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Yajima S, Nakanishi Y, Hirose K, Kataoka M, Masuda H. Standardization of robot-assisted radical nephroureterectomy via intraperitoneal approach: insights from a high-volume Japanese Center. J Robot Surg 2024; 18:330. [PMID: 39196300 DOI: 10.1007/s11701-024-02088-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2024] [Accepted: 08/21/2024] [Indexed: 08/29/2024]
Abstract
We present the trial-and-error process of standardizing robot-assisted radical nephroureterectomy (RANU) at a high-volume center in Japan. Our urology team performed 53 RANU cases using the Da Vinci Xi system, undergoing five major evolutionary stages. We performed RANU via transperitoneal approach in all cases and lymph-node dissection in selected cases. During the evolution, we adopted a lithotomy position and significantly modified port placement to facilitate lower ureter management. However, we ultimately arrived at a method that minimizes port and patient repositioning during lower ureter processing. By strategically placing ProGrasp™ forceps in the most caudal port, we effectively retracted the bladder and grasped the opened bladder wall during lower ureter manipulation. This approach also allowed us to perform pelvic, para-aortic, and renal portal lymph-node dissection without major changes in patient positioning or port placement. Nevertheless, we acknowledge that some variations in positioning and techniques may be necessary depending on specific case requirements.
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Affiliation(s)
- Shugo Yajima
- Department of Urology, National Cancer Center Hospital East, 6-5-1 Kashiwa no ha, Kashiwa City, Chiba, 277-8577, Japan.
| | - Yasukazu Nakanishi
- Department of Urology, National Cancer Center Hospital East, 6-5-1 Kashiwa no ha, Kashiwa City, Chiba, 277-8577, Japan
| | - Kohei Hirose
- Department of Urology, National Cancer Center Hospital East, 6-5-1 Kashiwa no ha, Kashiwa City, Chiba, 277-8577, Japan
| | - Madoka Kataoka
- Department of Urology, National Cancer Center Hospital East, 6-5-1 Kashiwa no ha, Kashiwa City, Chiba, 277-8577, Japan
| | - Hitoshi Masuda
- Department of Urology, National Cancer Center Hospital East, 6-5-1 Kashiwa no ha, Kashiwa City, Chiba, 277-8577, Japan
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O’Rourke TK, Thakker PU, Hemal AK. Refined step-by-step narrative review of robotic radical nephroureterectomy in the management of upper tract urothelial carcinoma. Transl Androl Urol 2024; 13:846-856. [PMID: 38855600 PMCID: PMC11157402 DOI: 10.21037/tau-23-209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 03/25/2024] [Indexed: 06/11/2024] Open
Abstract
Background and Objective Upper tract urothelial carcinoma (UTUC) is a challenging clinical entity to diagnose and manage. Recent advances in robotic technology have permitted optimization of surgical technique in robot-assisted radical nephroureterectomy with bladder cuff excision (RNU/BCE), regional lymphadenectomy, and intra or perioperative instillation of intravesical chemotherapy. This has optimized the management of bulky upper tract disease and high-grade disease not amenable to segmental ureterectomy or nephron-sparing surgery. The purpose of this article is to highlight and review the surgical technique if RNU/BCE and regional lymphadenectomy utilized in our high-volume clinical practice. Methods A review of our surgical approach was summarized for this narrative article. This technique has been refined over a course of more than 150 cases and 12 years of local experience with the procedure, as well as through multiple da Vinci® robotic surgical systems over the years. Key Content and Findings RNU/BCE, regional template-based lymphadenectomy, and intra or perioperative instillation of intravesical chemotherapy is technically feasible and the procedure has been optimized via multiple iterations with a decade of local experience. The appropriate steps are outlined in this review. Conclusions RNU/BCE, regional template-based lymphadenectomy, and intra or perioperative instillation of intravesical chemotherapy provides a refined, standardized, efficient approach for management of UTUC in appropriately selected patients. This surgical technique has also been undertaken in elderly patients including those with advanced age (>80 years old) with significant medical co-morbidities due to imperative, symptomatic indications. Further, this approach may be facilely adapted by urologists familiar with all forms of robotic renal surgery.
