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Total Intracorporeal Versus Open Bladder Cuffing in Robotic Radical Nephroureterectomy for Upper Tract Urothelial Carcinoma. Urology 2023; 174:111-117. [PMID: 36646178 DOI: 10.1016/j.urology.2022.09.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/12/2022] [Accepted: 09/18/2022] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To evaluate a single institution experience of total intracorporeal bladder cuffing and distal ureterectomy (DUBC) in robotic radical nephrouretectomy (RNU) for upper tract urothelial carcinoma (UTUC). MATERIALS AND METHODS One hundred sixty-eight patients treated for UTUC with robotic RNU at our institution from May 2009 to October 2019 were retrospectively analyzed. Ninety-two patients underwent total intracorporeal DUBC after robotic dock repositioning, whereas 76 patients underwent open methods via Gibson incision. Perioperative outcomes including operation time, estimated blood loss (EBL), transfusion rates, use of painkillers, Visual analogue scale (VAS) pain scores, and complication rates were compared, as well as pathological and oncological outcomes. Uni- and multi-variate Cox regression models were performed for survival analysis. RESULTS There were no significant differences in baseline patient characteristics between the 2 groups. Patients who underwent intracorporeal bladder cuffing had less EBL (169.8 ± 150.4 vs 214.6 ± 157.0, P = .091) and decreased pain at 1 week (VAS score 1.18 ± 1.1 vs 2.2 ± 1.1, P = .017). Pathological outcomes were not significantly different, and oncological outcomes including local and intravesical recurrence, cancer-specific and overall mortality were comparable to patients who received extracorporeal bladder cuffing. Intracorporeal bladder cuffing was not associated with increased risk of progression on univariate analysis (HR 0.600, 95% CI, 0.314-1.147; P = .122). CONCLUSION Based on our experience, intracorporeal DUBC can be a safe and oncologically non-inferior alternative method to RNU, with benefits of decreased EBL and postoperative pain. Future prospective trials are necessary to further validate our results.
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Saini S, Lukas V, Pathak RA, Hemal AK. Robot-Assisted Laparoscopic Ureteral Reconstruction for Malignant Pathology: Single-Center Experience with Analysis of Perioperative, Functional, and Oncologic Outcomes. J Endourol 2023; 37:42-49. [PMID: 36301931 DOI: 10.1089/end.2022.0477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Introduction: Radical nephroureterectomy with bladder cuff excision (BCE) is the standard of care all high-risk upper tract urothelial carcinomas. With continued advancements, robot-assisted segmental ureteral resection can be employed for ureteral tumors for ipsilateral renal preservation. Herein, we are presenting our experience of different techniques classified by the affected ureteral segment, along with perioperative and intermediate to long-term functional and oncologic outcomes. Methods: From January 2008 to June 2021, a total of 17 patients underwent robot-assisted renal preserving excisional procedures for ureteral tumors. We collected and analyzed baseline, perioperative and follow-up outcomes parameters from our prospectively maintained institutional database. Eleven patients underwent segmental ureterectomy (SU) with BCE and ureteroneocystostomy with psoas hitch, five patients underwent SU with ureteroureteral anastomosis with/without psoas hitch, and one patient underwent ileal patch interposition after segmental ureteral excision. Results: Although majority of the patients had inconclusive or low-grade pathology on initial ureteroscopic biopsies, 73.33% of the patients were found to have high-grade tumors on final pathology report. Median tumor size was 2.7 cm (1-5.5 cm), and the median operative duration was 193 minutes (142-400 minutes). None of the procedures required conversion to open. Overall, only one patient (5.9%) had Clavien-Dindo grade ≥ III complication (pelvic abscess). At median follow-up of 41 months (7-156 months), four patients (26.67%) developed urothelial recurrences out of which only one patient required nephroureterectomy. Overall survival and nephroureterectomy-free survival were 86.67% and 92.31%, respectively. Conclusions: Our study provides a comprehensive review of various surgical approaches of robot-assisted renal sparing management for ureteral tumors. These procedures are surgically safe, feasible, and effective with satisfactory oncologic outcomes at intermediate to long-term follow-up. These procedures may be safely employed in select patients with a localized ureteral tumor to salvage the ipsilateral kidney and estimated glomerular filtration rate.
