recurrence and distant metastases was similar between the two groups. There were no significant differences in the recurrence-free survival, cancer-specific survival and overall survival rates between the two groups.

CONCLUSIONS

Although the oncological and peri-operative outcomes of patients who underwent LESS-RALNU compared well with those who underwent M-RALNU and with series of other surgical approaches, LESS-RALNU might result in greater intra-operative blood loss. We suggest careful selection of patient for this technique.