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Affiliation(s)
- Timothy K. O’Rourke
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Parth U. Thakker
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Ashok K. Hemal
- Department of Urology, Wake Forest University School of Medicine, Winston-Salem, NC, USA
- Department of Urology, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Ji H, Wu Q, Ji J, Qian Y, Cai L, Bai K, Cao Q, Yang X, Cao Y, Lv Q, Li P. Modified robot-assisted nephroureterectomy with ureteral catheterization for radical resection of the distal ureter: Procedures and short-term outcomes. Heliyon 2024; 10:e29198. [PMID: 38644863 PMCID: PMC11033093 DOI: 10.1016/j.heliyon.2024.e29198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 03/28/2024] [Accepted: 04/02/2024] [Indexed: 04/23/2024] Open
Abstract
Objectives To describe a bladder cuff excision method modified with ureteral catheterization to better visualize the ureteral orifice during robot-assisted nephroureterectomy (RANU). Methods We retrospectively analyzed 66 patients with upper urinary tract urothelial carcinoma of the renal pelvis and/or upper-mid ureter treated between January 2020 and January 2023. Among them, 32 patients (group A) underwent RANU supported by ureteral catheterization, and the remaining patients (group B) received routine transperitoneal RANU. Postoperative cystoscopy was performed routinely to compare the rates of residual ureteral orifice between the two groups. Results Surgeries were completed uneventfully in all 66 patients, without blood transfusion or conversion to open procedures. The operative time, estimated blood loss, and postoperative length of hospital stay were similar between both groups. However, the mean time required for BCE in group A was shorter than that in group B (9.5 min vs. 16.0 min, p = 0.006). Cystoscopy at postoperative three months showed no ipsilateral ureteral orifice in group A, but residual ureteral orifice was found in 23.5% of patients in group B. During a short follow-up period of 16 months, no patients in group A experienced bladder tumor recurrence. However, two patients (5.9%) in group B developed bladder tumor recurrence, with one experiencing local tumor recurrence at the level of the ureteral stump. Conclusions Our novel technique enables complete ureteral retrieval, accurate and rapid bladder cuff excision, which makes the procedure less invasive and safely reproducible during robot-assisted nephroureterectomy.
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Affiliation(s)
- Hao Ji
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Qikai Wu
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Jianbo Ji
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
- Department of Urology, Yancheng Third People's Hospital, Yancheng Clinical Medical College, Nanjing Medical University, Yancheng, PR China
| | - Yuhang Qian
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Lingkai Cai
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Kexin Bai
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Qiang Cao
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Xiao Yang
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Yongke Cao
- Department of English, Nanjing Medical University, Nanjing, PR China
| | - Qiang Lv
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
| | - Pengchao Li
- Department of Urology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, PR China
- Department of Urology, The Affiliated Suqian First People's Hospital of Nanjing Medical University, Suqian, PR China
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Pathak RA, Hemal AK. Management of the distal ureter and bladder cuff at the time of nephroureterectomy: an overview of open, laparoscopic, and robotic approaches. Transl Androl Urol 2024; 13:109-115. [PMID: 38404548 PMCID: PMC10891381 DOI: 10.21037/tau-23-197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 12/21/2023] [Indexed: 02/27/2024] Open
Abstract
Radical nephroureterectomy remains the gold standard treatment for high-risk upper tract urothelial carcinoma. The procedure is subdivided into six main steps: nephrectomy, ureterectomy, bladder cuff excision, cystorrhaphy, template-based lymph node dissection, and perioperative instillation of chemotherapy. Crucial in performing radical nephroureterectomy is successful management of the distal ureter and bladder cuff. Improper, inadequate, or incomplete bladder cuff excision can lead to worse oncologic outcomes and inferior cancer-specific survival. Throughout the years, open, laparoscopic, endoscopic, and robotic approaches have all been reported in performing bladder cuff excision during radical nephroureterectomy. The procedure can be accomplished via an extravesical, intravesical or transvesical manner. Each approach has distinct advantages and disadvantages. The robotic approach offers inherent advantages including improved dexterity, range of motion, and visualization. Critical to choosing an approach, however, is surgeon experience and comfort level. To date, no data suggests superiority of one approach over another. Sound oncologic principles must be adhered to when performing radical nephroureterectomy and include (I) adequate bladder cuff excision, (II) lymphadenectomy, (III) no complications and (IV) negative surgical margins, and (V) perioperative instillation of chemotherapeutic agent. Herein, we describe the various approaches in performing a bladder cuff excision and provide technical commentary supporting the advantages and disadvantages of each technique.