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Affiliation(s)
- Sumit Saini
- Robotics and Minimally Invasive Surgery Fellow, Department of Urology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Vanessa Lukas
- Division of Urology at Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ram A Pathak
- Department of Urology, Mayo Clinic, Jacksonville, Florida, USA
| | - Ashok K Hemal
- Department of Urology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
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Abstract
Upper tract urothelial carcinoma is a rare malignancy for which surgery provides definitive management. Open radical nephroureterectomy was the gold standard treatment, but laparoscopic and robot-assisted approaches are alternative options. Kidney-sparing approaches are feasible for carefully selected patients with ureteral cancer. This article discusses the evaluation of patients with upper tract urothelial carcinoma and definitive management using robot-assisted surgical approaches. Patients with urothelial carcinoma of the upper tract can be treated with robot-assisted nephroureterectomy, distal ureterectomy, and segmental ureterectomy.
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Affiliation(s)
- Eric M Lo
- Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA
| | - Hyung L Kim
- Cedars-Sinai Medical Center, 8635 West Third Street, Los Angeles, CA 90048, USA.
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Seetharam Bhat KR, Moschovas MC, Patel VR, Ko YH. The robot-assisted ureteral reconstruction in adult: A narrative review on the surgical techniques and contemporary outcomes. Asian J Urol 2020; 8:38-49. [PMID: 33569271 PMCID: PMC7859418 DOI: 10.1016/j.ajur.2020.11.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Revised: 03/30/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022] Open
Abstract
Despite the rapid increase in the use of robotic surgery in urology, the majority of ureteric reconstruction procedures are still performed using laparoscopic or open approaches. This is primarily due to uncertainty regarding the advantages of robotic approaches over conventional ones, and the unique difficulty in identifying the specific area of interest due to the lack of tactile feedback from the current robotic systems. However, with the potential benefits of minimal invasiveness, several pioneering reports have been published on robotic surgery in urology. By reviewing the literature on this topic, we aimed to summarize the techniques, considerations, and consistent findings regarding robotic ureteral reconstruction in adults. Robotic applications for ureteral surgery have been primarily reported for pediatric urology, especially in the context of relieving a congenital obstruction in the ureteral pelvic junction. However, contemporary studies have also consistently demonstrated that robotic surgery could be a reliable option for malignant, iatrogenic, and traumatic conditions, which generally occur in adult patients. Nevertheless, the lack of comparative studies on heterogeneous hosts and disease conditions make it difficult to determine the benefit of the robotic approach over the conventional approach in the general population; thus, qualified prospective trials are needed for wider acceptance. However, contemporary reports have demonstrated that the robotic approach could be an alternative option for ureteral construction, even in the absence of haptic feedback, which can be compensated by various surgical techniques and enhanced three-dimensional visualization.
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Affiliation(s)
| | - Marcio Covas Moschovas
- Department of Urology, AdventHealth Global Robotics Institute, Celebration, FL, United States
| | - Vipul R Patel
- Department of Urology, AdventHealth Global Robotics Institute, Celebration, FL, United States
| | - Young Hwii Ko
- Department of Urology, Yeungnam University, Daegu, Republic of Korea
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Kwon SY, Ko YH, Song PH, Kim BH, Kim BS, Kim TH. The Remaining Ipsilateral Ureteral Orifice Provokes Intravesical Tumor Recurrence After Nephroureterectomy for Upper Tract Urothelial Carcinoma: A Multicenter Study With a Mid-Term Follow-Up. Urology 2020; 145:166-171. [DOI: 10.1016/j.urology.2020.06.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Revised: 06/26/2020] [Accepted: 06/30/2020] [Indexed: 11/16/2022]
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Robotic radical nephroureterectomy and segmental ureterectomy for upper tract urothelial carcinoma: a multi-institutional experience. World J Urol 2019; 37:2303-2311. [PMID: 31062121 DOI: 10.1007/s00345-019-02790-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Accepted: 04/26/2019] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To report a multi-institutional experience on robotic radical nephroureterectomy (RNU) and segmental ureterectomy (SU) for upper tract urothelial carcinoma (UTUC). METHODS Data were prospectively collected from patients with non-metastatic UTUC undergoing robotic SU or RNU at three referral centers between 2015 and 2018. Transperitoneal, single-docking robotic RNU followed established principles. Bladder cuff excision (BCE) was performed with robotic or open approach. Techniques for SU included: ureteral resection and primary uretero-ureterostomy; partial pyelectomy and modified pyeloplasty; ureteral resection with BCE and direct- or psoas hitch-ureteroneocystostomy. We retrospectively evaluated the technical feasibility, and peri-operative and oncologic outcomes after robotic RNU/SU. RESULTS 81 patients were included. No case required conversion to open surgery. Early major (Clavien-Dindo grade > 2) complications were reported in six (7.4%) patients (two after SU, four after RNU). Three patients experienced late major complications (one after SU, two after RNU). Median ΔeGFR at 3 months was - 1 ml/min/1.73 m2 after SU and - 15 ml/min/1.73 m2 after RNU. Positive surgical margins were recorded in five patients (one after SU, four after RNU). Median follow-up was 21 months and 22 months in the SU and RNU groups, respectively. Three (20%) patients had ipsilateral upper tract recurrence after SU, while five (7.5%) developed metastases after RNU. No case of port-site metastases or peritoneal carcinomatosis was reported. At last follow-up, 67 (82.7%) patients were alive without evidence of disease. CONCLUSION Robotic SU and RNU are technically feasible and achieved promising peri-operative and oncologic outcomes in selected patients with non-metastatic UTUC.
