Robotic Surgery for Upper Tract Urothelial Carcinoma. Li-Ming Su, MD

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1 Robotic Surgery for Upper Tract Urothelial Carcinoma Li-Ming Su, MD David A. Cofrin Professor of Urology, Associate Chairman of Clinical Affairs, Chief, Division of Robotic and Minimally Invasive Urologic Surgery, University of Florida College of Medicine; Gainesville, Florida Objectives: Describe the indications and contraindications for robotic surgery for upper tract urothelial carcinoma Outline operative setup and surgical steps for robotic nephroureterectomy with regional lymphadenectomy Discuss the operative setup and surgical steps Psoas hitch and ureteral reimplantation Review the published literature on robotic surgery for upper tract urothelial carcinoma as compared to conventional laparoscopic surgery

2 UF U N I V E R S I T Y of FLORIDA The Foundation for The Gator Nation Robotic Surgery for Upper Tract Urothelial Carcinoma Li-Ming Su, M.D. David A. Cofrin Professor of Urology Chief, Division of Robotic and Minimally Invasive Urologic Surgery Department of Urology University of Florida College of Medicine

3 Is The Robot Necessary? Laparoscopy Robotic Surgery vs. Not necessary for experienced laparoscopists Surgeons with limited laparoscopic experience Expansion of robotic practice and offerings Stepping stone towards robotic partial NTx

4 Indications and Contraindications Indications: Same as open or laparoscopic surgery Endoscopic or biopsy proven upper tract TCCa Normal contralateral kidney and renal function Contraindications: Contraindication to laparoscopy?evidence of regional spread (e.g. N+ disease) consider chemo

5 Robotic NUx: General Principles 3-armed robotic technique Single patient positioning Single trocar configuration (4 trocars) For NUx: Two robot docking setup nephrectomy distal ureterectomy and bladder cuff Extravesical approach to bladder cuff Single cystotomy

6 Operative Steps: RANUx Step 1: Dock robot 45 o angle from the head of OR table Step 2: Mobilize of ipsilateral colon Step 3: Clip ureter beneath lesion Step 4: Dissect renal hilum Step 5: Transect renal artery and vein Step 6: Complete mobilization of kidney Step 7: Perihilar lymphadenectomy Step 8: Dissect ureter as far distally as possible

7 Operative Steps: RANUx (cont.) Step 9: Instill intravesical mitomycin C Step 10: Re-dock robot at 45 o angle from the foot of OR table Step 11: Mobilize ipsilateral bladder Step 12: Dissect out ureterovesical junction; drain bladder Step 13: Excise bladder cuff and close cystotomy Step 14: Pelvic lymphadenectomy Step 15: Entrap specimens and place drain

8 Trocar Configuration: Nephrectomy 5 mm liver retractor (optional) 12 mm assistant trocar

9 Robot is docked at a 45 o angle from the head of the bed

10 Instrumentation: RANUx Endoscope 30 degree down lens Left robotic arm Maryland bipolar forceps Right robotic arm Monopolar curved scissors Assistant Suction-irrigator Clip applier EndoGIA linear stapler Ligasure Specimen entrapment bag

11 Dissection of Renal Hilum ureter clipped

12 Transection of Renal Vessels

13 Perihilar Lymphadenectomy

14 Trocar Configuration: Bladder Cuff New assistant trocar 8-12 mm hybrid robotic trocar

15 8-13 mm Robotic Convertible Trocar Avoids capacitance coupling

16 Robot is re-docked at a 45 o angle from the foot of the bed

17 Pelvic Lymphadenectomy

18 Dissection of Ureterovesical Junction

19 Excision of Bladder Cuff

20 Instrumentation: Cystotomy Closure Endoscope 30 degree down lens Left robotic arm Needle driver Right robotic arm Needle driver Assistant Suction irrigator Ligasure Clip applier Lap needle driver

21 Sutures Bladder mucosa 3-0 polyglactin SH (8 inches) Bladder muscularis propria 2-0 polyglactin UR6 (8 inches)

22 2-layered Closure of Cystotomy

23 Specimen Extraction Sites Drain Drain

24 Case Presentation

25 CT Scan Left lower pole filling defect

26 Flexible Ureteroscopy Multiple papillary tumors Biopsy: High grade urothelial carcinoma

27 Video: Robotic Nephrectomy

28

29 Video: Robotic Distal Ureterectomy and Bladder Cuff

30

31 Perioperative Data Total OR time: 4 hours EBL: Minimal LOS: 2 day Complications: none Pathology: pt2n0mx, high grade urothelial carcinoma of renal pelvis 11 nodes negative for tumor Margins free of tumor

32 Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013

33 Robotic NUx: Published Series OR Time EBL LOS Study Technique N (min) (ml) (days) Park et al Eandi et al Hemal et al Su, Hemal, Stifelman, 2013 Berger et al Wolf et al RANUx RANUx RANUx RANUx Lap NUx HAL NUx

34 Pathologic Outcomes Mean LN count: 11 (4-23) Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013

35 Complications 1 tx for postop bleed Grade II 2 postop pneumonia Grade II 1 TB for splenic bleed Grade IV 2 transient rhabdomyolysis Grade II, IV Pugh J, Stifelman M, Hemal A and Su LM BJU Int, 2013

36 Video: Robotic Psoas Hitch

37 umbilicus assistant port pubis

38 Robot is docked between the legs

39 Instrumentation: Robotic Psoas Hitch Endoscope Left robotic arm Right robotic arm Assistant 0 or 30 degree down lens Maryland bipolar forceps Monopolar curved scissors Monopolar hook Suction-irrigator Clip applier Ligasure Specimen entrapment bag

40 Sutures Cystotomy closure: mucosa 3-0 polyglactin SH (8 inches) Cystotomy closure: muscularis propria 2-0 polyglactin UR6 (8 inches) Psoas hitch 0 prolene (8 inches) Ureteral reimplantation 4-0 polyglactin RB1 (8 inches)

41

42 Conclusions Robotic nephroureterectomy and distal ureterectomy Easy techniques to adopt esp. for experienced robotic teams Simplifies bladder cuff dissection Avoids a second cystotomy Favorable ergonomics esp. suturing as compared to laparoscopic May serve as a stepping stone towards performing robotic partial NTx Similar perioperative outcomes to conventional laparoscopic techniques Longer oncologic followup required

43 Thank You

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