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Affiliation(s)
- Ram A. Pathak
- Department of Urology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Ashok K. Hemal
- Department of Urology, Wake Forest University, Winston-Salem, NC, USA
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Saini S, Deveshwar SP, Hemal AK. Narrative review of nephron-sparing surgical management of upper tract urothelial carcinoma: is there a role for distal ureterectomy, segmental ureterectomy, and partial nephrectomy. Transl Androl Urol 2024; 13:156-164. [PMID: 38404550 PMCID: PMC10891386 DOI: 10.21037/tau-23-123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 12/07/2023] [Indexed: 02/27/2024] Open
Abstract
Background and Objective Upper tract urothelial carcinoma (UTUC) is a relatively rare malignancy and radical nephroureterectomy (RNU) with bladder cuff excision (BCE) is considered as the standard of care for high-risk non-metastatic disease. Loss of the renal unit secondary to RNU, especially in elderly patients, causes significant decline in overall renal function which in turn negatively impacts the overall survival (OS). Such radical surgeries can be spared in a select group of the patients with segmental ureterectomy (SU) or distal ureterectomy to salvage the ipsilateral kidney. In this article, we will review the oncological and renal function outcomes following such procedures. This review excludes endourologic procedures. Methods This is a non-systematic review of the published literature focusing on the nephron-sparing surgical alternatives for the management of UTUCs. The following texts were used for literature search: "nephron-sparing surgery", "segmental ureterectomy", "total ureterectomy", "partial nephrectomy", and "ileal ureter". We included the articles indexed in PubMed, written in English language, and published within the last 15 years. Key Content and Findings The main argument against the utilization of these procedures is the lack of high quality, level I evidence, which is due to the rarity of this disease and the rates of ipsilateral recurrences. Despite that, the evidence in support of these nephron-sparing surgical alternatives is increasing over time. Published literature including single/multi-centric studies & systematic reviews, suggests comparable oncological outcomes and significantly improved renal function preservation. Lymph node dissection (LND) at the time of nephron-sparing surgical alternatives is largely underutilized. Similarly, the role of neoadjuvant or adjuvant systemic chemotherapy following such procedures is also not established currently. Conclusions With comparable oncological outcomes while preserving renal function, the nephron-sparing surgical alternatives to RNU are gaining momentum. These options can be offered to patients with low volume, localized UTUC with imperative indication for renal preservation such as solitary kidney, compromised baseline, and expected significant decline in post-RNU renal function without compromising oncological principles during surgery.
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Affiliation(s)
- Sumit Saini
- Department of Urology, Allegheny Health Network, Pittsburgh, PA, USA
| | | | - Ashok Kumar Hemal
- Department of Urology, Atrium Health Wake Forest Baptist, Winston-Salem, NC, USA
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Zuluaga L, Rich JM, Razdan S, Ucpinar B, Okhawere KE, Saini I, Badani KK. Robotic nephroureterectomy supplanting open and laparoscopic approach for upper tract urothelial carcinoma management: a narrative review. Transl Androl Urol 2023; 12:1740-1752. [PMID: 38106688 PMCID: PMC10719770 DOI: 10.21037/tau-23-73] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 10/31/2023] [Indexed: 12/19/2023] Open
Abstract
Background and Objective The use of robotic surgery for managing upper tract urothelial carcinoma (UTUC) has increased significantly over the years. Minimally invasive techniques (MIS) are now used for approximately half of all robot-assisted laparoscopic nephroureterectomy (RAL-NU) performed in the USA. However, there are currently no specific management guidelines that recommend the use of a robotic approach, and the available literature on this topic is limited. For this reason, we reviewed the history and current literature regarding this technique. Methods We searched Web of Science and PubMed for articles between 1934 to 2023 using 20 different search terms and combinations. We restricted our selection to only publications in English language. Key Content and Findings Comparative retrospective studies between techniques [open nephroureterectomy (ONU), laparoscopic nephroureterectomy (LNU), and RAL-NU] and case series of surgical groups, mostly at short- and mid-term follow-up, were included. Conclusions Robotic surgery for UTUC is on the rise and is predicted to become the preferred method for nephroureterectomy. A comparison of RAL-NU to LNU and ONU shows several advantages, including less blood loss, pain, and hospital stay, as well as a quicker recovery time. The safety and effectiveness of robotic surgery for lymphadenectomy also supports its use in RAL-NU. As more medical facilities adopt the technique and further studies support its benefits, it is likely that robotic surgery will become the preferred method for NU.