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Pal RP, Koupparis AJ. Expanding the indications of robotic surgery in urology: A systematic review of the literature. Arab J Urol 2018; 16:270-284. [PMID: 30147957 PMCID: PMC6105341 DOI: 10.1016/j.aju.2018.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 05/07/2018] [Accepted: 05/08/2018] [Indexed: 11/03/2022] Open
Abstract
Objectives To evaluate the recent developments in robotic urological surgery, as the introduction of robotic technology has overcome many of the difficulties of pure laparoscopic surgery enabling surgeons to perform complex minimally invasive procedures with a shorter learning curve. Robot-assisted surgery (RAS) is now offered as the standard for various surgical procedures across multiple specialities. Methods A systematic search of MEDLINE, PubMed and EMBASE databases was performed to identify studies evaluating robot-assisted simple prostatectomy, salvage radical prostatectomy, surgery for urolithiasis, distal ureteric reconstruction, retroperitoneal lymph node dissection, augmentation ileocystoplasty, and artificial urinary sphincter insertion. Article titles, abstracts, and full text manuscripts were screened to identify relevant studies, which then underwent data extraction and analysis. Results In all, 72 studies evaluating the above techniques were identified. Almost all studies were retrospective single-arm case series. RAS appears to be associated with reduced morbidity, less blood loss, reduced length of stay, and comparable clinical outcomes in comparison to the corresponding open procedures, whilst having a shorter operative duration and learning curve compared to the equivalent laparoscopic techniques. Conclusion Emerging data demonstrate that the breadth and complexity of urological procedures performed using the da Vinci® platform (Intuitive Surgical Inc., Sunnyvale, CA, USA) is continually expanding. There is a gaining consensus that RAS is producing promising surgical results in a wide range of procedures. A major limitation of the current literature is the sparsity of comparative trials evaluating these procedures.
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Key Words
- (L)(R)RP, (laparoscopic)(retropubic)radical prostatectomy
- (L)(RA) PN, (laparoscopic)(robot-assisted) partial nephrectomy
- (L-)(O-)(R-) RPLND, (laparoscopic)(open)(robot-assisted) retroperitoneal lymph node dissection
- (O)(L)(RA)SP, (open)(laparoscopic)(robot-assisted)simple prostatectomy
- (RA)RC, (robot-assisted) radical cystectomy
- (S)UI, (stress) urinary incontinence
- (s)RALP, (salvage)robot-assisted laparoscopic prostatectomy
- AUS, artificial urinary sphincter
- HoLEP, holmium laser enucleation of the prostate
- ICUD, intracorporeal urinary diversion
- LOS, length of hospital stay
- MIS, minimally invasive surgery
- PCNL, percutaneous nephrolithotomy
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- RAI, robot-assisted augmentation ileocystoplasty
- RAS, robot-assisted surgery
- RCT, randomised controlled trial
- RNL, robot-assisted nephrolithotomy
- RPL, robot-assisted pyelolithotomy
- Robot-assisted surgery
- Robotic surgery
- Urology
- sRRP, salvage RRP
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Affiliation(s)
- Raj P Pal
- Bristol Urological Institute, Southmead Hospital, Bristol, UK
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Kolontarev K, Kasyan G, Pushkar D. Robot-assisted laparoscopic ureteral reconstruction: а systematic review of literature. Cent European J Urol 2018; 71:221-227. [PMID: 30038814 PMCID: PMC6051367 DOI: 10.5173/ceju.2018.1690] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 04/16/2018] [Accepted: 04/21/2018] [Indexed: 11/24/2022] Open
Abstract
Introduction To review the literature, as well as to analyze and compare available data on robot-assisted laparoscopic (RAL) surgery versus open surgery, carried out in ureteral reconstructions in terms of different surgical characteristics. Materials and methods Eligible studies, published between 1997 and July 2016, were retrieved through MEDLINE by applying predetermined inclusion and exclusion criteria with the English language restriction. Publications on RAL surgeries, carried out in different ureteral reconstructions and of any study design, including case series and comparative studies, were included. The study was performed in accordance with the PRISMA statement. Results A total of 12 retrospective studies (case series and comparative studies) met the systematic review selection criteria involving 245 RAL and 76 open ureteral surgery cases. Main indications for ureter reconstruction were strictures, tumors and injuries. The individual results of comparative studies revealed that the EBL was statistically significantly lower for RAL than for open surgery. As for operation time, length of hospital stay and follow-up time, the data was contradictory. The rate of recurrent stricture in RAL and open groups was similar: -9.0%. The meta-analysis of three comparative studies confirmed that patients lose statistically significantly less blood in RAL, compared to open surgery. Conclusions The analysis of limited data available shows that robot-assisted laparoscopic ureteral reconstruction is a safe and effective minimally invasive technique with high cure rates similar to those of the conventional open approach and, with favorable safety profile. Future well-designed randomized controlled trials are required to strengthen our findings.
