Surgeon-controlled robotic ureteral surgery

Robotic radical nephroureterectomy and segmental ureterectomy for upper tract urothelial carcinoma: a multi-institutional experience

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.

Laparoscopic and robotic transperitoneal repair of retrocaval ureter: A comparison of the surgical outcomes from two centres with a comprehensive literature review

BACKGROUND

The use of minimally invasive surgical approaches for the repair of retrocaval ureter (RCU) has been increased in time. However, the results of the robotic approach have not yet been compared with those of open or laparoscopic approaches. We aimed to compare the results of laparoscopic and robotic transperitoneal repair of RCU from two centres.

PATIENTS AND METHODS

Initially, we performed a systemic literature search using MEDLINE/PubMed and Google Scholar about the RCU. Finally, a comparison of the efficacy and outcomes of the laparoscopic and robotic transperitoneal approaches for RCU repair was performed with the results of two centers.

RESULTS

The mean age was 27.5 ± 3.6 years. The mean operative time was 147 ± 63.6 min. The median estimated blood loss was 100 (20-423.9) ml. The median drain removing time and hospital stay were 2 (2-3) and 3 (2-4) days, respectively. The mean follow-up period was 17.85 ± 14.6 months. All of the parameters were similar between the laparoscopic and robotic repair groups except for the mean operative time. It was significantly shorter in robotic repair group than those of laparoscopic repair group (P = 0.02). Furthermore, a ureteral stricture of the anastomotic segment was detected in a patient treated with laparoscopy during the follow-up.

CONCLUSIONS

Robotic transperitoneal approach may shorten the operative time enabling a greater comfort in repair of RCU.

Current status of robotic surgery in urology

As a result of ergonomics, optimal magnification of the operative field, surgeon dexterity, and precision of surgical manipulation, robotic technology has been shown to overcome many difficulties associated with pure laparoscopy. With the recent expansion of robot-assisted surgery in the field of urology and following the success of robot-assisted prostatectomy and robot-assisted partial nephrectomy, robot-assisted surgery is being applied to treat many other genitourinary diseases, such as bladder cancer and ureteropelvic junction obstruction. The aim of the present review is to discuss the role of robotic surgery in urology and summarize recent developments in the field of urologic robotic surgery.

Robotic-assisted laparoscopic surgery: recent advances in urology

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.

Robotic ileal ureter: a completely intracorporeal technique

INTRODUCTION

The first laparoscopic case of ileal interposition was reported in 2000, proving the feasibility of the procedure in a minimally invasive fashion by duplicating the principles of open surgery. Robotic applications in urology are expanding worldwide, given the unique features of the robotic platform, which facilitates more advanced laparoscopic procedures. In this study, we report a case of completely intracorporeal robotic ileal ureter and thoroughly describe our technique for this complex minimally invasive procedure.

TECHNICAL CONSIDERATIONS

A 50-year-old gentleman with a history of right renal stones underwent multiple right ureteroscopies and thereafter developed 2 proximal ureteral strictures of 5 mm. Preoperative estimated glomerular filtration rate was 71 mL/min/1.73 m(2). Renal scan showed preserved function. The treatment options were discussed, and the patient elected to undergo a robotic ileal ureter interposition. Total operative time was 7 hours, the estimated blood loss was approximately 50 mL, and the patient progressed to regular diet on postoperative day 4 without any problem, being discharged without complications. On the postoperative day 12, a cystogram demonstrated no extravasation, and the Foley catheter was removed. After 1 month, renal scan showed the left kidney with 60.1% and the right kidney with 39.9% of total renal function. At 2 years follow-up, his serum creatinine was 1.14 and estimated glomerular filtration rate was 70 mL/min/1.73 m(2).

CONCLUSION

Robot-assisted laparaoscopic ileal ureter with a completely intracorporeal technique is feasible and appears to be safe. A larger number of procedures using this technique and longer follow-up are needed to further define its role in the treatment of ureteral strictures.

Robot-assisted reconstructive surgery for ureteral malignancy: analysis of efficacy and oncologic outcomes

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.