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Affiliation(s)
| | - Jordan M. Rich
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Burak Ucpinar
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | - Indu Saini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ketan K. Badani
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Saini S, Pathak RA, Hemal AK. Robotic nephroureterectomy in the management of upper tract urothelial cancer: inching toward standard of care? Int Urol Nephrol 2022; 54:1777-1785. [PMID: 35610528 DOI: 10.1007/s11255-022-03225-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/28/2022] [Indexed: 12/01/2022]
Abstract
Upper-tract urothelial carcinoma is a relatively rare malignancy. Current guidelines strongly recommend radical nephroureterectomy with bladder cuff excision and template-based lymph node dissection for all high-risk upper-tract urothelial carcinomas. Although the open approach is still considered the standard of care, evolution of minimally invasive approaches especially the robotic-assisted approach, has been found to be oncologically equivalent. Since its initial description in 2006, the surgical technique as well as the robotic surgical system has gone through a major evolution. With well-established advantages of the minimally invasive approach, robotic radical nephroureterectomy also has the ability to address both upper and lower urinary tract simultaneously without the need of patient repositioning, standardized single docking technique, ease of performing crucial steps like excision of ureterovesical junction and bladder cuff with watertight cystotomy closure, allowing perioperative instillation of intra-vesical chemotherapy. Robot-assisted radical nephro-ureterectomy and template-based lymph node dissection is gradually emerging as the current standard of care to achieve the best possible oncologic and functional outcomes. In this review article we are focusing on the evolution of this approach in the management of upper-tract urothelial carcinoma along with a review of oncologic outcomes.
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Affiliation(s)
- Sumit Saini
- Department of Urology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Ram Anil Pathak
- Department of Urology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Medical Center Boulevard, Winston-Salem, NC, 27157, USA
| | - Ashok Kumar Hemal
- Department of Urology, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist, Medical Center Boulevard, Winston-Salem, NC, 27157, USA.
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Pathak RA, Crain NA, Hemal AK. Radical robotic nephroureterectomy with bladder cuff excision: Overview of surgical technique. UROLOGY VIDEO JOURNAL 2022. [DOI: 10.1016/j.urolvj.2021.100119] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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Oshina T, Taguchi S, Miyakawa J, Akiyama Y, Sato Y, Kawai T, Fukuhara H, Nakagawa T, Kume H. Clinicopathological features and oncological outcomes of urothelial carcinoma involving the ureterovesical junction. Jpn J Clin Oncol 2022; 52:65-72. [PMID: 34510192 DOI: 10.1093/jjco/hyab143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 08/26/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The ureterovesical junction is the boundary between the urinary bladder and upper urinary tract. Because treatment strategies for bladder cancer and upper tract urothelial carcinoma are entirely different, urothelial carcinoma involving the ureterovesical junction requires special attention. Nevertheless, studies focusing on the disease are lacking. METHODS We reviewed consecutive patients with urothelial carcinoma treated via either transurethral resection of bladder tumor (n = 2791) or radical nephroureterectomy (n = 292) between 2000 and 2020 and identified those with bladder cancer involving the ureteral orifice (n = 64) and those with upper tract urothelial carcinoma involving the intramural ureter (≤2 cm) (n = 41). After excluding overlapping cases (n = 24), 80 patients with urothelial carcinoma involving the ureterovesical junction were analyzed. RESULTS The initial symptoms or reasons for diagnosing urothelial carcinoma involving the ureterovesical junction were hematuria (n = 30), hydronephrosis (n = 21), follow-up examinations for prior urothelial carcinoma (n = 13), screening examinations (n = 7), frequent urination (n = 6) and unknown causes (n = 3). During a median follow-up period of 42 months, 18 patients died of urothelial carcinoma. The definitive surgical treatments for urothelial carcinoma involving the ureterovesical junction were transurethral resection of bladder tumor alone (n = 26), radical nephroureterectomy (n = 41) and radical cystectomy (n = 13), with different treatments having different cancer-specific survivals. Multivariate analyses identified T stage (≥T2) as an independent predictor of shorter cancer-specific survival. CONCLUSIONS Given the positional property of urothelial carcinoma involving the ureterovesical junction, the profiles of patients with the disease were highly heterogeneous. Further optimization of treatment strategies for urothelial carcinoma involving the ureterovesical junction is urgently warranted for better clinical outcomes.
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Affiliation(s)
- Takahiro Oshina
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Satoru Taguchi
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.,Department of Urology, Kyorin University School of Medicine, Tokyo, Japan
| | - Jimpei Miyakawa
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yoshiyuki Akiyama
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Yusuke Sato
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Taketo Kawai
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroshi Fukuhara
- Department of Urology, Kyorin University School of Medicine, Tokyo, Japan
| | - Tohru Nakagawa
- Department of Urology, Teikyo University School of Medicine, Tokyo, Japan
| | - Haruki Kume
- Department of Urology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Robotic radical nephro-ureterectomy for high-risk upper tract urothelial carcinoma: Step-by-step illustrative video of surgical technique. UROLOGY VIDEO JOURNAL 2020. [DOI: 10.1016/j.urolvj.2020.100068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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