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Kroczak T, Reynolds LF, Ordon M. Robotic Autotransplantation and Management of Post-transplant Anastomotic Strictures: the Future Is Here. Curr Urol Rep 2018; 19:31. [PMID: 29572617 DOI: 10.1007/s11934-018-0781-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW We set out to review the current published experience with robotic autotransplantation. Although the experience to date is limited, this surgery appears to be safe and technically feasible. We also examined the use of the robotic surgical platform for the management of post-transplant uretero-vesical anastomotic strictures. RECENT FINDINGS To date, only four reported cases of robotic autotransplantation have been described with two being performed completely intra-corporeally. An intra-corporeal approach is feasible for benign conditions, while malignant masses should be inspected and dissected extra-corporeally. Ureteric strictures after renal transplantation are common. To date, the experience with robotic surgical management is limited but has also been shown to be safe and feasible. While robotic autotransplantation is still in its infancy, it is feasible and appears to be safe. Renal allograft function and surgical outcomes are favorable and provide patients the option to have a historically more morbid surgery performed with a minimally invasive approach.
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Affiliation(s)
- Tad Kroczak
- St. Michael's Hospital, Division of Urology, Department of Surgery, University of Toronto, 61 Queen St East Suite 9-103, Toronto, ON, M5C 2T2, Canada
| | - Luke F Reynolds
- St. Michael's Hospital, Division of Urology, Department of Surgery, University of Toronto, 61 Queen St East Suite 9-103, Toronto, ON, M5C 2T2, Canada
| | - Michael Ordon
- St. Michael's Hospital, Division of Urology, Department of Surgery, University of Toronto, 61 Queen St East Suite 9-103, Toronto, ON, M5C 2T2, Canada.
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Aro T, Mullerad M, Amiel GE. Expanding the Utilization of Robotic Procedures in Urologic Surgery. Rambam Maimonides Med J 2017; 8:RMMJ.10320. [PMID: 29059044 PMCID: PMC5652935 DOI: 10.5041/rmmj.10320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Although the word "robot" was coined in 1921, only close to 70 years later were robotic devices developed to assist during surgery. Urology has always been at the forefront of endoscopic, minimally invasive, and robotic developments in medicine. Robotic prostatectomy signaled the emerging role of robotic surgery in urology, but since then it has been applied to every urologic laparoscopic procedure.
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Affiliation(s)
- Tareq Aro
- Urology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Michael Mullerad
- Urology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Gilad E Amiel
- Urology Department, Rambam Health Care Campus, Haifa, Israel
- Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Gambachidze D, Phé V, Drouin SJ, Wolff B, Parra J, Mozer P, Renard-Penna R, Chartier-Kastler E, Rouprêt M. [Functional outcomes obtained after vesicoureteral reimplantation surgery in adults: A review]. Prog Urol 2015; 25:683-91. [PMID: 26184044 DOI: 10.1016/j.purol.2015.06.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 05/31/2015] [Accepted: 06/12/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVES Vesico-ureteral reimplantations (VUR) for adults are complex procedures, often practicing for distal ureteral lesions. Our goal was to synthesis the main indications for VUR, different techniques and their functional outcomes. MATERIAL AND METHODS A literature review in English by Medline, Embase and Google scholar was performed using the following keywords: ureter; laparoscopy; robotics, reimplantation; surgery; obstruction; morbidity; complications; psoas hitch; Boari flap; ureteroneocystostomy. RESULTS In more than half of the cases, aetiology was a iatrogenic ureteral lesion. When the ureteral defect was less than 2 cm, direct or non-refluxing VUR was the technique of choice. If defect was superior than 2 cm the Boari flap or vesicopsoas hitch were preferred. Several surgical approaches were feasible: open, laparoscopic only, robot assisted laparoscopic. Estimated blood loss, pain and mean hospital stay seemed better with conventional or robotic coelioscopy. Nevertheless, complications, pre-/post-operative renal function and mean operative time seemed similar. The most frequent major complication was the anastomotic urine leakage. CONCLUSIONS The VUR techniques are well codified now even if it's a rare procedure. Functional outcomes are satisfied according to literature and morbidity is more and more decreasing but the level of evidence of the studies is low.
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Affiliation(s)
- D Gambachidze
- Service d'urologie de l'hôpital Pitié-Salpêtrière, faculté de médecine Pierre-et-Marie-Curie, université Paris 6, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - V Phé
- Service d'urologie de l'hôpital Pitié-Salpêtrière, faculté de médecine Pierre-et-Marie-Curie, université Paris 6, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - S J Drouin
- Service d'urologie de l'hôpital Pitié-Salpêtrière, faculté de médecine Pierre-et-Marie-Curie, université Paris 6, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - B Wolff
- Service d'urologie de l'hôpital Pitié-Salpêtrière, faculté de médecine Pierre-et-Marie-Curie, université Paris 6, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - J Parra
- Service d'urologie de l'hôpital Pitié-Salpêtrière, faculté de médecine Pierre-et-Marie-Curie, université Paris 6, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - P Mozer
- Service d'urologie de l'hôpital Pitié-Salpêtrière, faculté de médecine Pierre-et-Marie-Curie, université Paris 6, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - R Renard-Penna
- Service d'urologie de l'hôpital Pitié-Salpêtrière, faculté de médecine Pierre-et-Marie-Curie, université Paris 6, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - E Chartier-Kastler
- Service d'urologie de l'hôpital Pitié-Salpêtrière, faculté de médecine Pierre-et-Marie-Curie, université Paris 6, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| | - M Rouprêt
- Service d'urologie de l'hôpital Pitié-Salpêtrière, faculté de médecine Pierre-et-Marie-Curie, université Paris 6, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France.
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Fifer GL, Raynor MC, Selph P, Woods ME, Wallen EM, Viprakasit DP, Nielsen ME, Smith AM, Pruthi RS. Robotic ureteral reconstruction distal to the ureteropelvic junction: a large single institution clinical series with short-term follow up. J Endourol 2015; 28:1424-8. [PMID: 25230048 DOI: 10.1089/end.2014.0227] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND AND PURPOSE Use of the robotic platform for urinary reconstructive surgery is growing in popularity since its initial application with pyeloplasty for ureteropelvic junction (UPJ) repair. Although clinical series of adult robotic ureteral reconstruction appear in the literature, these reports tend to be limited in size and scope. We present the largest series to date of patients undergoing surgery for any obstruction distal to the UPJ along with outcomes and short-term follow up. PATIENTS AND METHODS A retrospective chart review was performed for patients undergoing robotic ureteral reconstructive procedures for any indication at our institution. Patients undergoing pyeloplasty, planned open procedures, and pediatric patients were excluded from the current analysis. Patient demographic data, etiology, procedure performed, and perioperative outcomes were reviewed. Postoperative follow up, imaging, and any re-interventions were also captured. The procedures performed included ureteroneocystostomy, psoas hitch, Boari flap, ureteroureterostomy, ureterolysis, ureterolithotomy, and nephropexy. RESULTS A total of 55 patients underwent robotic ureteral reconstructive procedures distal to the UPJ. Of these patients, 45 underwent intervention for a benign etiology and 10 for upper tract malignancy. All cases were successfully completed robotically with no open conversions and no intraoperative complications. Concurrent endoscopy was performed in 31 patients. The median operating room time was 221 minutes overall. Median blood loss was 50 ml with no intraoperative transfusions. The average hospital stay was 1.6 days, with 39 patients (71%) discharged on postoperative day 1. All surgical margins were negative for malignancy. The median follow up with imaging was 181 days. There were two serious complications (3.6%) and three failures (5.3%). CONCLUSIONS Robotic reconstruction of the ureter distal to the UPJ is feasible, safe, effective, and able to replicate techniques of open surgery with equivalent outcomes to large robotic pyeloplasty and smaller distal ureteral reconstruction series.
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Affiliation(s)
- Gordon L Fifer
- Department of Urology, University of North Carolina , Chapel Hill, North Carolina
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13
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Risk-adapted strategy for the kidney-sparing management of upper tract tumours. Nat Rev Urol 2015; 12:155-66. [DOI: 10.1038/nrurol.2015.24] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Tyritzis SI, Wiklund NP. Ureteral strictures revisited…trying to see the light at the end of the tunnel: a comprehensive review. J Endourol 2014; 29:124-36. [PMID: 25100183 DOI: 10.1089/end.2014.0522] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
A ureteral stricture is a rather rare urological event defined as a narrowing of the ureter causing a functional obstruction and renal failure, if left untreated. The aim of this review article is to summarize and discuss current knowledge on the incidence, pathogenesis, management, and follow up of proximal, mid, and distal ureteral strictures.
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Affiliation(s)
- Stavros I Tyritzis
- 1 Section of Urology, Department of Molecular Medicine and Surgery, Karolinska Institutet , Stockholm, Sweden
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15
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Marshall S, Stifelman M. Robot-assisted surgery for the treatment of upper urinary tract urothelial carcinoma. Urol Clin North Am 2014; 41:521-37. [PMID: 25306164 DOI: 10.1016/j.ucl.2014.07.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Robot-assisted laparoscopic surgery is increasingly used in urologic oncologic surgery. Robotic nephroureterectomy is still a relatively new technique. As upper tract urothelial carcinoma is a rare disease, intermediate- and long-term outcome data are scarce. However, robotic nephroureterectomy does seem to offer advantages to open and laparoscopic counterparts, with comparable short-term oncologic and functional outcomes. Here the authors review the robotic surgical management of upper tract urothelial carcinoma, with a review of the steps and tips on making this approach more widely adoptable.
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Affiliation(s)
- Susan Marshall
- Department of Urology, NYU Langone Medical Center, 150 East 32nd Street, 2nd Floor, New York, NY 10016, USA.
| | - Michael Stifelman
- Department of Urology, NYU Langone Medical Center, 150 East 32nd Street, 2nd Floor, New York, NY 10016, USA
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Fifer GL, Raynor MC, Selph P, Woods ME, Wallen EM, Viprakasit DP, Nielsen M, Smith AM, Pruthi RS. Robotic Ureteral Reconstruction Distal to the Ureteropelvic Junction: A Large Single Institution Clinical Series with Short Term Follow-Up. J Endourol 2014. [DOI: 10.1089/end.2014-0227.ecc14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Autorino R, Zargar H, Kaouk JH. Robotic-assisted laparoscopic surgery: recent advances in urology. Fertil Steril 2014; 102:939-49. [PMID: 24993800 DOI: 10.1016/j.fertnstert.2014.05.033] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Revised: 05/08/2014] [Accepted: 05/21/2014] [Indexed: 12/11/2022]
Abstract
The aim of the present review is to summarize recent developments in the field of urologic robotic surgery. A nonsystematic literature review was performed to retrieve publications related to robotic surgery in urology and evidence-based critical analysis was conducted by focusing on the literature of the past 5 years. The use of the da Vinci Surgical System, a robotic surgical system, has been implemented for the entire spectrum of extirpative and reconstructive laparoscopic kidney procedures. The robotic approach can be applied for a range of adrenal indications as well as for ureteral diseases, including benign and malignant conditions affecting the proximal, mid, and distal ureter. Current evidence suggests that robotic prostatectomy is associated with less blood loss compared with the open surgery. Besides prostate cancer, robotics has been used for simple prostatectomy in patients with symptomatic benign prostatic hyperplasia. Recent studies suggest that minimally invasive radical cystectomy provides encouraging oncologic outcomes mirroring those reported for open surgery. In recent years, the evolution of robotic surgery has enabled urologic surgeons to perform urinary diversions intracorporeally. Robotic vasectomy reversal and several other robotic andrological applications are being explored. In summary, robotic-assisted surgery is an emerging and safe technology for most urologic operations. The acceptance of robotic prostatectomy during the past decade has paved the way for urologists to explore the entire spectrum of extirpative and reconstructive urologic procedures. Cost remains a significant issue that could be solved by wider dissemination of the technology.
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Affiliation(s)
- Riccardo Autorino
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Homayoun Zargar
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jihad H Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio.
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García-Segui A, Gómez I, García-Tello A, Cáceres F, Angulo JC, Gascón M. [Ureterectomy in the treatment of urothelial carcinoma of the distal ureter]. Actas Urol Esp 2013; 37:249-55. [PMID: 23398812 DOI: 10.1016/j.acuro.2012.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2012] [Revised: 09/04/2012] [Accepted: 09/06/2012] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Segmental ureterectomy with preservation of the kidney is a treatment option for the low grade urothelial carcinoma (LG-UC) in distal ureter that is not a candidate for endoscopic resection. Laparoscopic distal ureterectomy (LDU) with ureteral reimplantation is common in benign conditions (stenosis, iatrogenic lesion, endometriosis). However, it has been hardly described in malignant ureteral condition. The literature is reviewed in this regards and the surgical technique described. MATERIAL AND METHODS The experience regarding two cases of LDU due to low grade urothelial carcinoma in distal ureter is presented. In both, previous bladder transurethral resection (RTU) was performed. The urinary cytology was negative and the imaging studies identified urinary obstruction and distal ureter filling defect. One of the patients had a background of T1G3 bladder cancer and suffered renal failure. In both, the ureter was ligated early. Segmental ureterectomy was performed using a combined endoscopic and laparoscopic procedure with ureteral desinsertion in one case. In the other, it was exclusively laparoscopic. Both were done with 4 trocars. Ureteral reimplantation was conducted with continuous hermetic suture and without tension. In one case with background of high grade bladder tumor, pelvic lymphadenectomy was also performed. RESULTS Operating time was 180 and 240 min, respectively, with estimated bleeding of 100 and 250 ml. Hospitalization time was 6 and 4 days. The only post-operatory complication was paralytic ileum (Clavien I) in the first case. With a 20 and 12 month follow-up, there is no evidence of recurrence or dilatation. In the patient with renal failure, creatinine clearance improved. CONCLUSIONS The LDU with ureteral reimplantation is a complex technique. However, it represents a feasible and effective alternative for the treatment of LG-UC in distal ureter, as long as the oncological and reconstructive principles are respected.
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Affiliation(s)
- A García-Segui
- Servicio de Urología, Hospital General Mateu Orfila, Mahón, España.
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Musch M, Hohenhorst L, Pailliart A, Loewen H, Davoudi Y, Kroepfl D. Robot-assisted reconstructive surgery of the distal ureter: single institution experience in 16 patients. BJU Int 2013; 111:773-83. [DOI: 10.1111/j.1464-410x.2012.11673.x] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Michael Musch
- Department of Urology; Pediatric Urology and Urologic Oncology; Kliniken Essen-Mitte; Essen; Germany
| | - Lukas Hohenhorst
- Department of Urology; Pediatric Urology and Urologic Oncology; Kliniken Essen-Mitte; Essen; Germany
| | - Anne Pailliart
- Department of Urology; Pediatric Urology and Urologic Oncology; Kliniken Essen-Mitte; Essen; Germany
| | - Heinrich Loewen
- Department of Urology; Pediatric Urology and Urologic Oncology; Kliniken Essen-Mitte; Essen; Germany
| | | | - Darko Kroepfl
- Department of Urology; Pediatric Urology and Urologic Oncology; Kliniken Essen-Mitte; Essen; Germany
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Stanasel I, Atala A, Hemal A. Robotic Assisted Ureteral Reimplantation: Current Status. Curr Urol Rep 2012; 14:32-6. [DOI: 10.1007/s11934-012-0298-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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McClain PD, Mufarrij PW, Hemal AK. Robot-assisted reconstructive surgery for ureteral malignancy: analysis of efficacy and oncologic outcomes. J Endourol 2012; 26:1614-7. [PMID: 22849289 DOI: 10.1089/end.2012.0219] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND AND PURPOSE There have been previous reports of the use of robotic technology for the surgical treatment of ureteral neoplasms such as transitional-cell carcinoma. These have lacked long-term follow-up, been isolated cases, or focused on only the distal ureter. This investigation examines a series of mid and distal ureteral neoplasms managed with surgeon controlled robotic techniques at a tertiary care medical center. We present perioperative data and long-term follow-up, with emphasis on oncologic outcomes. PATIENTS AND METHODS This series includes six consecutive patients who have undergone robot-assisted surgical extirpation of mid and distal ureteral malignancies since 2008. Four patients underwent robot-assisted distal ureterectomy with ureteroneocystostomy, and two underwent midureter segmental excision with ureteroureterostomy. Patient demographics, intraoperative data, final pathology results, and oncologic follow-up were reviewed retrospectively. RESULTS Total mean operative time was 268.5 minutes, including the cystoscopy and change of position component of the procedure; mean estimated blood loss was 72.5 mL, and the mean length of stay was 1.8 days. All four patients who underwent distal ureterectomy also had excisions of the ipsilateral bladder cuff-three needed a psoas hitch to facilitate the ureteroneocystostomy. Final pathology results revealed four cases of transitional-cell carcinoma, one case of ureteral carcinoma in situ, and one case of non-Hodgkin diffuse-type B-cell lymphoma. The only complication was a small hydrocele in one patient. All patients underwent standard surveillance protocol, with a recurrence in the bladder developing in one patient. Ureteral obstruction did not develop in any patient postoperatively. Mean length of follow-up was 33 months. CONCLUSIONS Robot-assisted surgery is well suited for the complex reconstruction of the mid and distal ureter after excision of low-grade malignant lesions. This series demonstrates that this surgical approach offers excellent intermediate-term oncologic outcomes with preservation of ipsilateral renal function. We believe that robotic surgery may be considered as a first-line option for the minimally invasive excision and reconstruction of low-grade, localized ureteral malignancy in selected patients at centers with experienced teams.
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Affiliation(s)
- Paul D McClain
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Tsu JHL, Kan CF, Man CW, Chan SWH. Laparoscopic ureteral reimplantation using the dome advancement technique: A case series and review of the literature. SURGICAL PRACTICE 2012. [DOI: 10.1111/j.1744-1633.2012.00587.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Current Status of Robot-Assisted Laparoscopic Ureteral Reimplantation and Reconstruction. Curr Urol Rep 2012; 13:190-4. [DOI: 10.1007/s11934-012-0250-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Eandi JA, Nelson RA, Wilson TG, Josephson DY. Oncologic Outcomes for Complete Robot-Assisted Laparoscopic Management of Upper-Tract Transitional Cell Carcinoma. J Endourol 2010; 24:969-75. [DOI: 10.1089/end.2009.0340] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Jonathan A. Eandi
- Department of Urology, Department of Information Sciences, City of Hope, Duarte, California
| | - Rebecca A. Nelson
- Division of Biostatistics, Department of Information Sciences, City of Hope, Duarte, California
| | - Timothy G. Wilson
- Department of Urology, Department of Information Sciences, City of Hope, Duarte, California
| | - David Y. Josephson
- Department of Urology, Department of Information Sciences, City of Hope, Duarte, California
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Hemal AK, Nayyar R, Gupta NP, Dorairajan LN. Experience with robot assisted laparoscopic surgery for upper and lower benign and malignant ureteral pathologies. Urology 2010; 76:1387-93. [PMID: 20350753 DOI: 10.1016/j.urology.2010.01.044] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2009] [Revised: 12/02/2009] [Accepted: 01/05/2010] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To present our experience and outcomes of robot-assisted laparoscopic surgery (RALS) performed for different ureteral pathologies and to discuss the true utility of robotics in ureteral surgery. METHODS We reviewed a total of 44 procedures performed for diverse ureteral pathologies involving the proximal and distal ureter in 2 institutions from July 2006 to July 2009. Operative time, blood loss, length of stay, complications, and subjective and objective follow-up were evaluated. RESULTS The 44 cases included 18 distal ureteral procedures including 5 distal ureterectomy with ureteroneocystostomy; 1 ureteroneocystostomy with psoas hitch; 2 ureteroneocystostomy with vesicovaginal fistula repair; 9 megaureter repairs in 8 cases; there were 12 proximal ureteral procedures including 7 ureteroureterostomies and 4 retrocaval ureter repairs; 10 ablative procedures consisting of 5 nephroureterectomies with cuff of bladder and 5 nephroureterectomies and 4 miscellaneous procedures. The mean operative time was 137.9 minutes (range: 70-240). Mean blood loss was 98.2 mL (range: <50-400). There were no urine leaks. Mean drain tube duration was 1.4 days (range: 1-2.5) and mean hospital stay was 2.4 days (range: 1-6). Complications included 1 case of sepsis and 1 antibiotic-induced infection. Average follow-up period was 13.5 months. Operative success as defined by symptom resolution and imaging was 100%. CONCLUSIONS RALS is feasible, safe, and an effective option for ureteral pathologies at any level of the ureter with minimal peri-operative morbidity. However, appropriate port placement, patient positioning, and versatile experience of team is critical in handling such cases for better outcomes.
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Affiliation(s)
- Ashok K Hemal
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC 27157-1094, USA.
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Kang SG, Choi H, Ko YH, Tae BS, Cho S, Ahn HJ, Chae JY, Kang SH, Cheon J. Robot-Assisted Laparoscopic Distal Ureterectomy and Ureteral Reimplantation. Korean J Urol 2009. [DOI: 10.4111/kju.2009.50.9.921] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Sung Gu Kang
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Hoon Choi
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Young Hwii Ko
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Bum Sik Tae
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Seok Cho
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Hong Jae Ahn
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Ji Yun Chae
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Seok Ho Kang
- Department of Urology, Korea University School of Medicine, Seoul, Korea
| | - Jun Cheon
- Department of Urology, Korea University School of Medicine, Seoul, Korea
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